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A    TREATISE 


SURGERY, 


ITS    PRINCIPLES    AND    PRACTICE. 


BY 


T.    HOLMES,    M.A.    Cantab., 

SURGEON   TO   ST.    GEORGe's    HOSPITAL. 


WITH  FOUR  HUNDRED  AND  ELEVEN  ILLUSTRATIONS,  CHIEFLY  BY 
DR.  WESTMACOTT. 


MILLE    MALI   SPECIESr 


PHILADELPHIA: 
HENRY      C.      LEA. 

18  76. 


r  I?  1 1.  A  n  K  r,  p  II I  A : 

S  III:  KM  A.N     .1     <   "..     I' n  I  N  T  i;  If*. 


PREFACE. 


I  NEED  say  little  by  way  of  preface  to  this  volume,  which,  indeed, 
speaks  for  itself.  It  is  an  attempt  to  represent  the  present  condition  of 
Surgery,  as  it  is  practiced  in  this  country,  by  a  treatise  which  shall  be 
not  unworthy  to  rank  with  the  other  excellent  text-books  in  use  in  our 
schools.  I  have  intended  this  book  to  be  to  some  extent  an  introduc- 
tion to  the  more  elaborate  System  of  Surgery  of  which  I  am  the  editor, 
and  liave  freely  used  the  treatises  of  that  System  in'  composing  the 
various  chapters ;  and  when  any  quotations  are  made,  the  source  of 
which  is  not  distinctly  acknowledged,  it  will  be  understood  that  they 
are  taken  from  thence.  At  the  same  time  I  have  not  servilely  followed 
the  teaching  even  of  those  authorities;  and  I  hope  the  reader  will  find 
throughout  the  book  sufficient  evidence  of  that  personal  experience  of 
the  various  exigencies  of  surgery  which  can  alone  justify  an  author  in 
attempting  the  difficult  task  of  writing  on  the  general  subject  of  sur- 
gical theory  and  practice.  The  task  is  indeed  difficult.  It  is  not  only 
the  immense  number  of  topics,  and  the  endless  details  of  all  of  them — 
though  necessarily  some  of  these  topics  must  be  less  familiar  to  any 
single  surgeon  (however  wide  his  experience)  than  others  are,  and 
though  it  is  hardly  possible  but  that  some  of  the  details  should  escape 
the  writer's  attention — but,  added  to  this,  the  necessary  conditions  of 
space  press  hardly  on  the  writer  of  a  surgical  text-book.  Though  this 
volume  extends  to  over  900  pages,  the  space  allotted  to  each  topic  only 
permits  of  a  brief  and,  I  fear,,  far  too  meagre  account  of  each,  and 
leaves  hardly  any  room  at  all  to  discuss  varying  opinions  and  rival 
suggestions  of  practice.  My  endeavor  has  been  to  give  a  plain  and 
practical  account  of  each  surgical  injury  and  disease,  and  of  the  treat- 
ment which  is  most  commonly  advisable.  For  the  minuter  details  of 
pathology  I  must  refer  the  reader  to  some  of  the  many  admirable  works 
on  that  subject;  and  for  fuller  disquisitions  on  treatment,  either  to  the 
essays  in  the  System  of  Surgery  or  to  the  authors  quoted  in  the  text 
and  referred  to  in  the  index  of  authors. 

I  have  to  acknowledge  with  grateful  thanks  the  liberality  with  which 
the  rich  store  of  material  contained  in  the  Museum  and  case-books  of 
St.  George's  Hospital  has  been  put  at  my  disposal.  It  is,  of  course, 
from  the  school  of  this  hospital,  in  which  I  have  studied  and  practiced 


VI  PREFACE. 

snrgei'v  for  over  a  quarter  of  a  oentiiry,  that  my  illustrations  and  my 
teaching  have  been  chiefly  drawn;  but  I  have  not  neglected  the  teaching 
of  other  British  schools;  nor,  although  I  have  intended  this  work  to  be 
an  exposition  especially  of  British  surgery,  have  I  failed  to  refer,  as  far 
as  my  information  and  my  space  allowed,  to  the  works  of  American  and 
Continental  surgeons. 

For  the  illustrations  I  have  been  indebted  mainly  to  Dr.  Westmacott, 
to  whom  my  warm  thanks  are  due  for  the  great  interest  he  has  taken 
in  the  work  and  the  pains  he  has  spent  upon  it.  Many  of  the  minor 
illustrations  were,  however,  drawn  by  one  of  my  pupils,  Mr.  F.  D. 
Drewitt,  whose  intelligent  and  able  assistance  it  is  my  duty  to  acknowl- 
edge as  it  deserves ;  nor  must  I  omit  to  thank  Mr.  Evans,  the  engraver 
of  the  woodcuts,  for  the  great  care  which  he  has  bestowed  upon  them, 
and  for  several  of  the  diagrams  which  he  has  drawn  under  my  direction. 

I  have  thought  it  necessary  to  comprise  in  this  treatise  all  the  diseases 
which  are  included  under  the  title  "  surgical,"  so  that  chapters  will  be 
found  on  diseases  of  the  eye,  ear,  and  skin.  In  treating  the  first-men- 
tioned subject  I  have  availed  myself  of  the  able  assistance  of  my  colleague 
Mr.  Carter;  as  it  is  many  years  since  I  have  personally  engaged  in 
ophthalmic  practice,  and  it  is  only  from  recent  practice  that  a  branch 
of  surgery  can  be  taught  which  has  been  so  greatly  modified  by  recent 
discoveries.  But  I  hold  that  a  knowledge  of  the  main  principles  of 
diagnosis  and  treatment  ought  to  be  possessed  by  every  surgeon  in  the 
case  of  diseases  of  the  organs  of  the  special  senses  quite  as  much  as  those 
of  the  rest  of  the  body.  Among  the  many  injuries  which  the  curse  of 
specialism  has  inflicted  equally  on  the  profession  and  the  public,  not 
the  least  has  been  the.  neglect  of  the  diseases  of  these  organs  which  some 
practitioners  and  many  students  seem  almost  to  regard  as  natural.  I 
am  happy  to  think  that  in  the  subject  of  oi)hthalmic  surgery  my  readers 
will  have  the  benefit  of  so  competent  a  guide  as  Mr.  Carter.  The 
chapter  on  Diseases  of  the  Ear  is  necessarily  very  short,  and  is  intended 
only  to  point  out  the  leading  facts  in  Aural  Surgery,  and  those  methods 
of  treatment  with  which  every  practitioner  ought  to  be  familiar.  I 
must  express  ray  obligation  to  Mr.  Dalby,  who  has  been  so  kind  as  to 
peruse  it  and  correct  some  of  its  most  obvious  defects. 

I  must  now  submit  this  book  to  the  judgment  of  my  professional 
brethren,  though  fully  conscious  of  its  many  imiicrfcctidus.  I  fear  that 
as  we  advance  in  life  we  feel  more  and  more  the  dillicuity  of  coming  up 
to  our  own  expectations  in  any  enterprise  of  importance,  and  the  truth 
of  the  old  saying,  "Quid  tain  dcxiro  pcdo  concipis  ut  to  conatus  non 
peniteat  votique  peracti  ?" 

Great  Cumberland  Tlack, 
October,  1875. 


CONTENTS. 


CHAPTER  I. 


INFLAMMATION    AND    THE    PROCESS    OF    UNION    IN    SOFT    PARTS TRAUMATIC 

FEVER — -DRESSING    OF    WOUNDS. 


rAGK 

33 

33 
36 
36 


The  Process  of  Inflammation,   . 

Chief       Symptoms:       Kednoss, 

Swollini;-,  Heat,  Pain,  Fever, 
Pathology  of  Inflammation, 
Emigration  of  Leucocytes, 
Terminations  of  the  Inflamma- 
tory Process,    .  .         .  .38 
Wounds  and  Contusions,  .         .  .38 
Blood-tumor:     Organization    of 
Clot,          .         .  "^     .          .  .39 
Kinds  of  Wound,       .         .         .         .41 
Processes  of  Union  : 

1.  Primary  Adhesion,         .         .     41 

2.  Primary  Union,  or  Union  by 
First  Intention,        .  .  .41 

3.  Union  by  Suppuration,  or  by 

Second  Intention,         .  .     42 

Ulceration,       .  .         .         .43 


Processes  of  Union — coiitvnied. 

Granulation,    .  .  .         .44 

Cicatrization,  .         .         .  .44 

4.  Union    by  Secondary    Adhe- 

sion, or  by  Third  Intention,     44 

5.  Union  under  a  Scab,  .  .  45 
Cicatrices,  .  .  .  .  .45 
Traumatic  Fever,       .         .  .         .46 

Condition  of  llie  Blood  in  Inflam- 
mation,   .  .         .         .48 

Symptoms  of  Traumatic  Fever,  .  48 
Methods  of  Dressing  Wounds,  .         .     49 

Lister  .<  Antiseptic  Method,        .     50 

Di'essing  Wounds  where  Iia})id 
Union  is  not  sought,        .         .     52 

Irrigation,    Sutures,    Strapping, 
Bandages,         .         .         .         .53 


CHAPTER  II. 

THE    COMPLICATIONS    OF    WOUNDS    AND    INJURIES. 


Abscess,     ... 

Kinds  of   Pus  and  of   Abscess 
Progress  of  Abscess, 

Diagnosis — Fluctuation, 

Trejitinent  of  Abscess, 

Residual  Abscess, 
Sinus  and  Fistula, 
Pyjemia  and  Septicemia,  . 

Symptoms  of  Pyaemia, 

Pathology  of  I'yiEmia, 

Pathological  Anatomy  of  Pyos 
mia. 

Diagnosis  and  Treatment, 

Chronic  Pyiemia, 
Hectic  Fever,     . 
Visceral   Disease  produced  by 

continued  Suppuration, 
Erj'sipelas  and  Erythema, 

Various  Forms  of  Erythema, 

Cutaneous  or  simple.  Erysipelas, 

Phlegmonous     or    Cellulo-cuta 
neous  Erysipelas, 

Causes  of  Erysipelas,  . 

Diagnosis  and  Treatment,  . 


54 

55 
55 
56 
57 
58 
59 
59 
61 

62 
64 
64 
65 

66 
67 

67 
68 

70 
70 

72 


Erysipelas  and  Erythema— continued. 

Local  Treatment  of  Diffuse  In- 
flammation,    .         .         .         . 
Gangrene,  .         .  .  .  . 

Traumatic  and  Spontaneous  Gan- 
grene,      .         .         .         .         . 

Moist  and  Dry  Gangrene,  . 

Phenomena  of  Gangrene,   . 

Amputation  in  Gangrene,  . 

Local  and  General  Treatment,  . 
Special  Forms  : 

Bedsores,     .... 

Frostbite,    .... 

Hospital  Gangrene, 

Phagedena, 

Senile  Gangrene, 

Cancrum  Oris  and  Noma  Vulvfe 
Tetanus,     ..... 

Trismus  Nascentium, 

Diagnosis  of  Teianus, 

Pathology,  .... 

Treatment, 
Delirium  Ti'emens,    ... 


74 


76 
76 

77 
79 

80 
81 
81 
88 
84 
85 
86 
87 
87 
88 
89 
91 


vin 


CONTENTS. 


CHAPTER  III. 


POISONED    WOUNDS    AND    ANIMAL    POISONS. 


Dissertioii-woiinds,  ...  93 

Acute  and  Chronic  Form  ofDis- 

scclion-poison,        .         .         .  9i 
TrcatnuMit        of       Dissection- 
wounds,           ....  95 
Wounds  of  Venomous  Animals,       .  90 
Intravenous  Injection  in  kSnaUe- 

bite, 97 

Glanders, 98 


Glanders — continued. 

Farcy,       ... 

Equinia  Mitis,  . 
Hydrophobia,  ... 

The  Disease  in  the  Dosi;, 

Question  of  the    Existence 
Significance  of  "  Lyssi,' 

Diagnosis  of  Treatment, 


and 


99 
100 
100 
101 

103 
103 


CHAPTER  IV. 


HjEMOrriiage  and  collapse. 


Haemorrhage,  ..... 
Spontaneous  Hasmorrhage, 
The  Hicmorrhagic  Diathesis,    . 
General     Symptoms    of    Acci- 
dental Hiemorrhage, 
Injuries  of  Arteries,  . 

Contusion,     .... 
Partial  Laceration, 
Complete    Laceration,    Sub- 
cutaneous, .... 
Complete   Laceration    in    an 

Exposed  Artery, 
Incomplete  Division,     . 
Complete  Division, 
Injuries  of  Veins, 
•  Entrance  of  Air  into  Veins,  . 
Diagnosis  of  the  Sources  of  Ha^- 
morriiage,       .... 
Treatment:    Method  of  Tying 
Bleeding  Arteries, 
Cases    in     which     Wounded 
Art-'^ries     should      not     be 
Tied,  


105 
105 
105 

IPfi 
107 
107 
107 

108 

109 
109 
110 
110 

111 

111 
112 


113 


Hajmorrhage — continued. 

Cases   in   which   the   Artery 

above  may  be  Tied,    . 
Ligature  of  Arteries, 
Changes  subsequent  to  Liga- 
ture,    .... 
Secondary    Hivmorrhago 

and  its  Treatment, 
Recurrent  Haemorrhage, 
Gangrene, 

Recurrence  of  Pulsation, 

Ligature    of    Arteries    witli 

Carbolizcd      Catgut      (the 

"  Antiseptic  Method  "),     . 

Acupressure, 

Torsion,  .... 

Other  Means  of  Stopping  Ar- 
terial Hiemorrhage,   Unci- 
pression,Foicipres8ion,etc., 
Treatment  of  ordinary  Capil- 
lary   Ha'morrhage:    Styp- 
tics,    .         .         .  '      • 
Transfusi-n  of  Blood, 
Collapse,  ...... 


113 
114 

115 

iii; 

118 
118 
118 


119 
121 

1-23 


125 


125 
120 

128 


CHAPTER  V. 


BURNS    AND    SCALDS. 


Classification  of  Burns,    . 
Symptoms  and  Stages  of  Burn.-, 
Ulceration  of  the  Duodenum, 


132  I  Local  Treatment, 

132  I  General,   . 

i:!3  I  Litrhtning-stroke 


134 
135 
13r, 


CHAJ'TKK   VI. 

FRACTURES    AND    DISLOCATIONS — OENEUAL    P.\TII(tI.OO V. 


Fractures : 

Definition  and  Classification, 
Scfiaration  of  ICpiph3'.-es.  . 
Symptoms  and  Diagno.-is, 
Treatment, 


Treat  iiKint — continued. 
137  Setting  the  Fraclurt',     . 

139  Question    of   Amiiutaticm    or 

i;]9  Exci.sion,    .... 

14U  Treatment  of  C(>ni|tlieation.'(, 


141 


142 

143 


CONTENTS. 


IX 


Fractures — continued. 
Union  of  Fracture, 

Ui-ual  Process  in  Simple  Frac- 
ture (Primary  Union,  In- 
termediate Callus),  . 
Union  by  Provisional  Callus, 
Union  of  Inflamed  Simple, 
and  of  Compound  Frac- 
tures bv  Granulation, 


144 


145 
145 


146 


Union — continued. 
Defects  of  Union, 
Delayed   Union,     . 
Ununited  Fracture, 
Vicious  Union:   Refracturc, 
Dislocation  :  General  Pathology, 

Reduction, 
Injuries  of  Cartilage, 


147 
148 
148 
152 
154 
154 
155 


CHAPTER  VII. 


INJURIES    OF    THE    FIEAD. 


Classification,  .         .         .         .         .157 
Complications,  ....      157 

Surgical  Anatomy  of  the  Scalp,       .     157 

I.  Contusions  of  the  Soft  Parts,       .     157 

Diagnosis   between    Extravasa- 
tion and  Depressed  Fracture,     157 

II.  Scalp-wounds  and  their  Treat- 

ment,     .         .  .         .         .      158 

Complications  of  Scalp-wound: 

Erysipelas,     ....     159 
Suppuration  beneath  the  Cra- 
nium, .         .         .         .160 
Trephining  for  Pus,         .     161 

III.  Traumatic    Extravasation    bc^- 
tween  the  Bone  and  Dura  Mater,     162 

Trephining  for  "Wound  of  Mid- 
dle Meningeal  Artery,  .         .     163 
Extrava-sation  in  the  Arachnoid 
Cavity,  .....     165 
Organization   of  such    Ex 

travasation,      .         .         .     165 
Symptoms:  Diagnosis  from 
Apoplexy,        .         .  .166 

IV.  Fractures  of  the  Skull,     .         .     167 
Fractures  of  the  Vault,     .         .      167 

Depression    of    Outer     Table 
only  : 
Fractures    of    the    Frontal 
Sinus,      ....      168 


Fractures  of  the  Skull — continued. 
Depression    of    Inner    Table 

only,  

Fracture  with  Elevation, 
Fracture  by  Contre-coup, 
Treatment    of    Simple     and 
Compound  Fracture,  . 
Fractures   of  the   Base   of  the 
Skull,  .... 

In  Wounds  of  the  Orbit, 
Of  the  Anterior  Fos.-a,  . 
Of  the  Middle  Fossa,     .         .\ 
Of  the  Posterior  Fossa, 
Serous  Discharge  in  Fracture 

of  the  Skull, 
Union    of   Fractures    of    the 
Base,  ..... 
V.   Lesions  of  the  Brain, 

Concussion  of  the  Brain,    . 
Compression,     .... 

Trephining  for  Fracture, 
Cases  not  classifiable  as  Concus- 
sion or  Compression.     Contu- 
sion   and    Laceration  of   the 
Brain,     .... 
Traumatic  Inflammation, 
Hernia  Cerebri, 
Injuries  of  Cranial  Nerves, 
The  Operatii'n  of  Trephining, 


168 
168 
169 

169 

170 
171 
173 
173 
173 

174 

174 
176 
177 
178 
179 


180 
181 
182 
183 
184 


CHAPTER  VIII. 

INJURIES    OF    THE    SPINE. 

Sprains  of  the  Back,         .         .         .     185  i  Treatment :   Trephining  the  Spine,     189 
Fracture    and     Dislocation    of    the  I  Concussion  and  Railway  Injury,     .     192 

Spine, 186  I 


CHAPTER    IX. 

INJURIES    OF    THE     FACE. 


Bruises  and  Wounds,        .         .         .     195 
Salivary  Fistula,        .  .     195 

Foreign   Bodies  in  the  Nostril  and 
Ear, 196 

Fractures : 

or  Nasal  Bones,         .         .         .197 


Fractures — continued. 

Of  the  Upper  Jaw,  .  .  .197 
Of  the  Malar  Bone  and  Zygoma,  197 
Of  the  Lower  .Jaw.    .         .  .197 

Dislocation  of  the  Jaw,    .         .         .     200 
Subluxation  of  the  Jaw,    .         .     203 


CONTENTS. 

CHAPTER  X. 

INJURIES    OF    THE    NECK. 


Cut  throat, 203 

Contusions  of  the  Larynx,        .         .  20(5 

Dislocation  of  the  Hyoid  Bone,        .  '200 

Fractures  of  the  Hyoid  Bone,  .         .  207 

Of  the  Cartilages  of  the  Larynx,  207 


Rupture  of  the  Trachea,  .  .  .208 
Foreign  Bodies  in  the  Air-passages,  208 
Burn  and  Scald  of  the  Larynx,  .  214 
Foreign  Bodies  in  the  (Esophagus,  .  214 
(Esophagotoniy,  .         .  .     210 


CHAPTER  XI. 


INJURIES    OF    THE    CITEST. 


Contusions  and  Wounds  of  the  Pa- 

rietes,    ..... 
Fractured  Ribs, 

With  Wound  of  Lung, 
Complications  : 
Empiiysema, 
Pneumothorax, 
Hsemothorax,    Hydrothorax 
etc.,    .... 
Fracture  of  Costal  Cartilages, 
Fracture  of  the  Sternum, 


217 
218 
220 

221 

221 

221 
222 
222 


Dislocations  of  tiie  Ribs,  . 
Penetrating  Wounds, 

Hernia  of  the  Lung,  . 
Foreign  Bodices  in  the  Chest,  . 
Wounds  of  the  Mediastinum,  Peri- 
cardium, and  Heart, 

Paracentesis  of  Pericardium,     . 

Wounds  of  Internal  Mammary 
and  Intercostal  Arteries, 
Rupture  of  Viscera  without  Wound, 

Thoracentesis,  .         .         .         . 


223 
223 

224 


22G 

227 
228 
228 


CHAPTER  XII. 


INJURIES   OF    THE   ABDOMEN. 


Contusions,       ..... 
Contusion    with    Rupture  of  Intes- 
tine ; 
Rupture  of  the  Stomach,  . 
of  the  Intestines, 
of  the  Liver  and  Gall- 
bladder,   . 
of  the  Spleen, 
of  Kidney  and  Ureter, 
Wounds  ; 

I.  Superficial, 
II.   Penetrating  : 
a.  Simple:  Foreign  Bodies  in 
such  Wounds, 


230 


231 
231 

233 
234 
234 

235 


235 


Wou  nd  s — coil  i'mned. 

b.  With   Wound   of  Viscera 

which  do  not  f)rotrude,  . 

c.  With  Protrusion  of  Unin- 

jured Viscera, 

d.  With    Protrusidn    of    the 

Wounded  Viscera, 
Suture  of  the  Intestine, 
Foreign   Bodies  in  the  Stomacii  or 
Intestines,     .... 
Gastrotomy  and  Gastrostomy,  . 


236 


230 


237 
287 


237 
238 


CHAPTER  XIII. 


INJURIES    OF    THE    PELVIS. 


Contusion  and  Wound  of  the    But- 
tock,     ...... 

Fractures  of  the  Pelvis  : 

Of  the  Ala  of  the  Ilium,    . 

Of  the  True  Pelvis,  . 

Of  the  Acetabulum,  . 

Of  the  Coccyx,  .  .         .         . 

Rupture  of  the  Bladder,  . 
Rupture  of  the  Urethra,  . 


240 

241 
L'41 
243 
244 
244 
240 


Injuries  of  the  ^lale  Organs  of  Gen- 
eraliiui,  .  .  .  .  . 

Tying  a  Ligature  round  llie  Penis, 

Injuiii's  of  the  Female  Organs, 

Wounds  of  tlie  Bladder,   . 

Wounds  of  the  Hccluiti.  . 

Foreign  Bodies  in  the  Bhidder,  Va 
giiia,  or  Rectum,  . 


247 
248 
248 
240 
24!l 

24!) 


CONTENTS. 


XI 


CHAPTER  XIY. 


INJURIES    OP    THE    UPPER    EXTREMITY. 


Considerations  applicable  to  all  In- 
juries of  the  Upper  Extremity,     . 

Foreign  Bodies  in  the  Palm,     . 

Wounds   of  the   Palm   of   the 

Hand, 

Fractures  of  the  Clavicle  : 

Of  the  Body  of  the  Bone, 

Of  the  Sternal  End,  . 

Of  the  Acromial  End, 
Fractures  of  the  Scapula, 

Of  the  Neck  of  the  Scapula, 

Of  the  Coracoid  and  Acromion 
Processes,       .         .         .  . 

Fractures  of  the  Humerus: 

Fracture    of    the     Anatomical 
Neck,     .... 

Of  the  Surgical  Neck, 

Of  the  Epiphysis, 

Of  the  Great  Tuberosity,  . 

Of  the  Shaft,      . 

Of  the  Lower  End,   . 
Fractures  in  the  Forearm  : 

Of  the  Olecranon, 

Of  the  Coronoid  Process,  . 

Of  both  Bones  of  the  Forearm 

Of  one  Bone  alone,    . 

Colles's  Fracture  of  the  Lower 

End  of  the  Radius, 

Fractures  of  the  Carpus, 

Fractures    of   the    Metacarpus    and 

Phalansres,    .  .         .  .         . 


^50 
251 

251 

252 
254 
254 
256 
256 


258 
259 
261 
261 
261 
262 

264 

266 
266 
266 

267 
269 

269 


Compound  Fractures  in  the  Upper 

Extremity, 269 

Dislocation   of  the  Sternal  End   of 

the  Clavicle,  .         .  .         .270 

Dislocation  of  the  Acromion,  .         .  271 

Dislocation  of  the  Shoulder,     .          .  271 
Into  the  Axilla : 

Subcoracoid  and  Subglenoid,  272 

Subclavicular,         .         .          .  274 

Subspinous,    ....  274 
Earer  Dislocations  upwards  (su- 

pracoracoid),           .         .          .  275 
Dislocations    complicatf^d    with 

Fracture,        ....  276 
Reduction,          ....  276 
Compound  and  Partial  Disloca- 
tion,          279 

Dislocation  of  the  Elbow: 

Of  both  Bones  backwards,         .  280 
With  Fracture  of  the  Coronoid 

Process,  .         .         .         .281 

Of  the  head  of  the  Radius  only,  283 

Rarer  Dislocations,    .         .         .  283 

Compound  Dislocations,    .         .  283 

Dislocations  of  the  lower  End  of  the 

Radius, 284 

Dislocations  of  the  Wrist,         .          .  284 

Dislocations  of  the  Carpus,       .         .  285 

Dislocations  of  the  Thumb,     .         .  285 

Dislocations  of  the  Fingers,     .         .  287 


CHAPTER  XY. 


INJURIES    OF    THE    LOWER    EXTREMITY. 


Sprains  and  Wounds,       .         .         .     288 
Wound  of  Knee-joint,       .  .     289 

Fracture  of  Cervix  Femoris  : 

Extra  and  Inti'a-capsular  Frac- 
ture, Impacted   and  Non-im- 

pactcd, 289 

Du\gnosis,  ....     291 

Diagnosis    between    Extra  and 

Intra-capsular  Fracture,        .     292 
Method    of   Union  and    Treat- 
ment,     .....     294 
Fractures    of    Trochanter    and 
Separation  of  Upper  Ejjiphy- 

.'^is 295 

Fractui'e  of  the  Body  of  the  Femur  : 

In  the  Upper  Third,  .         .     296 

In  the  Middle  of  the  Bone,        .     298 
Near  the  Knee-joint,         .         .     302 
Fracture  of  the  Patella  : 

Transverse,         ....     306 
Y-shaped,  .         .         .         .309 

Compound,         ....     309 
Fractures  of  the  Leg: 

Of  both  Bones,  .         .         .310 


Fractures  of  the  Leg — continued. 

Of  the  Tibia  only,     .  .  .311 

Of  the  Fibula  only,  •         •         •  311 

Compound  Fractures,        .          .  312 

Fractures  of  the  Bonos  of  the  Foot,  314 

Dislocations  of  the  Hip: 

1.  Upwardson  the  Dorsum  Ilii,  315 

2.  Backwards     on     the    Sciatic 

Notch,        .         .         .         .318 

3.  Downwards  on  the  Obturator 

Foramen,    ....  322 

4.  Inwards  on  the  Pubes,          .  323 
Anomalous  Dislocations,  .         .  325 

Dislocation  of  the  Knee,           .         .  325 

Patella, 326 

Semilunar  Cartilages,        .         .  327 
Head  of  the  Fibula,  .         .          .  327 
Dislocations  of  the  Ankle,        .         .  328 
Pott's  Fracturi',         .         .         .328 
Compound  Dislocation,     .         .  329 
Dislocation  of  the  Astragalus,           .  330 
Subastragaloid  Dislocation,     .         .  331 
Dislocations  of  the  Tarsus,  Metatar- 
sus, and  Phalanges,       .         .         .  333 


Xll 


CONTENTS. 


CHAPTER  XVI. 


GUNSHOT    WOUNDS. 


I.  Gansliot  Wounds  in  General  : 

Definition,  .         .         .         . 

Mode  of  Union, 

Wound  of  Entrance  and   Exit, 

"  Wind  Contusions,"  or  Contu- 
sions from  Oblique  Impact,   . 

Symptoms  and  Method  of  Ex- 
amination,     .         .  .  . 

Treatn)eiit,         .  .         .  . 

II.  Gunshot  Wounds  in  each  Kegion 

of  the  Body : 
Of  the  Head,      .... 
Of  the  Spine,      .... 
Of  the  Face 


334 
3:^4 
335 

335 

335 
33G 


338 
339 
339 


II.  Gunshot  Woundsin  each  Region 
of  the  Body — continued. 

Of  the  Neck,     .         .         .         . 

Of  the  Chest,     .         .         .         . 

Diagnosis  and  Treatment  of 
Gunshot  AVounds  of  the 
Lung,     ..... 

Of  the  Abdomen, 

Of  the  Hypogastrium,  Peri- 
neum, and  Genital  Organs,   . 

Of  the  Extremities,  . 

Treatment  of  Gunshot  Injury 
of  the  Upper  and  Lower 
Extremities,  .... 


340 
340 


340 
342 

343 
343 


344 


CHAPTER  XVII. 


TUMORS. 


Deiinition  of  a  "  Tumor, 

CI a.ssiti cation,  . 

I.   Innocent  Tumors : 

Cysts :  Serous,  . 
Sanguineous, 
Compound     Cysts 
ceous, 

Congenital  Cutaneoi 

Dermal  Cysts, 

Proliferous  Cysts, 

Cystigerous  Cysts, 
Solid  Tumors  : 

Fatty, 

Fibrous,    . 

Fibroceilular,    . 

Cartilaginous,   . 

Bony, 

Vascular,  . 

Aneurism  by  Anastc 

Nicvus, 

Treatment  of  Nsevus, 

Degeneration  of  Nsevus, 


Seba 
s  Cysts, 


mosis. 


347 
348 

349 
350 

351 
352 
;-i53 
353 
353 

354 
355 
356 
3.57 
358 
359 
359 
3(;0 
3G0 
363 


Solid  Tumors — continued. 

II.  Sarcomatous  or  semi-malignant 

Tumors, 
Round-celled  Sarcoma, 
Spindle-celled  Sarcoma,    . 
Giant-celled      Sarcoma     (mye 

loid),      .... 
Net-celled  Sarcoma  (myxoma) 
Alveolar  Sarcoma,    . 
Pigmentary     Sarcoma     (mela 

nosis),    .... 
Diagnosis     of    Sarcoma     from 

•Carcinoma,    . 

III.  Carcinoma, 
Scirrhus,   .... 
Medullary, 
Melanotic, 

Osteoid,      .... 
Epithelioma 

Colloid,      .... 
Villous,     .... 


364 
364 
364 

366 
866 

366 

366 

367 
369 
370 
372 
373 
373 
374 
375 
376 


Struma  and  Scrofula, 

Tubercle,  its  Kinds  and  Manner 

of  Formation, 
Connection     between     Scrofula 
and  Ordinary  Inflammation, 


CHAPTER  XVIII 

SCROFULA. 
.     37 


37" 


Struma  and  Scrofula— con<('H»«/. 

Kinds  of  VarietitiS  of  Scrofula,  379 

Causes  of  Scrofula,    .         .  .  380 

Treatment,         ....  380 


Definition  and  Pathology, 

Nervous  Mimicry  or    Nervous 
Affections,      .         •         • 


CHAPTER  XIX. 

HYSTERIA. 

.     ;J82  I  Dcflnition  and  Pathology— coui(tn«c^Z. 

383  ' 


Symptoms  and  Diagnosis, 
Treatment, 


383 
3H5 


CONTENTS. 


Xlll 


CHAPTER  XX. 


GONORRH(EA    AND    SYPHILIS, 


Gonorrhoea  in  the  Male,  .         .         .  387 

Symptoms  of  its  Various  Stages,      .  387 

Gleet, 388 

Complications : 

Lacunar  Abscess,       .         .         .  388 

Balanitis, 388 

Phimosis 388 

Paraphimosis,    ....  388 

Spasms  and  Hjematiiria,    .  .  389 

Chordee, 389 

Bnbo, 389 

Gonorrhoeal  and  Capivi  Ea«h,  .  389 

Gonorrhoea!  Rheumatism,  .  390 

Other  Complications,         .         .  391 

Treatment  of  Gonorrhoea,         .         .  391 

Gonorrhoea  in  the  Female,        .         .  392 

Leucorrhoea  Infantum,      .         .  393 
Complications  of  Female  Gon- 

orrhoga,            ....  393 
Treatment,         ....  393 
Syphilis:  Definition  and  Nomencla- 
ture,          394 

The  Local  Forms  of  Syphilis,  or 

the  Non-infectinsr  Sore.  .  394 

1.  The  Common  Soft  Chancre,  394 

2.  The  Chancre  with  Suppu- 

rating Bubo,  .         .  .  395 


Syphilis — cotitinned. 

Svphilitic  Phimosis,  . 

"3.  The  Sloughing  Sore, 
The    Constitutional     Form     of 
Syphilis — the  "Hard,"  "  In- 
fecting,'^'     or     '■  Hunterian  " 
Chancre,         .... 
Diagnosis     between     the     two 

Forms  of  Chancre, 
Treatment :    the    use  of    Mer- 
cury,        

Secondary  Syphilis, 
Skin  Eruptions, 
Mucous  Tubercle, 
Alopecia,  . 
Sore  Throat, 
Affections  of  Glands, 

Inoculation      of      Secondary 

Syphilis,      .... 

Treatment,     .... 

Tertiary  Syphilis,     .... 

Infantile  or  Congenital  Syphilis,     . 

Non-congenital  Syphilis  in  Infants, 

Vaccino-syphilis,      .... 

Irregular  Forms  of  Syphilis,    . 

Syphilitic  Inoculation  and  Syphili- 

zation,   . 


395 

395 


396 

396 

398 
401 
401 
402 
403 
403 
403 

404 
404 
405 
407 
409 
409 
409 

410 


CHAPTER  XXL 


ULCERS — CICATRICES, 

Classification  of  Ulcers,    . 

411 

The  Healthy  Ulcer,  . 

412 

Inflammatory  Ulcer, 

412 

Eczematous  Ulcer,     . 

412 

Cold  Ulcer, 

413 

Senile  Ulcer, 

413 

Strumous  Ulcer, 

413 

Scorbutic  Ulcer, 

414 

Gouty  Ulcer, 

414 

Syphilitic  Ulcer, 

414 

Lupous  Ulcer,     . 

415 

Rodent  Ulcer,     . 

416 

Cancerous  Ulcer, 

417 

Varicose  Ulcer, 

417 

(Edematous  or  Weak  Ulcer 

418 

AND    THEIR    DISEASES. 

Classification  of  Ulcers — continued. 
Exuberant  Ulcer, 
Hajmorrhagic  Ulcer,  . 
Neuralgic  Ulcer, 
Inflamed  Ulcer, 
Callous  or  Indolent  Ulcer 
Phagedenic  Ulcer, 
Cicatrices  antl  their  Diseases,  . 
Ulceration  of  Scars,  . 
Neuralgia  of  Scars,    . 
Excessive  Formation  of  Scars 
Keloid  Tumor  of  Scars, 
Warty  and  Epithelial  Tumors 
Contracted  Cicatrix, 
Sl<in-<jraftinir, 


418 
418 
418 
418 
418 
418 
419 
419 
419 
419 
419 
420 
420 
421 


CHAPTER  XXII. 

DISEASES    OP    THE    BONES. 


Ostitis  or  Inflammation  of  the  Sub- 
stance of  Bone,     .... 
Periostitis,        ..... 

Nodes, 

DiflTuse  Periostitis :   Acute  Peri- 
osteal Abscess, 


Osteo-Myelitis,  ....  426 

422  Chronic  Abscess,       ....  4'J8 

423  Caries, 431 

428    Phagedenic  Ulceration  of  Bone,      .  433 

Necrosis,  ......  433 

425  i  Acute  Necrosis,         .         .         .  436 


XIV 


CONTENTS. 


Necrosis — continued. 

Treatment  of  Necrosis,     . 

Complications :  Fracture  from 

Necrosis,     .... 

Scrofula  in  Bono,      .... 

Sypliilis  in  Bone,      .... 

C'ancer  in  Bono,        .... 

Osteoid  Cancer, 
Myeloid  and  Sarcomatous    Tumors 
of  Bone,         ..... 
Innocent  Tumors: 

Enchondroma,  .... 


f'.\(;E 

Innocent  Tumors — continued. 

PAGE 

43(3 

E.vostosis,            .         .         .         . 
Fibrous  and  Fibro-cellular  Tu- 

447 

489 

mors 

451 

439 

Hydatids, 

451 

440 

Pulsatile  Tumor:   Osteo-Aneurism, 

452 

442 

Mollities  Ossium,     .... 

453 

442 

Rickets, 

455 

Hypertrophy  of  Bone, 

457 

445 

Atrophy  of  Bone,     .... 

4.58 

Spontaneous  Fracture, 

459 

445 

CHAPTER  XXIII. 


DISEASES    OP    THE    JOINTS. 


General  Pathology  and  Di.seases 

OF  THE  Knee. 
Atfections  of  the  Synovial  Membrane  : 
Acute  Synovitis,        .         .         .     460 
Abscess  of  Joints,       .         .         .     461 
Chronic  Synovitis,    .         .  .     462 

Hydrops  articuii,  .  .         .     462 

Pulpy  DegeneratioQof  Synovial 

Membrane,     ....     462 
Pendulous  Growths  from  Syno- 
vial Membrane,      .         .         .     463 
Diseases  of  the  Articular   Ends  of 

Bones, 463 

Aflections  of  the  Cartilages  :   '>  Ul- 
ceration of  Cartilage,"           .         .     466 
Loose  Cartilages,  or  Loose  Bodies  in 
Joints, 469 


Chronic  Rheumatic  Arthritis, 
Anchylosis,       .... 

Forcible  Extension,  . 

Subcutaneous  Section  of  Bone 
Hysterical    and     Neuralgic    AtFec 

tions,     ..... 
Diseases  of  Particular  Joint.s 

Of  the   Hip:    "Morbus  Coxa 
rius,"      .... 

Congenital  Dislocation, 

Other  Affections  of  the  Hip, 
Of  the  Sacro-iliac  Articulation, 
Of  the  Ankle  and  Tarsus, 
Of  the  Sterno-clavicular  Joint, 
Of  the  Shoulder, 
Of  the  Elbow,  .... 
Of  tlie  Wrist  and  Carpus, 


471 
472 
473 
473 

474 


475 

478 
480 
480 
481 
482 
482 
483 
483 


CHAPTER  XXIV. 

DISEASES    OF    THE    SPINE. 


Caries  of  the  Spine, 

Affection  of  the  Cord, 
Spinal  Abscess, 

Psoas  Abscess, 
Treatment  of  Diseased  Spine, 
Disease  of  Cervical  Vertebra?, 


.     484 

Lateral  Curvature,  . 

491 

.  .  485 

Kyphosis,  Lordosis,  and 

ilher 

Cnr- 

.     487 

vatures, 

494 

.     487 

Anchylosis  of  the  Spine, 

494 

.     488 

Cancer,     . 

494 

.     489 

Spina  Bifida,     . 

495 

CHAPTER  XXV. 


DISEASES   OF    MUSCLES   AND    BURSyE. 


Rupture  of  Muscles  and  Tendons,    .  496 

Inflammation    of    Muscles:    Gum- 
matous Tumors,    ....  497 

Inflammation  of  Tendons,         .         .  497 

Whitlow, 497 

Diseases  of  Burste  : 

Housemaid's  Knee,    .                   .  498 
Affections     of     other      Bursa-, 

Natural  or  Acquired,              .  600 

Bunion,     .....  501 

Ganglion,           ....  501 


Diseases  of  Bur.sffi — continued. 

Compound  Palmar  Ganglion,  502 

Degeneration  of  Muscles : 

Simple  Atri)|iii3',        .         .  .  502 

Progressive  Muscular  Atrophy,  502 

Fatty  and  other  Di'geiieralioiis,  503 

Infantile  I'aralysis,  .  .  .  .■)03 

Hypertrophic     Paralysis     (of     Du- 

chenne),        .....  504 

Tumors  in  Muscles,  .  .  504 


CONTENTS. 


XV 


CHAPTER  XXVI. 

CLUBFOOT    AND    OTHER    DEFORMITIES ORTHOP^TEDIC    SURGERY. 


Pathology  of  Congenital    Deformi- 
ties,       .         .       "  .         .         .         .505 
Tenotomy,        .....     505 
Talipes  Equinus,       ....     507 

Division  of  the  Tendo  Achillis,  508 
Talipes  Varus,  .         .         .         .509 

Division  of  the  Tibial  Tendons,  510 
Talipes  Valgus  and  Equino-valgus,  51"2 
Talipes  Calcaneus,    .         .  .  .512 

Flatfoot,  or  Spurious  Valgus,  .         .     512 


PAGE 

Talipes  Cavus,           ....  513 
Relapsed  Clubfoot,  .          .          .         .513 
Irregular  Deformities  :   Clubhand,  514 
Contraction  of  Palmar  Fascia,         .  514 
Knockknee,      .....  514 
Wryneck,          .....  515 
Division  of  the  Sternomastoid 
Muscle,            ....  515 
Emotional  and  Hysterical  Contrac- 
tion,     ......  616 


Wounds  of  Nerves, 
Neuralgia, 


CHAPTER  XXVII. 

AFFECTIONS    OF    NERVES. 

517  I  Neurotomy, 
.     518  I  Neuroma, 


519 
520 


CHAPTER  XXVIII. 


DISEASES    OP    THE    ARTERIES. 


Atheroma  and  Calcification, 

521 

Occlusion  and  Embolism, 

522 

Arteritis, 

523 

Aneurism, 

523 

Causes  of  Aneurism, 

524 

Classification,    . 

526 

Dissecting  Aneurism, 

527 

Cirsoid  Aneurism, 

527 

Arteriovenous  Aneurism, 

527 

Treatment    of    Arteriove- 

nous Aneurism, 

528 

Symptoms   of    Arterial 

Aneu- 

rism, 

529 

Diagnosis, 

529 

Relations  between  the  S 

ac  and 

Artery,  . 

530 

Progress  of  Aneurism, 

531 

Symptoms  of  Rupture, 

531 

Spontaneous  Cure,     . 

581 

Teatment : 

Medical  or  Internal, 

531 

The  Old  Operation,  . 

532 

Hunter's  Operation, 

532 

Failures  of  Ligature, 

534 

Distal  Ligature, 

535 

Compression, 

535 

"  Rapid"  Pressure, 

637 

Genuflexion, 

537 

Manipulation,   . 

538 

Coagulating  Injections, 

538 

Galvano-puncture,     . 

538 

Introduction  of  Foreign  Bodies, 

538 

The  Chief  Forms  of  Aneuris 

m  and 

Operations  on  the  Various 

Arte- 

ries: 

Thoracic  Aneurism,  . 

539 

Innominate  Aneurism, 

539 

Carotid  Aneurism,  ....     540 
Brasdor    and    Wardrop's    Ope- 
rations, ....     540 
Ligature  of  the  Common  Caro- 
tid Artery,     .         .         .         .641 
Ligature  of  the  External  Caro- 

•  tid, 543 

Ligature   of  the    Lingual    and 
Thyroid  Arteries,  .         .  .     543 

Orbital  Aneurism,    ....     544 

Subclavian  Aneurism,      .         .         .     545 
Ligature  of  the  Innominate  or 
First  Part  of  Right  Subcla- 
vian.      .....     546 

Axillary  Aneurism,          .         .          .     546 
Ligature  of  the  Subclavian  Ar- 
tery,        547 

Aneurism  below  the  Axilla,     .         .     548 
Ligature    of  the  Axillary  Ar- 
tery,         548 

Ligature    of  the  Brachial   Ar- 
tery,        549 

Ligature  of  the  Ulnar  Artery,     649 
Ligature  of  the  Radial  Artery,     550 
Abdominal  Aneurism,     .         .  550 

Ligature    of     the     Abdominal 
Aorta  and  of  the  Iliac    Ar- 
teries,    .....     561 
Gluteal  Aneurism,  ....     553 
Femoral  Aneurism,  .         .         .     664 

Ligature  of  the  Common  Femo- 
ral Artery,     ....     566 
Ligature  of  the  Superficial  Fe- 
moral Artery,         .         .         .     656 
Popliteal  Aneurism,  .         .         .     656 

Aneurism  below    the  Ham  :    Liga- 
ture of  the  Tibial  Arteries,  .         .     668 


XVI 


CONTENTS. 


CHAPTER  XXIX. 


DISEASES    OP    THE    VEINS    AND    ABSORBENTS. 


Phlebitis  and  Tlironibosis, 

Various  Kinds  of  Phlebitis, 
Treatment  of  Phlebitis,     . 
Varicose  Veins,        .... 
Treatment :   Operations  for  Va- 
ricose Veins, 
Phlebolithes  and  other  Affections  of 
Veins, 


PAGE 

560 
562 
563 
563 

564 

565 


Lymphatic  Fistula, 

Inflammation  of  the  Absorbent  Ves- 
sels and  Glands,    .... 

Affections  of  Absorbents  and  Glands 
in  Various  Diseases, 

Lymphadenoma,      .         .         .         . 


PAGE 

566 


566 


567 
568 


CHAPTER  XXX. 

SURGICAL   DISEASES    OF    THE    HEAD    AND    PACE. 


Congenital  Malformations. 

Harelip,    . 
Incomplete  Harelip, 
Double  Harelip, 
Complicated  Harelip, 
Fissured  Palate, 

Staphyloraphy, 
Meningocele  and  Encephalocele, 
Tumors  of  the  Cranium,    . 

Disease  of  the  Lips  and  Mout 

Herpes  of  the  Lip,  . 

Fissures  of  the  Lip, 

Strumous  Lip, 

Najvus  of  the  Lip,    . 

Cancer  of  the  Lip,  . 

Chancre  of  the  Lip, 

Kanula,    . 

Salivary  Calculus,    . 

Acute  Tonsillitis  or  Quinsy,     . 

Chronic  Enlargeraentof  the  Tonsils, 

Relaxed  Uvula,         .... 

Alveolar  Ab.scess,     .... 

Necrosis  of  the  Jaws, 

Phosphorus  Necrosis, 
Exanthematous  .Jaw  Necrosis, 

Tooth  Tumors,  .... 

Tumors  of  the  Jaw. 

Cysts, 

Cysts  of  the  Antrum, 
Dropsy  and  Abscess  of  the  Antrum, 
Operations    for  Cystic  Tumors 
of  the  Jaw,     .... 


569 
572 
572 
573 
574 
576 
579 
580 

H. 

581 
581 
582 
582 
582 
582 
583 
583 
583 
584 
585 
686 
586 
586 
587 
587 


588 
588 


389 


Epulis,      ...... 

Fibrous  Tumor  of  the  .Jaw, 
Enchondroma  of  the  .Jaw, 
Exostosis  of  the  Jaw, 
Cancer  of  the  Jaw,  .... 

Tumors  of  the  Antrum,    . 

Total    removal    of    the    Upper 
Jaw,       ..... 

Partial  removal  of  the   Upper 
Jaw,       ..... 

Osteoplastic  Operation  on  Upper 
Jaw,        ..... 

Operations  on  Lower  Jaw, 
Closure  of  the  Jaws, 

Diseases  of  the  Nose. 

Acne  Rosacea, 

Lipoma  Nasi,  .... 

Lupous,  Rodent,   and  Epithelioma 

tons  Ulceration,    . 
Malformations, 

Rhinolithes,      .... 
Epistaxis,  .... 

Plugging  thi-  Nostril, 
Chronic  Thickening  of  tiie  Schnei 

derian  Membrane, 
Ozasna,      ..... 

Tluidichum's  Nasal  Douche, 
Tumors  and  Abscess  of  the  Septum 
Nasal  Polypus,         ... 
Fibrous  and  Nasopharyngeal   Poly 

P"s, 

Malignant  Polypus, 


590 
590 
591 
591 
591 
591 

592 

502 

593 
593 
593 


594 
594 

595 
595 
595 
596 
596 

597 
598 
598 
.599 
599 

GO! 
603 


CHAPTER  XXXI. 


SURGICAL 

DISEASES 

OP 

Diseases  of  the  Tongue. 

Tongue-tic, 

603 

Ulceration     an 

d     Cancer 

of 

the 

Tongue, 

604 

Treatment 

of    Cancer 

of 

the 

Tongue, 

605 

THE   DIGESTIVE   TRACT. 

j  Ulceration  and  Cancer  of  Tongue — 
continued. 

Partial  Remuvai  of  tlin  Tongue, 

Total    licmoval  of  the  Tongue, 

Syphilitic  Affection  of  the  Tongue, 


605 
60i) 
60H 


CONTENTS. 


XVll 


Glossitis,  ..... 
Abscess  of  the  Tongue, 
Macroglossifi,   .... 
Congenital  Tumor  of  the  Tongue, 
Naevus  of  the  Tongue, 
Ichthyosis  of  the  Tongue, 


PAGE 

608 
609 
609 
609 
609 
609 


Diseases  of  the  Pharynx  and 
(Esophagus. 

Pharyngitis, 577 

Tumors  of  the  Pharynx,  .  .     577 

Malformation  of  the  Pharynx,         .     577 


Strictures  of  the  Oesophagus, 
Nervous  'Dysphagia, 


PAGE 
610 

611 


Affections  op  the  Intestinal  Tube. 


Internal  Strangulation,    . 
Impaction  of  Faeces, 

Treatment  of  Obstruction 

Colotomy, 

Gastrotomy,   . 

Littre's  Operation, 
Intussusception, 
Umbilical  Fistula,    . 
Paracentesis  Abdominis,  . 


612 
613 
613 
614 
614 
614 
614 
616 
616 


CHAPTER  XXXII. 


HERNIA. 


Congenital  and  Acquired  Hernia 
General   Symptoms  of  Hernia, 
Irreducible  Hernia, 
Strangulated  Hernia,. 
Inflamed  Hernia,     ... 
Gangrene,         .... 
Ulceration    and  Perforation  of  thi 
Bowel,    .... 
Treatment:  Reduction  by  Taxis 
Dangers  of  Forcible  Taxis, 
Question     of     Repetition     o: 
Taxis, 
Treatment  of  Irreducible  Her 

nia,         .... 
Accidents  in  Taxis — Rupture  of 
Bowel, 
Reduction  en  masse, 
Trusses,     .... 
Radical  Cure  of  Hernia,    . 
Herniotomy, 

Extra  and  Intra-peritoneal 

Operation,  . 
Seat  of  Stricture,    . 
Inspection   of  Contents  of  Sac 

Omental  Sacs, 
Treatment      of       Strangulated 
Bowel,    .... 
Ulceration  in  the  Course  of 
the  Stricture,  . 
Treatment      of      Strangulated 
Omentum, 


618 
618 
618 
618 
619 
619 

619 
619 
621 

621 

622 

622 
622 
623 
629 
630 

631 
632 
633 
633 

634 

635 

635 


Herniotomy — continued. 

Operations  in  Cases  of  Reduc- 
tion en  tnasse, 
After-treatment     in     Herniol- 


636 


omy,        .... 

636 

SequeliB  of  Strangulation, 

636 

Peritonitis  after  Operation, 

637 

Fiscal     Fistula    and    Artificial 

Anus  after  Operation,    . 

638 

Various  Forms  of  Hernia. 

Inguinal  Hernia, 

640 

Oblique,     .... 

640 

With  Retained  Testis,  . 

641 

Various    Forms    of    Obi 

ique 

Hernia,    . 

642 

Bubonocele, 

642 

Operations  for  Oblique  Her- 

nia,    .... 

645 

Direct,        .... 

646 

Inguinal  Hernia  in  the  Feir 

ale. 

646 

Femoral  Hernia, 

647 

Irregular   Distribution  of  Ves- 

sels in  Femoral  Hernia, 

647 

Umbilical  Hernia,   . 

650 

Obturator  Hernia,    . 

651 

Ventral  Hernia, 

652 

Phrenic  Hernia, 

652 

Vaginal  Hernia, 

653 

Perineal,   Pudendal,    Ischiatic 

and 

Lumbar  Hernia,    . 

653 

CHAPTER  XXXIII. 


DISEASES    OF    THE    RECTUM. 


External   Piles, 

654 

Internal  Piles  or  Hemorrhoids, 

654 

Operations  for  Piles, 

655 

Prolapsus  Ani, 

657 

Fistula  in  Ano, 

657 

Ischio-rectal  Abscess, 

658 

Ulcer  or  Fissure  of  the  Anus,  . 

660 

Pruritus  Ani,  .... 

661 

Polypus  of  the  Rectum,  . 

66] 

Villous  Tumor, 

661 

Mucous  Tubercles  and  Condylomata,  662 
Stricture  of  the  Rectum,         .         .  662 
Colotomy  in  Disease  of  the  Rec- 
tum,          665 

Malformations  :  Imperforate  Anus,  665 
Imperforate  Anus,  with  Facal 

Fistula, 666 

Imperforate    Anus,   with   Defi- 
ciency of  the  Bowel,       .         .  667 
Imperforate  Rectum,         .         .  668 


xvin 


CONTENTS. 


CHAPTER  XXXIV. 


DISEASES    OP    THE    LARYNX. 


PAGE 

Laryngoscopy,          ....  669 

Rliinoscopy,       .         .         .         .671 

Laryngitis,  Acute,    ....  672 

Croup  or  Cynanche  Trachealis,  673 

Laryngismus  Stridulus,     .          .  674 

Chronic  Laryngitis,       .         .  G74 

Syjihilitic  Disease,       .         .  675 

Follicular  Laryngitis  ;    Dys- 

phonia  Clericorum,     .          .  675 


Tumors  of  the  Lar3^nx,    . 

Removal  from  the  Mouth, 

Thyrotomj'-, 

Extirpation  of  the  Larynx, 
Nervous  and  Hysterical  A})honia, 
Aphonia  from  Paralysis, 
Spasm  of  the  Glottis, 
Tracheotomy,  .... 


CHAPTER   XXXV. 

DISEASES    AND    INJURIES    OF    THE    EYE    (bY    MR.    CARTER) 
.     683 


General  Considerations,  . 
Diseases  of  the  Lids  : 
Tarsal  Tumors, 
Blepharitis, 

Styes,  .... 

Malposition  of  Eyelashes, 
Redundancy  of  Eyelashes, 
Incurvation  of  Cartilage, 
Ectropium, 

Wounds  of  the  Eyelids,  . 
Ptosis,        .  .        _. 

Diseases  of  the  Conjunctiva  : 

Simple  or  Catarrhal    Conjunc- 
tivitis,    .         .  .  .         . 
Infantile  Purulent  Ophthalmia, 

Implication  of  the  Cornea, 
Gonorrhceal  Ophthalmia, 
Ejiidcmic  Ophthalmia, 

Follicular  or   "  Sago-grain,' 

Granulations, 
Papilhiry  Granulations, 
Diphtlicntic  Conjunctivitis, 
Phlyctenular  Conjunctivitis, 
Conjunctival  Growths :    Ptery 

gium,      . 
Episcleritis, 
Diseases  of  the  Cornea  : 
Pannus, 

Corneal  Phlyctenular, 
Recurrent  Vascular  Ulcer 
Photophobia, 
Iridectomy,    . 
Keratitis,   . 
Vascular, 
Interstitial,    . 
Suppurative,  . 
Acute  Ulcer, . 
Cicatrices, 

Complete  Staphyloma, 
Partial  Stiiyphyloma, 
Ccmical  Cornea, 
Diseases  of  ih*;  Iris  : 

Cysts,  or  Morbid  Growths 
Coloboma, 
Iritis,  Plastic,    . 
Complications, 
Iridectomy, 


684 
685 
686 
686 
686 
686 
687 
687 
687 


689 
690 
690 
690 
693 

693 
695 
696 
69  J 

697 
697 

698 
699 
699 
699 
701 
701 
701 
704 
705 
707 
708 
709 
710 
710 

711 
711 
711 
711 
715 


Diseases  of  the  Iris — conibiued. 
Serous  Iritis. 
Iridochoroiditis,     . 
Diseases  of  the  Ijcns  : 

Cataract,    .... 
Congenital,     . 

Removal  by  Solution, 
Laminar, 

Removal  by  Suction,  . 
Senile,  .... 

Removal  by  Extraction 
Cataract-glasses,    . 
Diseases  Posterior  to  the  Lens — The 
Ophthalmoscope, 
Glauc(mia, 
Iridectomy,    . 
Diseases  of  the  Choroid, 
Diseases  of  the  Vitreous  Body, 


Morbid 
Eye, 


Growths    within     the 


Injuries  of  the  Eye  : 

Foreign   Bodies, 

Wounds  and  Contusions.     Sym- 
pathetic (.»phthalmia,     . 

Operation  of  Enucleation, 

Contusions  of  the  Eve, 

With  Rupture  of'the  Glob 

Wounds  oi'  the  Cornea,     . 
Wounds  of   the  Iris  and  Lens, 

Injuries    from    Corrosive   Sub- 
stances, .... 
Affections  of  the  External  Muscles 

Doui)le  Vision,  . 

Squint,       .         .         • 
Secondary    Squint, 
Operation  for  Scpiint,     . 
]'aral.>  li<;  Strahi^riius,    . 
Divergent  Stral)ismu<,   . 

Paralysis  of  Ocular  Muscles, 
Disea.ses  of  the  Lachrynuil  Apparatu 

Obstruction  of  the  Nasal    Duct, 
The  Use  of  Spectacles, 

Presl)yopia, 

Ilypermetropia, 

Myopia,     .... 

Astigmatism,     . 


CONTENTS. 


XIX 


CHAPTER  XXXYL 


DISEASES    OF    THE    EAR. 


Affections  of  the  External  Ear  : 

Malformations  of  the  Auricle,  .     756 
Htematoma  Auris,     .         .         .     756 
Keloid  and  other  Tumors  of 

the  Auricle,        .         .         .     756 
Eruptions,      .         .         .  .     756 

Periostitis  and  Caries  of  the  Ex- 
ternal Meatus,    .         .         .     757 
Examination  of  the  External 

Meatus,       ....     757 
Accumulation  of  Wax,  .     757 

Otorrhcea,  ....  757 
Syphilitic  Affections,  .  .  758 
Tumors  of  the  Meatus,  .  .  758 
Exostosis,  ....  758 
Affections  of  the  Middle  Ear: 

Examination  of  the  Membrana 

Tympani,        ....     758 
Perforation  of   the   Membrana 
Tympani,        ....     758 


Affections  of  the  Middle  Ear — con- 
tini'.ed. 
Artificial  Membrana  Tympani,     759 
Examination  of  the  Eustachian 

Tube  (Politzor'smeth<.d),      .      760 
Acute  Inflammation  of  the  Tym- 
panum, .....     761 
Moist  and  Dry  Catarrh,    .         .     762 
Accumulation  of  Mucus  in  the 

Tympanum,        .         .  .     762 

Incision    of    the    Membrana 
Tympani,    .         .         .  .76^ 

Disease  of  the   Tympanum   in 

Scarlet  Fever,         .         .  .762 

Disease  of  the  Mastoid  Cells,     .     763 

Polypi 763 

Affections  of  the  Internal  Ear,         .     764 

Diseases  implicating  the  Brain,     764 

Meniere's    Disease,         .         .     765 


CHAPTER  XXXVII. 


DISEASES    OF    THE    URINARY    ORGANS. 


Surgical   Affections  of  the 

Ki:  NEY. 

Acute  Nephritis,       ....  766 
Affections  simulating  Nephrit- 
is : 

Calculous  Nephralgia,  .         .  766 

Calculous  Pyelitis,         .          .  706 
Pvheumatism,  Spinal  Abscess, 

Cystitis,  etc.,       .         .          .  766 

Nephrotomy,     ....  767 

Chronic  Nephritis,  ....  767 

Hffiniaturia  :  its  Various  Sources,     .  767 

Diseases  of  the  Bladder. 

Malformations,         ....  768 

Extroversion 768 

Inversion  of  the  Female  Bladder,  .  770 

Hernia  of  the  Bladder,    .         .         .  770 

Tumors:  Villous,     ....  770 

Cancer,  .         .         .         .771 

Cystitis, 778 

Vesico-intestinal  Fistula,          .          .  776 

Diseases  of  the  Prostate. 

Acute  Pro>tatitis,     ....  776 

Abscess  of  the  Prostate,    .         .  776 

Chronic  Prostatitis,  .         .         .777 

Enlarged  Prostate,  ....  779 

Prostatic  Hauiorrhage,     .         .  778 

Puncture  of  the  Bladder  above 

the  Puiies,       .  .  .  .780 

Cancer  of  the  Prostate,     .         .         .  781 


Diseases  of  the  Urethra. 

Malformations :     Hypospadias    and 

■   Epispadias, 781 

Stricture : 

Causes  of  Stricture,  .         .          .  782 
Seat  of  Stricture,        .          .         .  784 
Forms  of  Stricture,   .         .          .  784 
Symptoms  and  Sequela^  of  Stric- 
ture,         784 

Com])lications : 

Fistula  in  Perinajo,         .         .  785 

Urinary  Abscess,  .         .  .  785 

Extravasaticm  of  Urine,         .  785 

Rupture  of  the  Bladder,         .  786 

Treatment : 

Catheterization,      .  .         .     787 

Gradual    and    iiapid    Dilata- 
tion,        .         .         .         .788 
Method    of  Tying    in     the 
Catheter,  /       .         .790 

Treatment  of  Impassable  Stric- 
ture : 
Puncture  from  the  Rectum,  .     791 
Puncture  with  the  Aspirator,     792 
Perineal  Section,    .         .  .792 

Treatment  of  Abscess  in  Peri- 

uieo, 793 

Treatment  of  Fistula  in  Peri- 

nseo,    .....     794 
Ante-scrotal  Fistula,     .         .     794 


XX 


CONTENTS. 


Strictures — continued. 

Treatment  of  Non-dilatable  or 
Recurring  Stricture : 
Syme's  Operation,  or  Exter- 
nal Uretlirotomy, 
Rupture,  or  Forcible  Dilata- 
tion,   ..... 
Internal  Urethrotomy, 


795 

796 
797 


"  Spasmodic  Stricture,"  . 
Various  causes  of  Retention  of  Urine, 
Stricture  of  the  Female  Urethra,     . 
Retention    distinguished    fi-om    Pa- 

ral^'sis  and  Atony, 
Incontinence  of  Urine,    . 
Juvenile  Enuresis,     . 


PAGE 

798 
799 
799 

799 
799 
800 


CHAPTER  XXXVIII. 


CALCULUS. 


Urinary  Deposits,    . 

801 

Kinds  of  Calculi : 

Litbate  of  Ammonia, 

804 

Lithic  Acid, 

804 

Oxalate  of  Lime, 

804 

Xantbic  and  Cystic  Oxide, 

804 

Pbosphate  of  Lime,  . 

804 

Triple  Phosphate, 

805 

Fusible  Calculus, 

805 

Alternating  Calculi, 

805 

Carbonate  of  Lime,  . 

805 

Pseudo  Calculi, 

805 

Chemical  Tests  for  Calculi, 

806 

Calculus  in  the  Bladder  :  Symptoms 

806 

Sounding  for  Stone,  . 

807 

The  Endoscope, 

808 

Termination  of  Stone, 

808 

Operations  for  Stone  :  Compari- 

son of  Lithotomy  and  Lilbot- 

rity, 

809 

Lateral  Lithotomy,  . 

809 

Lateral  Lithotomy — contimied. 

Accidents  and  Complication.s, 
After-treatment,    . 
Dangers  of  the  Operation, 
Rectovesical     and     Recto 
urethral  Fistula, 
Median  Lithotomy,  . 
Other  Methods  of  Perineal  Lith 

otomy,  .... 
Rectal  Lithotomy,     . 
The  Hypogastric  or  High  Opera 

tion,        .... 
Perineal  Lithotrity,  . 
Lithotomy  in  the  Female, 
Lithotrit}', 

Complications, 
Removal  of  Foreign  Bodies  from  the 

Bladder,         .... 
Prostatic  Calculus,  . 

Vesicoprostatic  Calculus,  . 
Stone  in  the  Urethra, 


812 
813 
814 

814 
814 

815 

815 

816 
816 

81fi 
817 
821 

823 
824 
824 
824 


CHAPTER  XXXIX. 


DISEASES   OF   THE   MALE   ORGANS   OF   GENERATION. 


Affections  of  the  Testicle 
AND  ITS  Appendages. 

Congenital  Malformations:  Retain- 
ed Testicle, 825 

Hydrocele  : 

Common  or  Vaginal,         .         .  826 

Congenital,        ....  829 

Infantile, 829 

Hydrocele  of  the  Cord,      .         .  830 
Encysted  Hydrocele  of  the;  Tes- 
ticle,         830 

Loose  Bodies  i  n  the  Tu  n  ica  Vag- 
inalis,     .....  831 
Hematocele,    .....  831 
Acute    Orchitis— Gonorrhccal    Epi- 
didymitis,     .....  832 
Chronic  and  Syphilitic  Orcliitis,      .  834 
Strumous  Orchitis,    .          .         .  835 
Hernia  Testi.-,   ....  835 
Cystic  Disease  of  the  Testis,     .         .  835 


Enchondroma  of  the  Testis, 
Innocent  Tumors  in  the  Scrotum, 
Cancer  of  the  Testis, 

Castration, 
Dermal  and  other  Frctal  Tumors, 
Functional    Disorders  :    Spermator 

rhcva,     ..... 
Affections  of  liie  Cord  :   Varieocele 
Tumors  in  the  Spermatic  Canal, 

Affections  of  the  Sckotum 
G5dema  and  Inflammation, 
Elephantiasis,  ..... 
Chimney-sweep's  Canci-r, 

A  FF  EC  T  IONS    O  F    'r  1 1  E    V  K  N  I S . 

Cancer  of  the  Penis, 

Amputation  of  the  Peni.s, 
Circumcision,  ..... 
Persistent   Priajiism — Gangrene    of 
the  Penis,      ..... 


830 
836 
8J7 
837 
838 

838 
839 
841 


841 
811 
8-12 


842 
843 
848 

814 


CONTENTS. 


CHAPTER  XL. 


SURGICAL   DISEASES    OF    THE    FEMALE    ORGANS    OF   GENERATION, 


Malformations  : 

Adhesion  of  the  Labia,      .          .  844 
Imperforate  Hymen,         .          .  844 
Imperforate  Vagina,          .          .  845 
Vascular  Tumors  of  the  Urethra,    .  845 
Tumors  of  the  Vulva,       .          .         .846 
Hypertrophy  of  the  Labia  and  Clit- 
oris,         846 

Cancer  of  the  External  Parts,  .  846 

Accidents  in  Parturition  :   Ruptured 

Perineum,  .         .  .  847 

Prolapsus  Uteri,    .         .         .  848 

Vaginal  Cystocele,         .         .  849 

Vesieo-vaginal  Fistula,     .         .  849 


Accidents  in  Parturition — continued. 

Recto-vaginal  Fistula,       .         .  850 

Surgical    Operations     for     Uterine 

Polypi, 850 

Hysterotomy,  .....  851 

Exci.sion  of  "the  Os  Uteri,  .         .  852 

Ovarian  Tumors  : 

Cysts  of  the  Broad  Ligament,  85"2 

Suppuration  in  Ovarian  C^'sts,  853 

Termination  of  Ovarian  Dropsy,  854 

Diagnosis,  ....  854 

Treatment;  Paracentesis,  .  855 

Ovariotomy,      .         .         ,  855 


CHAPTER  XLI. 


DISEASES    OF    THE    BREAST. 


Hypertrophy, 

858 

Atrophy, 

859 

Inflammation,           ,          .          .         , 

859 

Chronic  Abscess, 

859 

Lacteal  Abscess, 

859 

Lobular  Induration  ;  Neuralgia  and 

Hysterical  Pain,  ,         .          .         , 

861 

Functional  Disorders, 

861 

Tumors  of  the  Breast :   Adenoma,    . 

861 

Serocystic  Tumor,     . 

862 

Simple  Cysts,    .         ,         ,          . 

863 

Milk  Cysts,        .         .         ,         , 

864 

Tumors  of  the  Breast — continued. 
Rarer  Forms  of  Innocent  Tu- 
mors,     .         ,         .         ,         .     864 

Cancer, 864 

Amputation  of  the  Mamma,       866 
Diseases  of  the  Mammilla  :   Malfor- 
mations,        ....     867 

Cancer, 867 

Eruptions,  followed  by  Scirrhus 
of  the  Breast,  .         .         .867 

Diseases  of  the  Male  Breast,    .         .     867 


CHAPTER  XLII. 

DISEASES    OF    THE    THYROID    BODY. 


Endemic  Goitre,       ....     868 

Sporadic  or  Common  Bronchoeele,      868 

Removal  of  Bronchoeele,  .         .     869 


Exophthalmic  Goitre,      .         .         .869 
Cancer  of  the  Thyroid  Body,  .         .     869 


CHAPTER  XLIII. 


DISEASES    OF    THE    SKIN    AND   ITS   APPENDAGES. 


SiviN  Diseases. 
Exanthemata:   Roseola.  . 

Urticaria, 
Hiemorrhagia :  Purpura, 

Scorbutus, 
Vesiculse  :  Sudamina  and  Miliaria 

Eczema,    .... 

Herpes,      .... 
Parasitae  :  Tinea  Tonsurans,    . 

Tinea  Decalvans :   Alopecia, 

Tinea  Favosa  or  Favus,    . 


Parasitae — continued. 

.     870 

Tinea  S_ycosis  or  Mentagra, 

.     871 

Chloasma  or    Pityriasis  Versi 

.     871 

color,      .... 

.     871 

Scabies,      .... 

872 

Bullae  :   Pemphigus, 

.     872 

Rupia,        .         .         ... 

.     873 

Pustulas:  Impetigo, 

.     874 

Eczema  Impetiginodes, 

.     875 

Porrigo, 

.     875 

876 

876 
877 
878 
878 
878 
879 
879 


CONTENTS. 


PAGE 

PustuliC — eonlbiued. 

EctliyiUii,  . 

879 

rapiiUe  :  Strophulus, 

880 

Lichen, 

880 

Prurigo,     . 

881 

Squam:¥:   Pityriasis, 

882 

Psoriasis  and  Lepra, 

882 

TuberculaliiB :   Acne, 

882 

Syphilitic  Tubercle, 

883 

JMoliuscum, 

888 

Lupus, 

883 

Elephantiasis:  Leprosy 

e'. 

Grie 

- 

corum. 

884 

Barbadoes  leg,  E    A 

■ah 

um, 

885 

Keloid,      . 

885 

Framboesia, 

886 

Maculae, 

88P, 

Ichthyosis, 

886 

Diseases  of  the  Api'kndages  of 

THE  Skin:   Plica  Polonica 
Corns, 
Warts, 

Venereal  Warts  and  Condy 
loniata. 

Verruca  Necrogenica, 
Horns, 
'      Boils, 

Carbuncle, 

Facial  Carbuncle,  . 
Malignant  Pustule,  . 
Chilblains, 
Onychia,    . 
Syphilitic  Disease  of  the  Nails, 
Psoriasis  of  the  Nails, 
Ingrowing  Toenail,  . 

Avulsion  of  the  Nail, 


PAGE 

886 
88G 
887 

887 
888 
888 
888 
889 
890 
891 
891 
892 
892 
892 
892 
893 


CHAPTER  XLIV. 


MINOR  AND  OPERATIVE  SURGERY. 


Minor  Surgery. 

Bandaging: 

Spiral  Bandages,       .         .         .  894 

Figure  of  8,  or  Spica  Bandage,        .  895 

Four-tailed  Bandage,         .         .  895 

Scalp  or  Capelline  Bandage,     .  896 

T-bandage 896 

Suspensory  Bandage,         .         .  896 

Many-tailed  Bandage,       .          .  896 

Splints,  and  immovable  Apparatus,  897 

Plaster  of  Paris  Splint,     .         .  898 

Sutures, 898 

Clove-hitch,      .         .         .         .900 

Counter-irritants : 

Blisters, 900 

Issues, 900 

Moxa, 901 

Setons, 901 

Actual  Cautery,         ...         .  901 

Galvanic  Cautery,     .         .         .  901 

Potential  Cauteries,  .          .          .  901 

Cauterization  en  fl{;ches,           .         .  902 

Bloodletting : 

Venesection,      ....  902 

Cupping, 903 

Vaccination,    .....  903 

Anaesthetics. 

Local  Anaesthesia,   ....  905 

Ether  and  Chloroform,    .          .         .  906 

Bichloride  of  Methvlene,          .         .  908 

Nitrous  Oxide,        \         .         .         .  908 

Means  of  Re.strainino  Haemorrhage. 

The  Common  Tourniquet,        .          .  909 

Tlie  Horseshoe  Tourniquet,      .         .  909 
Digital  Pressure,      .          .         .         .909 

Esrnarch's  Bandage,         .          .          .  909 

Plastic  Surcikry. 

Principles  of  Plastic  Oj/crations,     .  910 

Rhinoplasty, 911 


Operations  for  Contracted  Cicatrix, 

912 

Cheiloplasty,    .... 

913 

Operations  for  Webbed  Fingers, 

913 

Amputations. 

General    Observations,  Circular  anc 

Flap  Amputations, 

915 

Instruments  for  Amputations, 

915 

Special  Amputations  : 

At  the  Shoulder-joint, 

916 

Of  the  Arm,      .  '       . 

917 

Through  the  Elbow, 

918 

Of  the  Forearm, 

918 

At  the  Wrist,    . 

919 

Of  the  Fingers, 

9 1 9 

Of  the  Thumb, 

920 

At  the  Hip-joint, 

921 

Of  the  Thigh,  . 

923 

At  the  Knee,     . 

923 

Of  the  Leg,       . 

924 

Teale's  Amputation, 

924 

At  the  Ankle,  Syme's, 

955 

Pirogofl'  -,       . 

927 

Subastragaloid  Amputation, 

927 

Hancock's  Amjiutation,    . 

927 

Chopart's  Amputation, 

927 

Lisfranc'sor  Hey's  Amputation 

,    928 

Amputation  of  the  Toes,  . 

928 

Ex(;isions  ok  Bones  and  Joints. 

General  Observations, 

929 

Excision  of  the  Shoulder, 

930 

Scapula,     .... 

931 

Clavicle,    .... 

!I31 

Elbow,       .... 

932 

Wrist,       .... 

935 

Hip,           .... 

937 

Kricf^         .... 

938 

Ankle,        .... 

943 

Os  Caleis, 

944 

Astragalus, 

945 

Metatarsal  Bonos, 

946 

LIST    OF    ILLUSTRATIONS. 


FIG. 
1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19 
'20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 

38. 
39. 
40. 
41. 
42. 
43. 
44. 


iture 


Cohnheim's  Experiment,  sliowin<^  the  Emigration  of  Leucocytes, 

Pi's-corpiiscles — (after  Riiidfleiscli), 

Diagram  of  granulation — (after  Riridfleisch), 

Thcrmograpli  of  Traumatic  Fever, 

Syme's  Abscess-knife,     ..... 

Paget's  or  Pollock's  ditto,       .... 

Thermograph  of  Pypemia,       .... 

Diagram  of  Thrombus  in  a  Vein — (after  Billroth 
Thermograph  of  Hectic  Fever, 
Thermograph  of  Erysipelas,  .... 

Obstruction  of  Artery  from  Embolus,    . 
Thermograph  of  Tetanus,        .... 

Laceration  of  the  Inner  Coats  of  an  Artery, 
Diagram  of  complete  Division  of  an  Artery, 
Aneurism-needle,  ...... 

Effects  of  Ligature  on  an  Artery,  . 
Obliteration  of  a  very  small  part  of  the  Artery  by  Lig 
Effects  of  Carbolized  Catgut  Ligature  on  Arteries, 
Liston's  Tenaculum,        ..... 

Assalini's  Tenaculum,     ..... 

Acupressure — Circumclusion — (after  Pirrie), 
Acupressure — Torsoclusion — (after  Pirrie), 
Acupressure — Retroclusion — (after  Pirrie), 
Torsion  of  Artery,  ..... 

Torsion-forceps,      ...... 

Method  of  performing  Direct  Transfusion,    . 

Ulceration  of  the  Duodenum  in  Burn — (from  Syst.  of  Sur 

"  Greenstick  "  Fracture  of  the  Clavicle — (from  Syst.  of  Surg.), 

Separation  of  Epiphyses  in  Lower  Limb, 

Union  of  Fracture  with  ends  overlapping,     . 

Union  of  Fracture  by  Periosteal  Bridge — (from  Syst.  of  Surg.), 

Union  of  Fracture  by  Provisional  Callus — (from  Syst.  of  Surg.), 

The  same  at  an  earlier  stage,  ...... 

Ununited  Fracture — soft  union,     ...... 

Ununited  Fracture — false  joint,     ...... 

Ununited  Fracture — complete  non-union,      .... 

Extravasation  of  Blood  beneath  the  Cranium — wound  of  middle 
artery,         .......... 

Blood-membrane  in  Arachnoid  Cavity,  .... 

Blood-cyst  in  Arachnoid  Cavity,    ...... 

Blood-cyst  in  Arachnoid  Cavity  from  disease. 

Fracture  passing  vertically  round  the  Skull, 

Union  of  Old  Depressed  Fracture,  ..... 

Fracture  limited  to  the  Base  of  the  Skull,      .... 

Hernia  Cerebri  into  the  Meatus  Auditorius,  .... 


). 


XXIV 


LIST    OF    ILLUSTRATIONS. 


FIG. 

45.  Frju-tm-e  through  the  Internal  Auditory  Meatus, 

46.  United  Fracture  of  the  Anterior  Fossa  of  the  Skull,     . 

47.  United  Fracture  of  the  Posterior  Fossa  of  the  Skull,    . 

48.  United  Fracture  of  the  Posterior  and  Middle  Fossie  of  the  Skull, 
40.  Depression  in  the  Brain  after  Old  Concussion — (from  Syst.  of  Sur 

50.  Thermograph  of  Concussion,  ..... 

51.  Result  of  Trephining  for  Depressed  Fracture  of  Skull,  . 

52.  Compound  Fracture  of  the  Skull,  with  depression, 

53.  Thermograph  of  Traumatic  Encephalitis, 

54.  Extravasation  in  the  Sheath  of  the  Optic  Nerve — (from  Sy.^t.  of  Surg 

55.  Hey's  Saw,      ....... 

56.  Elevator,         

57.  Trephine,         ....... 

58.  Trephining — unequal  thickness  of  Skull, 

59.  United  Fracture  of  the  Spine, 
60    Dislocation  of  the  Spine,         .... 

61.  Fracture  of  the  Spine,  showing  the  nature  of  the  displacement, 

62.  Unilateral  Dislocation  of  the  Jaw— (from  U.  W.  Smith), 

63.  Dislocation  of  the  Jaw  —  (from  Malgaigne),  . 

64.  Fracture  of  the  Larynx,  ...... 

65.  Foreign  Body  in  the  Eight  Bronchus,   .... 

66.  View  of  the  Bifurcation  of  the  Trachea — (from  Syst.  of  Surg.), 

67.  The  Horsehair  Probang,         ..... 

68.  The  Aspirator, 

69.  Diagram  of  Repair  of  Wound  of  Bowel, 

70.  United  Fracture  of  False  Pelvis,    .... 

71.  Comminuted  Fracture  of  the  Pelvis, 

72.  Diagram  of  Fractures  of  the  Clavicle,    . 

73.  74.    Bandage  for  Fractured  Clavicle, 
75  Fracture  of  Sternal  End  of  Clavicle, 

76.  Fracture  of  Acromial  End  of  Clavicle, 

77.  Comminuted  Intracapsular  Fracture  of  the  Humerus 

78.  Bony  union  of  Impacted  Intracapsular  Fracture  of  the  Hume 

R.  W.  Smith), 

79.  Fracture  of  the  Surgical  Neck  of  the  Humerus,     . 

80.  Separation  of  the  Upper  Epiphysis  of  the  Humerus, 

81.  Diagrams  of  Dislocation  of  the  Elbow  backwards,  and  Fracture  of 

End  of  the  Humerus,  to  show  their  points  of  contrast, 

82.  Two  figures,  to  show  the  position  of  the  Lower  Epiphysial   L 

Humeru.s — (from  Holmes's  Surg.  Dis.  of  Childhood), 

83.  Fracture  of  the  Olecranon — bony  union, 

84.  Colles's  Fracture— (from  R.  W.  Smith), 

85.  Gordon's  Splint  for  Colles's  Fracture,   . 

86.  Dislocation  of  the  Shoulder — general  appearance, 

87.  Subcoracoid  Dislocation — (after  Flower), 

88.  Intracoracoid  Dislocation — after  Flower), 

89.  Subglenoid  Dislocation — (after  Flower), 

90.  Subclavicular  Dislocation — (after  Flower),    . 

91.  Subspinous  Dislocation — (after  Flower), 

92.  Dislocation  of  the  Elbow  backwards,     . 

93.  Dislocation  of  the  Elbow  backwards,  with  Fracture  of  the  Coronoid  Process, 

94.  Dislocation  of  the  Head  of  the  Radius  backwards 

95.  Dislocation  of  the  Head  of  the  Radius  forwards, 

96.  Dislocation  of  the  Thumb — faft'T  Fabbri),    . 

97.  Reduction  of  this  Dislocation — (after  Fabbri), 


[  from 

the  Lower 
ne  of  the 


LIST    OF    ILLUSTRATIONS.  XXV 

FIG.  PAGE 

98.  Non-impacted  Intnicap?uliir  Fracture  of  Cervix  Femoris,           .         .         .  290 

99.  Impacted  Extracapsular  Fracture  of  Cervix  Femoris,  ....  290 
100.  Comminuted  Non-impacted  Fracture  of  Cervix  Femori.s,  ....  290 
lOL  Gunshot  Fracture  (intracapsular)  of  Cervix  Femoris,  ....  290 
102.  Fracture  of  Neck  of  Thi<j,-h-hone— 2;eneral  aspect — (after  Sir  A.  Cooper),  .  291 
103    Atrophy  of  Neck  of  Femur  in  Old  Age, 293 

104.  Bony  union  of  Impacted  I ntracajisular  Fracture,         .....  293 

105.  Earle's  Hed, 295 

106.  Fracture  of  Upper  Third  of  Femur— (after  Sir  A.  Cooper),         .         .         .293 

107.  Irregular  Consolidation  of  this  Fracture,     .......  2't7 

108    A  different  example  of  Union  in  this  Fracture — (after  Malgaigne),  .         .  297 

109.  Union  of  Fracture  two  inches  below  the  Trochanter  Minor — (after  Mal- 

gaigne),  .......-■••••  298 

110.  Union  of  Displaced  Fracture  in  Middle  of  Femur, 298 

111.  A  Fracture  of  the  Femur  put  up  in  Long  Splint, 299 

112.  Details  of  the  apparatus, 299 

113.  Extension  Apparatus  for  Fractured  Thigh — (after  Gurdon   Buck),     .         .  300 

114.  Leather  Collar  for  Fractured  Thigh  in  childhood,   • 302 

115.  Fractured  Femur  in  Infancy  treated  without  Splints,          ....  303 

116.  117.   Partial  Separation  of  Lower  Epiphysis  of  Femur— (from  Holmes's 

Surg.  Dis.  of  Childhood), 304 

118.  Union  of  Fracture  of  Femur  above  the  Condyles— (after  Malgaigne),         .  305 
119    Fracture  of  Lower  End  of  Femur,  with  injury  to  Knee-joint — (al'ter  Mal- 
gaigne), .         .          ........••■  305 

120.  L^nion  of  Fracture  into  Knee-joint,      .         .         .         .         .         .         .         •  306 

121.  Transverse  Fraclureof  Patella  without  Laceration  of  Ligamentum  Patella;,  306 

122.  Fractureof  both  Patolla3,       . 307 

123.  Malgaigne's  Hooks  for  Fractured  Patella,  .......  308 

124.  Union  of  Fractured  Patella,  with  inflammation, 309 

125.  Y-shaped  Fracture  of  Patella, 310 

126.  Oblique  Fracture  of  Patella,  internal  view, 310 

127.  Salter's  Swing  for  Fracture  of  Leg, 313 

128.  Macintyre's  Si)lint — modified, 313 

129.  Assalini's  Fracture  Box, 314 

130.  Dislocation  of  Hip  on  Dorsum  Uii— general  features— (after  Sir  A.  Cooper).  316 

131.  Reduction  of  this  Dislocation— (after  Sir  A.  Cooper),           ....  317 

132.  Dislocation  into  the  Sciatic  Foramen — (after  Sir  A.  Cooper),     .         .         .  319 
183.   Reduction  of  this  Dislocation— (after  Sir  A.  Cooper),           .         .         .         .320 

134.  Relation  of  Tendon  of  Obturator  Internus  to  Dislocation  into  the  Sciatic 

Notch— (after  Bigelow), 320 

135.  "  Dorsal  Dislocation  "  below  the  Tendon— (after  Bigelow),         .         .         .  320 

136.  Dislocation  into  the  Obturator  Foramen— (after  Sir  A.  Cooper),         .         .  821 

137.  Reduction  of  this  Dislocation — (after  Sir  A.  Cooper),          ....  321 

138.  Reduction  of  this  Dislocation  by  the  Flexion  method— (after  Bigelow),     .  322 
189.   Diagram  showing  the  Mechanism  of  Reduction  by  Flexion — (after  Bigelow),  323 

140.  Dislocation  on  the  Pubes — (after  Sir  A.  Cooper), 323 

141.  Reduction  of  this  Dislocation— (after  Sir  A.  Cooper),           ....  324 

142.  Pott's  Fracture— (after  Pirrie), 328 

143.  The  Skeleton  of  the'foot  in  Pott's  Fracture— (after  Pirrio),         .         .         .  328 

144.  Dislocation  of  the  Foot  Inwards— (after  Pirrie), 329 

145.  Dislocation  of  the  Astragalus,      .......••  330 

146.  Subastragaloid  Dislocation, 332 

147.  Nelaton's  Probe, 336 

148.  Coxeter's  Extractor, 337 

149.  Gunshot  Wound  of  Bone  by  Conoidal  Bullet— (from  Syst.  of  Surg.),         .  344 


XXVI 


LIST    OF     ILLUSTRATIONS. 


FIG. 

150  Gviiisliot  Wound  of  Bone  by  Round  Bullet — (from  Syst.  of  Snr 

15L  Bui'>^al  Tumors,     ......... 

152.  Blood-cyst  of  the  Leii, 

153.  Sarcomatous  Tissue  from  the  Walls  of  this  Cyst, 

154.  Lobulatod  Fatty  Tumor, 

155  Encapsulated  Fatty  Tumor, 

156.  Fibroid  Tumiu- of  Iliac  Fossa,      ...... 

157  Fibrocellular  Growths  of  Labium,       ..... 

158.  Aneurism  by  Anastomosis  of  Upper  Lip,     .... 

159.  Subcutaneous  Lis^ature  of  Naevus,  ..... 

160.  "  Fergusson's  Knot"  for  Strangulating  Large  Nsevi,  . 

161.  Ligature  for  Piecemeal  Strangulation  of  Large  Na3vi, 

162.  Round  or  Oval-colled  Sarcoma,     ...... 

163.  Spindle-cellcd  Sarcoma,        ....... 

164.  Giant-celled  Sarcoma,  or  Myeloid  Tumor — (after  Billroth), 

165.  M\-.\oma,  or  Net-celled  Sarccjma,  ..... 

166  Alveolar  Sarcoma — (after  Billroth),     ..... 

167  Microscopical  Appearances  of  Scirrhus — (after  Arnott), 

168.  Cancer  Stroma — (after  Arnott),   ...... 

169.  Medullary  Carcinoma — (after  Arnott),         .... 

170.  Melanosis  springing  from  Urethra,      ..... 
17L  ^[icroscopical  Appearances  of  the  above — (from  Path    Trans.), 
172  Epithelioma — (after  Arnott),        ...... 

173.  Colloid  Cancer — (after  Arnott),  ...... 

174.  Microscopical  Appearances  of  Tubercle — (after  Rindfleisch), 

175.  Microscopical  Appearances  of  the  Secretion  from  the  Local  or  Su 

anil  the  Indurated  Venereal  Sore — (after  H.  Lee), 

176.  Syphilitic  Teeth— (from  Path.  Trans.), 

177.  Skin-grafting  Scissors,  ....... 

178.  Periostitis— (from  Syst.  of  Surg.),         ..... 

179.  The  Entire  Diaphysis  of  the  Tibia  removed  in  a  Case  of  Acute 

—  (from  Holmes's  Surg    Dis.  of  Childhood),  . 

180.  Osteomyelitis  of  the  Femur,  ...... 

181.  Inflammation  of  the  Femoral  Vein  in  Osteomyelitis,  . 

182.  Chronic  Osteomyelitis  following  Amputation  —  (after  Longmorf 

183.  Chr(jnic  Osteomyelitis  of  tiie  Whole  Shjift  of  a  Bone  from  luju 

L(jngmore),     ........ 

184.  Chronic  Absoe.ss  in  Lower  End  of  the  Tibia, 

185.  Chronic  Abscess  making  its  way  into  the  Knee-joint, 

186.  Uns'iccessful  Trephining  for  Chronic  Abscess — (from  Syst 

187.  Caries  of  Humerus,        ...... 

188.  Necrosis  of  the  Tibia  implicating  the  Ankle, 

189.  Extensive  Ulceration  nnd  Necrosis  of  the  Tibia, 

190.  Fracture  from  Necrosis  of  the  FiMnur. 
191  Necrosis  ..f  the  Whole  Shaft  of  the  Tibia,    . 
192.  Deposit  of  Tubercle  in  the  Head  of  the  P^miur,    . 
193  Deposit  of  Tubercle  in  the  Head  of  the  Femur,   . 

194.  Periosteal  Cancer  of  the  Humerus, 

195.  Cancer  of  the  Tibia, 

196.  Epithelioma  of  the  Tibia, 

197.  Multiple  Enchondroniata, 

198.  Enchondrr)ma  of  the  Humerus,    .... 

199.  Ivory  Exostosis  of  the  Lower  .Jaw, 
2U0.  Ivory  P^xostosis  of  the;  Antrum,  .... 
:;01.   Result  of  operation  for  Ivory  Exostosis  of  the  Skul 


of  S 


)pur 


ry— 


urg. 


iting. 


Periostitis 


after 


from  Syst.  of  Surg.), 


LIST    OF     ILLUSTRATIONS. 


XXVll 


the 


Tran 


FIG. 

202.  Os.sifying  Enchonflroma, 

203.  Exostosis  of  the  Phalanx, 

204.  Diffused  Bony  Tumor  of  tlie  Jaw,         .... 

205.  Acute  Inflammation  of  Cartihii^e— (after  Redfcrn),     . 

206.  Section  of  Inflamed  Cartilage— (after  Redfern),  . 

207.  Dislocation  of  the  Hip  from  Disease — (from  Syst.  of  Suri:;.), 

208.  Congenital  Dislocation  of  the  Hip— (from  Syst.  of  Surg), 

209.  Angular  Curvature  of  the  Spine,  .... 

210.  Abscess  from  Caries  of  the  Spine,         .... 
2U.  Compression  of  the  Spinal  Cord  by  Carious  Bone, 

212.  Apparatus  for  Angular  Curvature,       .... 

213.  Caries  of  the  Cervical  Vertebra?  opening  into  the  Pharynx 

214.  Back  view  of  the  same  preparatit)n,     .... 

215.  Disease  of  the  Cervical  VertebriB,  Partial   Destruction  of 

Ligament,  ........ 

216.  Dislocation  of  the  Odontoid  Process  in  Disease,  . 

217.  Extreme  Lateral  Curvature,         .  .  •       . 
218    Apparatus  for  Lateral  Curvature,         .... 

219.  Spina  Bifida, 

220.  Division  of  Tendo  Achillis, 

221.  The  External  Pvectus  of  the  Eye  after  Division,  . 

222.  Talipes  Equinus — internal  view,  ..... 

223.  The  same — external  view,    ...... 

224.  Shoe  for  Talipes  Equinus— (from  Holmes's  Surg.  Di:'.  of  Childhood), 

225.  Skeleton  of  Foot  in  Extreme  Talipes  Varus— (after  Little), 
22(5.  Shoe  for  Talipes  Varus — (from  Holmes's  Surg.  Dis.  of  Childhood), 

227.  Talipes  Calcaneo-Valgus — (from  Holmes's  Surg.  Dis.  of  Childhood), 

228.  Flat-foot— (from  Holmes's  Surg.  Dis.  of  Childhood),  . 

229.  Neuroma,      ......... 

280.   Diagram  of  True  Aneurism,         ..... 

231.  Diagram  of  False  Aneurism,         ..... 

232.  Diagram  of  Hernial  Aneurism,    ..... 

233.  Diagram  of  Traumatic  Aneurism,        .... 

234.  Diagram  of  Dissecting  Aneurism,         .... 

235.  Tubular  Aneurism,       ....... 

236.  Cirsoid  Aneurism  —  (from  Syst.  of  Surg.),    ... 

237.  238.   Diagrams  of  the  Relation  between  the  Aneurismal  Sac 

239.  Diagram  of  Anel's  Operation,       ..... 

240.  Diagram  of  Hunter's  Operation,  .         .... 

241.  Cure  of  Aneurism,         ....... 

242.  The  Circulation  after  the  Cure  of  Aneurism  by  the  Ligatu 

of  Surg.),  ......... 

243.  Diagram  of  Wardrop's  Operation  by  Distal  Ligature, 

244.  Diagram  of  Brasdor's  Operation  by  Distal  Ligature,  . 

245.  Ligature  of  the  Carotid  Artery,  ..... 

246.  Ligature  of  the  Sul)clavian  Artery,      .... 

247.  Ligature  of  the  Brachial  Artery,  .... 
248  Ligature  of  the  Ulnar  and  Radial  Arteries, 

249.  Ligature  of  the  External  Iliac  Artery, 

250.  Ligature  of  the  Femoral  Artery,  .... 

251.  Ligature  of  the  Posterior  Tibial  Artery, 

252.  Ligature  of  the  Anterior  Tibial  Artery, 

253.  Diagramof  the  Common  Harelip — (from  Holmes's  Surg  Di 

254.  Harelip  with  Unequal  Sides— (from  Holmes's  Surg.  Dis.  of  Childhood),    . 
255  Harelip  with  its  Two  Parts  on   Different  Levels — (from   Holmes's  Surg. 

Dis.  of  Childhood) 


and  the  A 


from 


•lery,     59 


Svst. 


of  Childhood) 


570 


LIST    OF    ILLUSTRATIONS. 


FIG. 

2-36. 


2-'i8 
259. 

200. 

2(;l 

262. 

203. 

2(i4. 

205. 

260 

267. 

208. 

260. 

270. 

271 

272. 

273. 

274. 

275. 

276. 

277. 

278. 

279, 

281. 

282. 

283. 

284. 

285. 

286. 

287. 

288. 

289. 

290. 

291. 

292. 

293. 

294. 

295. 

296. 

297. 

298 

299. 

300. 

301. 

302. 

303. 

304. 

305. 

306, 

307. 

308, 


from  Ilolints's  Surtr.  Dis.  of 
Di.s.  of 


alat 


Jaw, 


se, 


Oppration  for  Harolip  witli  Unequal  Side* 

Childho..d),     .  .  .         . 

Cleinot's  Operation  for  Incomplete  Harelip — (from  Holmes's  8iir: 

Ciiildhood) "     . 

Diagram  of  Double  Harelip— (from  Holmes's  Surg.  Dis.  of  Childhood), 
Front  View  of  Double  Harelip  with  Projection  of  Intermaxillnrj'  Bone— 

(from  Holmes's  Surg.  Dis.  of  Childhood), 

Side  View  of  the  same  case— (from  Holmes's  Surg.  Dis.  of  Childhood), 
Giraldes's  Operation  for  Harelip— (from  Holmes's  Surg.  Dis.  of  Childhood 
Hainsby's  Truss,  ......... 

Smith's  Gag  for  Staphyloraphy, 

ilethod  of  Passing  and  Tying  the  Sutures  in  Staphyloraphy, 
Muscles  of  Soft  Palate— Pollock's  Method  of  Dividinix  the  Levator  P 
Fibrous  Tumor  of  the  Skull, 
Bellocq's  Sound,   ..... 

Plugging  the  Nares,     .... 

Polypus  Nasi — (after  Liston), 

Hilton's  Snare  for  Polypus, 

Nasopharyngeal  Polypus  removed  by  Excision  of  the 

Mr.  H.  Lee's  Clamp,    ..... 

The  Ecraseur,        ...... 

Hutchinson's  Gag,        ..... 

Internal  Strangulation,        .... 

Intussusception,    ...... 

Rupture  of  Hernial  Sac  by  Taxis, 
Kujjture  of  the  Mesentery  from  the  same  cause, 
280.   Diagrams  of  the  Two  Modes  of  Reduction  en  mas. 

Right  Inguinal  Truss, 

Left  Inguinal  Truss,     ..... 

Left  Scrotal  Truss, 

Double  Inguinal  Truss,         .... 

Spiral  Sjiring  Truss,     ..... 

Salmon  and  Ody's  Truss,      .... 

The  same,  double,  ..... 

Moc-main  Lever  Truss,         .... 

Hernia  Knife,        ...... 

Strangulation  by  Ni-ck  of  Sac, 

Omental  Sac,  ...... 

Contraction  of  the  Bowel  after  Strangulation 
Artificial  Anus,    ...... 

Dupuytren's  Enterotome,     .... 

Nonclosure  of  the  Tunica  Vaginalis,    . 

Retained  Testicle  with  Hernia,    .         .         . 

Diagram  of  Congenital  Inguinal  Hernia,     . 

Diagram  of  Infantile  Inguinal  Hernia, 

Diagram  of  Encysted  Inguinal  Hernia, 

Diagram  of  Common  Inguinal  Hernia, 

Diagram  of  Partial  Obliteration  of  tin;  Funicular  Process, 

Diagram  of  Formation  of  Hernia  into  the  Funicular  Procos.s, 

Dis.section  of  Oblique  Inguinal  Hernia,         .... 

A  notiier  view  of  the  same  preparation,         .... 

Dissection  of  I'^-mural  Hernia,      ...... 

Irregular  Distribution  of  Obturator  Vessels  in  Fciiimal  lli-rnia 
Obturator  Vessels  Encircling  the  Sac  of  a  Femnral  Hernia, 
Obturator  Hernia,         ........ 


571 


572 
572 


LIST    OF    ILLUSTRATIONS. 


XXIX 


FIG. 

309.  Mr.  H.  Smith's  Clamp  for  Piles,  .... 

310.  Fistiihi  in  Ano  without  any  Internal  Opening,    . 

311.  Preparation  showing  the  Ordinary  Anatomy  of  Fistula  in  Ano, 

312.  Simple  Stricture  of  the  Koctum,  ..... 

313.  Cancerous  Stricture,     ....... 

314.  Strumous  Ulceration  and  Stricture  of  the  Rectum, 

315.  Bistouri-caclie,      ........ 

316.  Imperforate  Anus  with  Scrotal  Fistula — (after  Larcher), 

317.  Dissection  of  the  above  case — (after  Larcher),     . 

318.  Imperforate  Rectum  —  (after  Girald^s), 

319.  Imperforate  Rectum — Result  of  Paracenteses — (from   Holmes's  Surj 

of  Childhood), 

320.  Fuller's  Bivalve  Traclieotomy  Canula, 

321.  Durham's  Canula  with  "Lobster-tail  "  Director, 

322.  Bryant's  Tracheotomy  Canula — (after  Bryant),  . 

323.  Needle  for  Paracentesis  Corneaj,  .         .         .  '       . 

324.  Effects  of  Atropine  in  Iritis,         ..... 
325  Diagram  to  Illustrate  the  Position  of  Laminar  Cataract, 

326.  Curette  and  Mouthpiece  for  Suction  Operation  for  Cataract 

327.  Focal  Illumination  for  the  Detection  of  Cataract, 

328.  Linear  Knife  for  E.xtraction  of  Cataract,    . 

329.  Diagram  showing  the  Incision  for  Linear  E.xtraction, 

330.  Diagram  of  Correct  and  Faulty  Section  of  Iris  in  Iridectomy, 

331.  Iridectomy  Forceps,     ....... 

332.  Diagram  of  Direct  Ophthalmoscopic  Examination,     . 

333.  Diagram  of  Indirect  Ophthalmoscopic  Examination,  . 

334.  Lance-knife  for  Iridectomy,  .         .         . 

335.  Diagram  to  Illustrate  the  Formation  of  Double  Images 

336.  Diagram  to  Elucidate  the  Mechanism  of  Squint, 

337.  Diagram  to  Illustrate  the  Ofieration  for  Squint,  . 

338.  Diagram  to  Show  the  Method  of  E.stimating  the  Degree  of  Squint, 

339.  The  Strabismus  Hook, 

340.  Weber's  Canaliculus  Knife, 

341.  Slilling's  Knife  for  Lachrymal  Fistula, 

342.  Diagram  of  Emmetropia,  Myopia,  and  Hypermetropia, 

343.  Aural  Polypus,     .  .  .' 

344  Congenital"  Cyst  of  the  Bladder, 

315.  Cancer  of  the  Bladder,  covered  tjy  a  Villous  Growth, 

346.  Villous  Tumor  of  the  Bladder, 

347.  Difl"u..^ed  Cancer  of  the  Bladder, 

348.  Glandular  Tumor  of  the  Prostate,         .... 

349.  Enlarged  Prostate, 

350.  Forcible  Catherization  in  Enlarged  Prostate, 

351.  Stricture!  in  the  Spongy  Portion  of  the  Urethra, 

352.  Stricture  at  the  Meatus,        ...... 

353.  Annular  Stricture  of  the  Un-thra,        .... 

354.  Lithate  of  Ammonia  deposit  in  Urine, 

355.  Uric  Acid  deposit  in  Urine,  ..... 

356.  Oxalate  of  Lime  deposit  in  Urine,        .... 

357.  Phosphate  of  Lime  deposit  in  Urine,. 

358.  Triple  Phosphate  deposit  in  Urine,      .... 

359.  Urate  of  Ammonia  Calculus  (impure) — (after  Poland), 

360.  Uric  Acid  Calculus— (after  Poland),    .         . 

361.  Oxalate  of  Lime  Calculus — external  view,  . 

362.  Oxalate  of  Lime  Calculus  in  section — (after  Poland), 


Dis. 


XXX 


LIST    OF    ILLUSTRATIONS. 


on), 
oil), 


FIG. 

363.  Pliospliatc  of  Lime  Calculus  with  nucleus  of  Lithic  Acid — (after  Poland), 

3G4.  Alternating  Calculus — (after  Poland),  .... 

365.  Dissection  of  the  Perineum  — (after  Pirrie), 

366.  The  Second  Step  of  the  Operation  for  Stone — (after  Pirrie), 

367.  Median  Lithotomy— Sacculated  Bladder,    .... 

368.  The  common  Screw  Lithotrite,     ...... 

369.  Civiale's  Lithotrite, 

370.  Sir  H.  Thompson's  Lithotrite,      ...... 

37L  The  English,  or  Brodie's,  Method  of  Lithotrity— (after  Sir  H.  Thomp 

372.  The  French,  or  Civiale's,  Method  of  Lithotrity— (after  Sir  H.  Thomp: 

373.  Clover's  Syringe  for  Lithotrity,  ..... 

374.  Fasciculated  Bladder  with  Adherent  Calculi,     . 

375.  Impaction  of  Fragments  in  a  Pouch  of  the  Bladder,  . 

376.  Result  of  Lithotrity  in  a  case  of  Enlarged  Prostate,   . 

377.  Calculus  Impacted  in  the  Neck  of  the  Bladder,   . 

378.  Tapping  a  Hydrocele — (after  Liston),  .... 

379.  Cystic  Disease  of  the  Testicle, 

380.  Watery  Cy.st  of  the  Broad  Ligament,          ... 
38L  The  common  Leg  Bandage, 

382.  Bandage  for  the  Hand  and  Forearm,  .... 

383.  The  Spica  Bandage, 

384.  Four-tailed  Bandage  for  the  Knee,       .... 

385.  The  Scalp  or  Capelline  Bandage,  .... 

386.  T-bandage 

387.  The  Continuous  Suture, 

388.  The  Tsvisted  Suture, 

889.  The  Clove-hitch, 

390.  Venesection — (after  C.  Heath), 

391.  Amputation  of  the  Shoulder-joint,       .... 

392.  393.  Diagram  of  the  Front  and   Back  of  the  Arm,  siiowii 

for  various  Operations,     ...... 

394.  Diagram  of  a  Section  of  the  Upper  Arm,    . 

395.  Diagram  of  a  Section  of  the  Forearm, 

396.  Diagram  of  the  Incisions  for  various  Operations  on  the  Trunk,  . 

397.  Diagram  showing  the  Incisions  for  various  Operations  on  the  Low 

tremity,    ........... 

398.  Lines  of  various  Amputations  at  the  Back  of  the  Lower  Extremity, 

399.  Flap  of  Amputation  at  the  Hip, 

400.  Diagram  of  Circular  Amputation  of  tlic  Thigh,  . 

401.  Tcale's  Amputation  of  the  Leg, 

402.  Syine's  Amputation, 

4(J8.  Skeleton  of  the  Foot,  showing  the  lines  for  Chojiart's  and 

putations,  ........ 

404.  Method  of  Slinging  the  Arm  after  Excision  of  the  Elbow, 

405.  Mr.  Svme's  case  of  Repair  after  Excision  of  the  Elbow, 

406.  Diagram  of  the  Excision  of  the  Wrist — (after  Lister), 

407.  S<!cliori  through  the  Bones  of  the  Knee  in  Ciiildhood,  to  si 

(if  the  Epiphysial  Lines — (from  the  Syst.  of  Surg  ), 

408.  Anterior  view  of  the  same  Femur,  to  mark  the  Level  at 

should  be  applied, 

409.  Splint  for  Exci-ion  of  the  Knee, 

410.  Dr.  P.  II.  Watson's  Suspension-rod  for  Excision  of  the  Knee, 

411.  Dr.  P.  U.    VVatson'.s  Sjjlints  for  Excision  of  the  Knee, 


the  Inci 


Lisfranc'; 

ow  the  pi 
wiiich    ill 


Ex 


All 


Saw 


PACE 

805 

805 

810 

811 

815 

817 

817 

817 

818 

819 

820 

820 

820 

821 

824 

827 

836 

853 

894 

894 

894 

895 

896 

896 

899 

899 

900 

903 

916 


INDEX  OF  AUTHORS. 


The  following  List  is  intended  to  eml)riice  tlie  chief  references  that  have  been  made  in  the  foregoing 
Volume  to  the  published  labors  of  others. 

Adams  J.  :  fibroej'stic  tumors  of  bone,  451 

Adams  R. :  chronic  rheumatic  arthritis  of  shoulder  and  injury,  258;  partial  disloca- 
tion of  shoulder,  279 ;  pendulous  growths  from  synovial  membrane,  463  ;  rheu- 
matic arthritis,  472 

Adams,  \V. :  fracture  of  ossa  nasi,  107;  dissection  of  dislocation  of  hip,  325;  subcu- 
taneous section  of  neck  of  femur,  473  ;  union  of  tendons  after  subcutaneous  sec- 
tion, 505,  511  ;  abscess  and  cysts  of  antrum,  588 

Addison  :  migration  of  leucocytes,  86  ;  keloid,  885 

Alliirton:  median  lithotomy,  814 

Allbiiti:  paracentesis  of  pericardium,  221 

Aiinandale:  arteriovenous  aneurism,  113,  528 

Arnoft :  pyaemia  and  phlebitis,  60;  cesophagotomy,  217 

Arnott,  H. :  structure  of  cancer,  370 

Arnott,  Jas. :  cold  as  an  amesthetic,  905 

Assnllnl :  wound  of  intercostal  artery,  227 

Aveling :  transfusion,  127 

Avery :  staphyloraphy,  578;  reduction  en  masse,  623 

Bahin'gtcin  :  syphilitic  sore  throat,  403 

Ballard:  congenital  syphilis,  407 

Barclay :  delirium  tremens,  91 

Barweli:  foreign  body  in  windpipe,  211  ;  cure  of  nievus,  363  ;  gonorrhoenl  rheuma- 
tism, 390  ;  ostitis,  423  ;  caries,  432  ;  disease  of  cartilages,  466  ;  shortening  in  hip 
disease,  476  ;  treatment  of  clul)foot,  506 

Bell,  Charles:  dislocation  of  the  spine,  188 

Bell,  Jnse-ph  .■  trephining  for  matter,  162 

Beylard :  rickets,  454 

Bibra,  voH  :  caries,  423 

Bickersietli  :  antiseptic  ligature  of  arteries,  119;  ununited  fracture,  151;  osteo- 
aneurism,  453 

Bigehiw :  fracture  of  cervix  femoris,  296;  dislocation  of  hip,  317 

Blllndk  :  traumatic  fever,  46;  pviemia,  62;  tetanus,  89;  classification  of  tumors, 
365  ;  extirpation  of  cancer  of  oesophagus,  611 

Bird,  Golding  :  uric  acid  deposits,  801 

Birheti :  structure  of  naevus,  361;  injuries  of  pelvis,  ch.  xiii ;  hernia,  ch.  xxxii  ; 
diseases  of  the  breast,  ch.  xli,  passim. 

Black:  tuberculous  disease  of  bone,  423,  439 

Blamiiii. :  operation  for  complicated  harelip,  574 

Bloxam:  treatment  of  fractured  thigh  in  children,  302;  fractured   patella,  308 

Bond:  gonorrhoeal  rheumatism,  390 

Bouley :  hydrophobia,  101 

Bowman:  orbital  aneurism,  545;  treatment  of  conical  cornea,  710;  tension  of  eye- 
ball, 729 


XXXll  INDEX    OF    AUTHORS. 

Boyer :  bilateral  lithotomy,  815 

Brninard :  injection  of  spina  bifida,  496 

Breschei :  osteoaneurism,  452 

Brisfowe  :  phosphorus  necrosis,  587 

Broadheitt :  reduction  en  masse,  G'23 

Brod/iiivfif :  reduction  of  old  dislocation,  278,  31G  ;  loose  cartilages,  470 

Broca  :  return  cif  cii-culation  after  ligature,  115  ;  aneurisnuil  clots,  533  ;  tuotii  tumors, 
588 

Brodie  :  tetanus,  86  ;  lightning  stroke,  137  ;  foreign  body  in  bronchus,  212;  hysteria, 
384;  treatment  of  congenital  syphilis,  408  ;  abscess  of  bone,  428  ;  chronic  thick- 
ening of  s\-novial  membrane,  463  ;  ulceration  of  cartilages,  465;  disease  of  tarsus, 
481  ;  varicose  veins,  564  ;  decomposition  of  urine  in  cj'stitis,  775  ;  forcible  cathe- 
terization, 780;  removal  of  fragments  in  litliotrity,  822;  loose  body  in  tunica 
vaginalis,  831 ;  serocystic  tumor,  862 

Brown,  Baker:  needle  for  ruptured  perineum,  848 

Brown-Sequard  :  trephining  tiie  spine,  190;  injuries  of  nerves,  ch.  xxvii,  j'^s-stm. 

Bruns :  operation  for  complicated  harelip,  574 

Bryant:  tetanus,  89  ;  dislocation  of  jaw,  201  ;  scald  of  larynx,  214  ;  gastrotomy,  240; 
rupture  of  bladder,  246;  fracture  of  clavicle,  254;  fracture  of  coracoid  process, 
257  ;  reduction  of  dislocation  of  shoulder,  277  ;  test  for  displacement  of  head  of 
thigh-bone,  291  ;  dislocations  of  hip,  315;  disease  of  cartilages,  465;  introduction 
of  foreign  bodies  into  aneurismal  sac,  538;  treatment  of  nasal  polj^pus.  601  ; 
internal  strangulation,  612  ;  reduction  en  mnsse,  623  ;  galvanic  cautery  for  piles, 
606;  Bavarian  splint,  898 

Buchanan :  division  of  plantar  fascia  in  club  foot,  510;  rectangular  lithotomy,  812 

Buck,  Gurdon:  extensicui  in  fractured  thigh,  300 

Bulteel:  wound  of  artery,  113 

Busk:  snakebites,  96 

Butcher:  subcutaneous  division  of  cicatrices,  913;  amputation  at  knee,  924;  excision 
of  knee,  942 


Cadge:  dissection  of  dislocation  of  hip,  324 

CaZ/ewrfe?-;,  septicaemia  and  pyajmia,  59  et  seq  ;  delayed  union  of  fracture,  148; 
Colles's  fracture,  267  ;  rupture  of  axillary  artery,  278;  wound  of  ulnar  nerve, 
518;  diseases  of  veins,  ch.  xxix,  ^ja.ssim  ;  nephrotomy,  767  ' 

Campbell,  U.  S. :  ligature  of  artery  in  inflammation,  114,  119 

Campbell,  of  Montreal :  ligature  of  sciatic  artery,  242 

Catiion:  gun.-hot  wound  of  spine,  339  ;  excision  of  knee  for  injury,  806 

Carden:  amputation  of  thigh,  923 

Carte:  compression  of  aneurism,  535 

Carter,  Vandyke:  lymphatic  fistula,  560;  nrrves  in  anaesthetic  leprosy,  885 

Carnochan:  ligature  of  artery  in  elephantiasis,  885 

Celsus :  inflammation,  33 

Chassaignac  :  compression  of  carotid  arterj',  541 

Chaussier  :  fracture  of  sternum,  222 

Cheever :  oesophagotomy,  216 

Chiene  :  fracture  of  exostosis,  450 

Ciniselti :  gaivanopuiicture  in  thoracic  aneurism,  539 

Clarke,  Le  Gros :  injuries  of  the  brain,  166;  fracture  of  outer  table  of  skull,  167; 
fracture  by  contre-coup,  169  ;  escape  of  cerebrospinal  fluid,  175;  tcmperaturcMii 
injuries  of  head,  178;  lesions  of  cranial  nerves,  183;  dislocation  of  spine,  188; 
trephining  of  the  spine,  190;  concussion  of  spine,  192;  fracture  of  larynx,  207; 
foreign  body  in  windpipe,  211  ;  scald  of  larynx,  214;  fractured  ribs,  210;  em- 
physema, 221 ;  wound  of  lung,  224  ;  hernia  of  lung,  224;   wound  of  heart,  226; 


INDEX    OF    AUTHORS.  XXXIU 

blows  on  abdomen,  230;  rupture  of  liver,  233;  of  bladder,  245;  partial  disloca- 
tion of  shoulder,  279  ;   phrenic  hernia,  658  ;  treatment  of  carbuncle,  890 

Clarke,  Fairlie  :  diseases  of  the  tongue,  fi08 

Clarke,  Lockh.art :  tetanus,  88;  concussion  of  spine,  193  ;  progressive  muscular  atro- 
phy, 503  ;  injuries  of  nerves,  cli.  xxvii,  pasfihn. 

Cock:  cesophagotomy,  216;  dislocation  of  the  ankle,  329;  aneurism  of  profunda 
femoris,  554  ;  puncture  of  bladder  from  rectum,  791 

Cockle:  distal  ligature  in  thoracic  aneurism,  539 

Cohnheim:  migration  of  leucocytes,  36 

Colles  :  fracture  of  radius,  267 

Cooper,  Branshy  :  caries,  432 

Cooper,  Sir  A. :  ligature  of  artery  with  catgut,  119  ;  dislocation  of  foot,  154  ;  disloca- 
tion of  jaw,  201;  fracture  of  neck  of  scapula,  256,  276;  fracture  of  acromion, 
258  ;  dislocation  of  shoulder,  271  ;  reduction  of  old  dislocation,  278;  fracture  of 
neck  of  femur,  289,  294;  fracture  of  upper  third  of  thigh,  295;  treatment  of 
compound  fractures,  313  ;  dislocation  of  hip,  315  ;  incision  for  sciatic  hernia,  653  ; 
lute  descent  of  testicle,  825  ;  varicocele,  839  ;  chronic  mammary  tumors,  861 

Coote,  Holmes:  abscess,  gangrene,  ch.  ii ;  injuries  of  face,  ch.  ix  ;  diseases  of  tongue, 
ch.  xxxi ;  diseases  of  thyroid,  ch.  xlii 

Cordwent:  entrance  of  air  into  veins.  111 

Coulo)! :  fracture  of  ribs  without  laceration  of  periosteum,  219 

Crampton:  ligature  of  common  iliac  artery,  551 

Cripps :   secondary  hemorrhage,  117 

Critcliett :  use  of  setons  in  keratitis,  700;  operation  for  staphyloma,  709 

Croft:  hectic,  66;  colloid  tumors,  376 

Criiveilhier :  pj'ajmia,  61  ;  progressive  muscular  atrophy,  502 

Curling :  delayed  union  of  fracture,  148  ;  atrophy  of  bone,  458  ,  enchondroma  of  testis, 
800;  tumors  of  cord,  841 

Czermak:  laryngoscopy,  670 

Dolby:  rupture  of  membrana  tymjiani,  758  ;  relaxation  of  membrana  tympani,  760; 

aural  polypi,  763;  syphilitic  deafness,  764;  Meniere's  disease,  765 
Dalrytnple :  mollifies  ossium,  454 
Davies,  Redfern :  neurotomy,  520 
Delagarde :  on  Chopart's  amputation,  928 
Dela  Martinih-e :  foreign  body  in  windpipe,  209 
Deleiis:  orbital  aneurism,  544 
De  Mor-gan :  erysipelas,  &1  et  seq. ;  use  of  chloride  of  zinc  in  wounds,  50;  tenotomy 

in  fracture,  314  ;  division  of  spinal  accessory  nerve  in  spasmodic  wryneck,  516 
Delpech:  fracture  of  sternum,  222;  tenotomy,  505;  operation  for  varicocele,  840 
Dickinson:  suppurative  disease  of  viscera,  66;    tetanus,   88;  glanders,   99;  rickety 

disease  of  viscera,  455 
Diejfenbach  :  ununited  fracture,  151 

Dixon:  bullet  lodged  in  the  bladder,  343  ;  treatment  of  gonorrheal  ophthalmia,  691 
Dolbeaii:  perineal  lithotrity,  816 
Donovan:  subperiosteal  excision,  931 
Doutrelepont :  subperiosteal  excision  of  elbow,  935 
Duchenne:  pseudo-hypertrophic  paralysis,  504 
Diika:  ivory  exostosis  of  antrum,  447 
Dumville:  abscess  in  arachnoid  cavity,  160 

Dupuytren :  burns,   132;  Pott's  fracture,  328;  artificial  anus,  039;  bilateral  lithot- 
omy, 815 
Diu'ham:  injuries  of  neck,  ch.  s.,  passim ;  foreign  bodies  in  windpipe,  211;  scald  of 

larynx,  214  ;  resophagotomy,  217  ;  gastrotomy,  239  ;  moUities  ossium,  456  ;  hyper. 

trophy  of  bone,  458  ;  acne  rosacea,  594  ;  disease  of  nose,  ch.  xxx  ;  electrolysis  in 

tumors  of  liver,  617;  diseases  of  larynx,  ch.  xxxiv,  ^:)«ssim. 

c 


XXXI V  INDEX    OF    AUTHORS. 

Earle:  soot  cancer,  842 

EllioUon:  glanders,  100 

Ellis:  aniostliotics,  180;  vaccination,  904 

Emmet:  gunshot  wound  of  vagina,  348 

Erichsen:  secondary  luemorrliage,  117;  ununited  fracture,  151  ;  concussion  of  spine, 
194;  extension  in  fractured  thigh,  300;  treatment  of  fractured  thigh,  302;  re- 
duction of  old  dislocation,  315  ;  removal  of  bursal  tumor,  499  ;  orbital  aneurism, 
544;  aneurism  of  profunda  femoris,  554;  ligature  of  common  femoral,  555 

Esinarch :  clastic  bandage  for  restraining  hiumorrhage,  909 

Fabbri:  dislocation  of  thumb,  28G ;  dislocation  of  hip,  817 

Facfge^  HMoh:  aneurism  of  abnormal  femoral  artery,  55G;  treatment  of  cysts  of  liver, 
584;  psoriasis  of  nails,  892 

Fayrer :  snakebites,  97;  osteomyelitis,  427 

Fearii :  distal  ligature  in  innominate  aneurism,  540 

Fe)\(/tis:  rupture  of  gall-bladder,  233 

Fergiisson  :  dressing  wounds,  49  ;  fractures  of  coronoid  process  of  jaw,  198;  manipu- 
lation in  aneurism,  538;   harelip,  569;  stapliylorapliy,  575 

Fifiher :  wound  of  heart,  226 

Flower:  dislocation  of  acromion,  271  ;  of  shoulder,  271  ;  injuries  of  upper  extremity, 
ch.  xiv,  passim. 

Forde  :  hernia  of  lung,  224 

Forster,  Cooper:  harelip,  569 

Fox,  Tilbury:  parasitic  fungi,  874 

Fox,  Wilson:  structure  of  tubercle,  377 

France:  orbital  aneurism,  544 

Frogley :  enchondroma,  446 

Gairdner :  rupture  of  aneurism,  531 

Ghmgee:  enchondroma  of  femur,  445 

Gaseoyen  :  sj'philitic  reinfection,  411 

Gay:  wound  of  bowel  in  paracentesis,  617;  e.xlraperitoneal  herniotomy,  650 

Gibb :  dislocation  of  hyoid  bone,  207;   follicular  laryngitis,  675 

Giruldis :  operation  for  liarelip,  573;  cysts  of  antrum,  588 

Gordon,  of  Belfast :  fracture  of  clavicle,  254  ;   IVaclurc  of  lower  end  of  radius,  208 

Gordon:  tre]iliining  the  spine,  190 

Gosseiin:  rupture  of  lung,  228 

Graefe,  Von:  applications  in  juii-ulent  oplitljiilniia,  (JU4  ;  treatment  of  conical  cornea, 
710;  extraction  of  oatai'act,  724;  membranous  lilni  in  vitreous  body,  785 

Gray :  serous  discharge  in  injuries  of  tiie  head,  175 

Green:  structure  of  tubercle,  377  ;  of  gumauita,  405 

Greene :  removal  of  bronchocele,  869 

Gritti:  amputation  at  knee,  924 

Gross,  Prof.  S. :  foreign  bodies  in  windpipe,  209  ;  subcutaneous  section  of  bone,  473  ; 
deviation  of  septum  nasi,  595;  treatment  of  cystitis,  775 

Gross:  injuries  of  the  head,  102 

Gulliver:  atheroma,  521 

Guthrie:  injuries  of  vessels,  107;  wound  of  vein,  110;  contractility  of  arteries,  110; 
bleeding  from  lower  end  of  artery,  118;  bullet  in  pleura,  342;  ligature  of  pos- 
terior tibial,  579 

Guyon:  ligature  of  external  car(jtid,  543 

Jlalford:  snakebites,  98;   rupture  of  trachea,  208 

HamilUm:  subluxation  of  jaw,  203;  dislocation  of  sliould(,'r,  275 

Jlainilton,  of  Ayr :  transfusion,  128 

Ilancoc/c:  subastragaloid  amputation,  927 


INDEX     OF    AUTHORS.  XXXV 

Hardie:  transplantation  of  bono,  912 

Hardy:  mollusciun,  883 

Harley,  Dr.  J.:  succus  eonii  in  inusciilur  spasm,  510  ;  treatment  of  hydaticls  of  liver, 
617 

Ilaward:  sulphuric  acid  treatment  of  diseases  oi  joints,  4()r) ;  ethc^r  as  an  anjesthetic, 
906 

Hawkins,  Ccesar :  definition  of  tumors,  347;  subcutaneous  bony  tumor,  358;  warty 
tumor  of  cicatrices,  420;  ulceration  of  bono,  433;  cancer  of  spine,  494;  fibrous 
tumor  of  cranium,  581  ;  diseases  of  the  tongue,  G04  ;  cyst  of  broad  ligament,  853  ; 
tuberocystic  tumor,  8G2  ;  cancer  of  thyroid,  869 

Heath  :  fracture  of  neck  of  jaw,  198  ;  fracture  of  jaw,  200  ;  dislocation  of  jaw,  203  ; 
distal  ligature  in  thoracic  aneurism,  539;  diseases  of  antrum,  588;  tumors  of 
jaw,  591 ;  closure  of  jaws,  594;  removal  of  tongue,  606 

Hehra:  erythema  nodosum,  68;   acne  rosacea,  594;  eczema,  872;  plica  polonica,  886 

Ileiberg :  pyaemia  and  bacteria,  63 

Hennen  :  hospital  gangrene,  81 

Henry,  M. :  recurrence  of  myeloid  tumor,  367 

Hewett :  injuries  of  head,  cli.  vW,  passim ;  extravasation  in  arachnoid  cavity,  165; 
fracture  of  one  table  of  skull,  168;  fractures  of  base  of  skull,  171  ;  opium  in  in- 
juries of  the  head,  182;  bleeding  in  injury  of  the  head,  182;  wound  of  rectum, 
249,  343  ;  disappearance  of  nasvus,  364  ;  fibrocystic  tumor  of  bone,  451 ;  omental 
sacs,  634  ;  femoral  aneurism,  554;  gouty  phlebitis,  562;  meningocele,  579;  spon- 
taneous cure  of  fistula,  660;  laryngotomy,  672;  amputation  of  forearm,  918 

Hey:  dislocation  of  jaw,  201  ;  fungus  hjematodes,  372;  mortification  in  hernia,  640; 
infantile  hernia,  642  ;  amputation  of  metatarsus,  928 

Hill,  B.:  fracture  of  jaw,  200 

Hilton:  opening  abscesses,  57;  foreign  body  in  windpipe,  212;  nasal  snare,  600 

Htidon :  diseases  of  the  ear,  ch.  xxxvi,  2mss'im. 

Hirscliherg :  glioma  of  eye,  736 

Hitzig :  dislocation  of  metatarsus,  333 

Hodges :  excision  of  knee,  943 

Hodgson :  macroglossia,  609 

Hodgson,  of  Brighton:  cancer  of  retained  testis,  826 

Hodgkin  :  lymphadenoma,  568 

Holden:  catgut  ligature,  120;  abscess  in  brain,  160;  fracture  of  base  of  skull,  183; 
digital  jiressure  in  aneurism,  536 

^oZ^  ;  prolonged  pressure  for  cure  of  aneurism  under  anaesthesia,  537  ;  tumor  of 
pharynx,  610;  rupture  of  stricture,  796 

Holthouse:  dislocation  of  knee,  325;  injuries  of  lower  extremity,  ch.  xv,  passim. 

Hornidge :  fractures,  general  pathology,  ch.  vi,  passiin. 

Huguier :  operation  for  imperforate  anus,  667 

Hulke :  fracture  of  inner  end  of  clavicle,  252;  dislocation  of  acromion,  270;  disloca- 
tion of  shoulder,  271 ;  compound  dislocation  of  shoulder,  279  ;  injuries  of  upper 
extremity,  ch.  xiv,  passiin. 

Humphry:  dressing  wounds,  49;  dislocation  of  the  thumb,  287;  excision  of  condyle 
of  jaw,  472;  thrombosis,  561  ;  macroglossia,  609  ;  diseases  of  the  male  organs, 
ch.  xxxix,  passim,. 

Hunt:  fracture  of  larynx,  207 

Hunter:  temperature  in  inflammation,  34;  organization  of  blood,  40;  gangrene,  77; 
contractility  of  arteries,  110;  ligature  of  arteries,  119;  inoculation  of  himself 
with  venereal  matter,  404  ;  loose  cartilages,  470;  rupture  of  tendo  Achillis,  497; 
union  of  tendons  after  subcutaneous  division,  505  ;  multijde  stricture,  784 

Hutchinson:  fractured  patella,  306  ;  syphilitic  teeth,  408;  syphilis  conveyed  to  the 
mother, 408;  injuries  of  nerves,  517  ;  intussuscejition,  gastrotomy,  615;  interstitial 
keratitis,  704;  diseases  of  women,  ch.  x\,  passitn. 


-XXXVl  INDEX    OP    AUTHOKS. 

Ilott :  exostosis  of  cranium,  449 

Jackson,  Carr :  abscess  in  bone,  430 

Jenner :  forms  of  scrofula,  379  ;  moUities  ossium,  455  ;  diseases  of  skin,  ch.  xliii,  passim 

Jones:  ligature  of  arteries,  115 

Jo7ies,  Bence:  tests  for  calculi,  805 

Johnso7i,  G.:  cancer  of  retained  testis,  826 

Johnson,  H.  C. :  ligature  of  common  carotid  for  wound  of  internal  carotid,  113 

Johnstone:  congenital  tumor  in  spinal  canal,  355;  diseases  of  joints,  ch.  xxiii,^jffssi??i. 

Jordan:  ununited  fracture,  152 

Key,  Asfon:  fracture  of  trochanter,  295;  treatment  of  inflamed  gut  in  hernia,  635 

Khigdon:  obturator  hernia,  652 

Kirkes:  embolism,  522 

Kirkpatrick:  potassa  cum  calce  in  caries,  433 

Knapp:  glioma  of  the  ej'e,  736 

Lancereaux :  period  of  incubation  after  syphilitic  inoculation,  396;  effects  of  removal 
of  syphilitic  sores,  401 ;  syphilitic  fever,  401 ;  classification  of  syphilis,  401  ;  in- 
oculation of  secondary  syphilis,  404 

Langenbeck:  vicious  union,  153;  excision  of  ankle  in  gunshot  wounds,  346;  subcu- 
taneous section  of  bone,  473 ;  operation  for  complicated  harelip,  574  ;  staphy- 
loraphy,  578;  osteoplastic  resection  of  jaw,  592;  extirpation  of  larynx,  678 

Lane/ton:  treatment  of  irreducible  hernia,  622 

Larrey :  wound  of  intercostal  artery,  227 

Lebert:  classification  of  tumors,  348,  365 

Lee,  H. :  primary  excision  of  ankle,  329;  syphilis  and  gonorrhoea,  ch.  xx,  passim;  on 
Hunter's  self-inoculation,  404  ;  phlebitis,  561  ;  varicose  veins,  565  ;  prostatic  dis- 
charges, 778;  operation  for  varicocele,  841;  rectangular  amputation,  925 

Lee,  S. :  dissection  of  dislocation  of  hip,  319 

Lefort:  congenital  communication  of  rectum  and  vagina,  666 

Letenneur:  aneurism  of  external  circumflex,  554 

Levis:  introduction  of  horsehair  into  aneurism,  538 

Lisfranc:  amputation  of  metatarsus,  928 

Lister:  microscopic  phenomena  of  inflammation,  37;  dressing  wounds,  49  et  seq.  ; 
ligature  of  arteries,  antiseptic,  119;  vicious  union,  153  ;  chloroform,  906;  aortic 
tourniquet,  021 ;  excision  of  wrist,  935 

Liston :  hospital  gangrene,  82;  foreign  body  in  bronchus,  212;  cysts  of  bone,  452 

Little:  orthopiedic  surgery,  ch.  xxvi,  pass'nn ;  spinal  curvature  and  empyema,  493 

2/iiire/ concussion,  176 

Lloyd,  Dr.  :  elephantiasis  of  the  scrotum,  841 

Lloyd,  Mr. :  rectal  lithotomy,  816 

Longmore:  gunshot  wounds,  ch.  xvi,  passim;  trephining  in  wounds  of  head,  338; 
osteomyelitis,  338 

Loizbeck:  fracture  of  neck  of  scapula,  257 

Louis:  tumors  of  dura  mater,  581 

Lowe:  dislocation  of  shoulder,  277 

Lukomsky  :  bacteria  and  erysipelas,  71 

Mackenzie  :  treatment  of  bronchocele,  868 

Madrod:  hospital  gangrene,  81 

Maisonnnuve :  dislocation  of  jaw,  202;  cauterisation  en  fll'ches,  902 

Mulgaigiie :  fracture  of  neck  of  scapula,  256;  of  neck  of  humerus,  259;  dislocation 

of  shoulder,  272  ;  fracture  of  \\\)\\i-v  third  of  femur,  297  ;   fractured  femur,  301  ; 

dislocation  of  toes,  334 
Mapother :  osteo-aneurism,  453 


INDEX    OF    AUTHORS.  XXXVll 

Marcet :  hydrophobia,  102 

Marfih:  operation  for  rickety  deformity,  457  ;  intussusception,  gastrotomy,  GIG;  ex- 
traperitoneal operation  for  hernia,  G3'2 

Marson:  treatment  of  gonorrlicca  in  the  femak',  394 

Martin  and  ColLineau :  shortening  in  hip  disease,  475 

Martin,  R. :  injection  of  iiydrocele  with  iodine,  829 

Martyn:  enchondroma  of  phaUmges,  44G 

Mason:  ununited  fracture,  151  ;  congenital  tumor  of  tongue,  GOO 

Maunder:  ligature  of  artery  in  inflammation,  119;  fracture  of  exostosis,  450;  elastic 
ligature  in  fistula,  659 

Maury:  gastrotomy,  239 

Messer :  enlarged  prostate,  778 

Moore,  C  H.  :  hasmorrhage,  ch.  iv,  passim;  entrance  of  air  into  the  veins.  111 ;  rup- 
ture of  stomach,  231 ;  impaction  of  femur  in  acetabulum,  244  ;  rodent  cancer, 
416;  atheroma,  521 ;  introduction  of  wire  into  sac  of  aneurism,  538  ;  division  of 
lingual  nerve,  607;  tumors,  ch.  xvu,  passim. 

Moore,  S.   W. :  antiseptics,  52 

Morris  :  reduction  en  masse,  623 

Mott:  ligature  of  common  femoral,  555;  excision  of  clavicle,  931 

Moxon :  serous  discharge  in  injuries  of  the  head,  175;  classification  of  tumors,  367; 
atheroma,  521 

Mnrchison :  lyn)phadenoma,  568 

Murray,  Dr.:  chloroform  rash,  G7 

Murray,  of  Newcastle  :  introduction  of  carbolized  gut  into  aneurism,  538  ;  compres- 
sion of  aorta  for  aneurism,  551 

Nayler :  alopecia,  403  ;  eczematous  ulcers,  413;  lupus,  416;  diseases  of  skin,ch.  xliii, 
passim. 

Nelaton:  dislocation  of  jaw,  201;  emphysema,  223;  hernia  of  lung,  224;  dislocation 
of  the  thumb,  287  ;  test  for  displacement  of  head  of  femur,  291 ;  cysts  of  bone, 
452;  ganglion,  501  ;  removal  of  nasopharyngeal  polypus,  601 

Norris:  ununited  fracture,  151  ;  atrophy  of  bone  after  fracture,  458 

Nunn :  wasting  in  hip  disease,  475 

Nunneley :  orbital  aneurism,  544 

Nuashaum:  transplantation  of  bone,  152 

Obre :  obturator  hernia,  651 

Ogle:  hydrophobia,  104 

Oilier:  grafting  of  periosteum,  423;  subperiosteal  excisions,  931  ;  of  os  calcis,  945 

Ormerod:  mollities  ossiam,  454 

Oshorn  :  origin  of  encysted  hydrocele,  831  ;  cysts  of  broad  ligament,  852 

O'Shaughncssy  :  enchondroma  of  jaw,  591 

Otis  :  natural  calibre  of  the  urethra,  788 

Pagan:  operation  for  hernia  testis,  835 

Page  :  skin-grafting,  421 

Pagenstecker :  ointment  for  cornea,  695 

Paget:  tumors,  ch.  xvii,  passim;  ulcers,  ch.  xxi,  passim,;  union  of  wounds,  45; 
chronic  pyiemia,  64;  dissection  wounds,  94  ;  treatment  of  sprains,  288;  sebaceous 
tumors,  351  ;  fibrocellular  tumors,  358  ;  enchondroma  running  a  malignant 
course,  858;  residual  abscess,  58,  378  ;  senile  scrofula,  381  ;  nervous  affections, 
883 ;  harm  from  healing  of  ulcers,  413  ;  scars,  419 ;  forms  of  ulcer  in  bone,  441 ; 
osteoid  cancer  of  soft  parts,  442;  tumors  of  bone,  444  ;  temperature  in  joint  dis- 
ease, 474;  hysterical  disease  of  joints,  474  ;  wasting  in  joint  disease,  482  ;  phle- 
bitis, 562;  removal  of  tongue,  606  ;  oesophiigeal  stammering,  611 ;  warm  bath 
in  strangulated  hernia,  622  ;  extraperitoneal  operation  for  hernia,  632;  venereal 


XXXVlll  INDEX    or    AUTHORS. 

ulcers  of  rectum,  G63;  sexual  hypochondriasis,  839;  varicocele,  840;  phimosis 
treated  without  operation,  842  ;  disease  of  nipple  followed  by  cancer  of  breast, 
867  ;  carbuncle,  891 ;  facial  carbuncle,  890 

Pancoast:  aortic  tourniquet,  921 

Pamun  :  bacteria  and  blood-poisoning,  G3 

Partridge:  laceration  of  duodenum,  232;  anatomy  of  imperforate  anus,  GGG ;  gan- 
grene of  penis,  844 

Peacock:  dissecting  aneurism,  522 

Pearson:  mercurial  erethism,  399 

Perrive:  rupture  of  stricture,  79G 

P/iillips,  B. :  dislocation  of  astragalus,  330 

Pick:  traumatic  fever,  46,  48;  phagedena,  83  ;  injury  of  artery,  108 

Pilz  :  statistics  of  ligature  of  carotid,  542 

Pirogoff :  amputation  of  foot,  927 

Pirric  :  acupressure,  122;  reduction  of  dislocation  of  shoulder,  277  ;  reduction  of  dis- 
location of  hip,  325 

Poland:  injuries  of  chest,  ch.  x\,  jjassitn;  tetanus,  89;  glanders,  99;  injuries  of  car- 
tilage, 155;  dislocation  of  ribs,  223;  wound  of  heart,  226;  compound  fracture 
of  patella,  310  ;  dislocation  of  ankle,  329  ;  subclavian  aneurism,  54G 

Politzcr :  method  of  inflating  the  tympanum,  760 

Pollock:  injuries  of  abdomen,  ch.  xii,  passim;  dislocation  of  the  jaw,  201  ;  foreign 
body  in  oesophagus,  21G  ;  blows  on  abdomen,  230;  rupture  of  the  liver,  233  ;  for- 
eign body  in  stomach,  237  ;  dislocation  of  astragalus,  332;  skin-grafting,  421; 
sulphuric  acid  in  caries,  433  ;  mesenteric  aneurism,  550;  median  harelip,  569; 
staphyloraphy,  577;  tumors  of  jaw,  590;  pouch  of  the  ossophagus,  GIO;  mollus- 
cum  tibrosum,  883  ;  excision  of  scapula,  931 

Pooley :  gastrotomy,  239 

Porta:  anastomotic  circulation,  110;   torsion,  123 

Porter  :  ligature  of  common  femoral,  555 

Pott:  injuries  of  the  head,  161  ;  hernia  of  the  bladder,  770 

Qiiain,  Mr.  :  foreign  body  in  bowel,  238;  dissection  of  dislocation  of  hip,  319 

Reilfern  :  injuries  of  cartilage,  156  ;  ulceration  of  cartilage,  467 

Rcverdin :  skin-grafting,  421 

Reyker :  antiseptics,  52 

Richardson  :  ether  spray,  905 

Richerand:  experiment  to  illustrate  the  production  of  popliteal  aneurism,  524 

Ricord  :  length  of  mercurial  course,  406;  syphilitic  inoculation,  410 

Rindfeisch  :  organization  of  blood,  40;  granulation,  43  ;  pus,  42  ;  cicatrization,  45  ; 

tubercle,  377  ;  rickets,  pathology  of,  457  ;  ulceration  of  cartilage,  467  ;  atheroma^ 

521 
Rivlngton  :  dislocation  of  sternum,  223  ;  orbital  aneurism,  545 
Rizzoli :  operation  for  disease  of  jaw,  593;  operations  for  irn]>erforate  anus,  6G7 
Roberts:  flatfoot,  513 

Rochard  :  operation  for  imperforate  anus,  667 
Rodr/ers,  J.  K. :  ligature  of  left  subclavian  (first  ]>art),  546 
Rokiiansky  :  hypertrophy  of  bone,  458 

Roux  :  intracranial  suppuration,  160;  sta|)liyloraphy,  575 
Rfiux,  Jules :  gunshot  wounds  of  femur,  345 

Saemisch:  creeping  ulcer  of  cornea,  672  ;  treatment  of  cornenl  ulcer,  708 

Salter:  swinging  fracture,  143  ;  alveolar  abscess,  585;  phosphorus  necrosis,  587  ;  exan- 

thematous  tooth-tumors,  587  ;  jaw  necrosis,  687  ;  abscess  of  antrum,  589;  epulis, 

590. 


INDEX    OF    AUTHORS.  XXXIX 

Sanderson :  migration  of  IcucocytciS,  "O  ;  inflamrnation,  cli.  i,  pnsfihn  ;  1  yiiiphadenoma, 
5G8 

Sanson:  fracture  of  coronoid  process  of  jaw,  198 

Savory:  scrofula,  ch.  xviii ;  hysteria,  eh.  xix,  pff.s.sim ;  wounds  of  vessel,  109:  col- 
lapse, 108;  concussion,  176;  pathology  of  tumors,  139;  kinds  of  scrofula,  378; 
incision  in  enlarged  bursa,  499  ;   rapid  dilatation  of  stricture,  789 

Sayre:  excision  of  hip,  937 

Scnn  :  bilateral  lithotomy,  815 

Shaw:  injuries  of  spine,  ch.  vu\,  passim. ;  recovery  after  fracture  of  cervical  sj>ine, 
187;   fracture  of  leg,  311  ;  rickets,  45G 

SiMcy :  colloid  and  villous  tumors,  37G 

Sedilloi :  evidenient  des  os,  43'J  ;  incision  in  harelip,  574 

Simon.,  John:  heat  in  inflammation,  34;  inllammation,  cli.  \,  passim;  loose  bodies  in 
joints,  470 

Simon,  of  Rostock  :  primary  union  in  gunshot  wounds,  334 

Simpson,  Sir  J. :  sulphate  of  zinc  as  a  caustic,  901 

Skry :  refracture  of  bone,  153;  dislocation  of  shoulder,  270;  rhinoplasty,  912 

Smith,  H.:  diseases  of  rectum,  ch.  xxiii, /jassiwi. 

Smit/i.,  li.  W. :  dislocation  of  jaw,  201  ;  fracture  of  sternal  end  of  clavicle,  254  ;  frac- 
ture of  neck  of  humerus,  259  ;  separation  of  upper  epiphysis  of  humerus,  251  ; 
injuries  near  the  elbow,  2G3 ;  Colles's  fracture,  267;  dislocation  of  acromion, 
271 ;  extracapsular  fracture  of  femur,  294  ;  dislocation  of  metatarsus,  333  ;  rheu- 
matic arthritis,  471 

Smith,  S. :  dislocation  of  semilunar  cartilages,  327 

Smith,  T. :  congenital  tumor,  496;  harelip  foi'ceps,  570;  staphyluraphy,  575;  affec- 
tions of  cutaneous  system,  892  et  seq. 

Smyth:  successful  ligature  of  innominate,  545 

Soden  :  partial  dislocation  of  shoulder,  279 

Solly:  cyst  of  back  (meningocele?),  495 

South:  fracture  of  neck  of  scapula,  256;  fracture  of  coracoid  iirocess,  257;  jiartial 
dislocation  of  shoulder,  279;   removal  of  scapula,  504 

Souitiam:  cure  of  aneurism  by  anastomosis,  360 

/S/JC/<6'e .-'treatment  of  arteriovenous  aneurism,  528;  amputation  at  shoulder  for  sub- 
clavian aneurism,  545;  elevation  of  shoulder  in  axillary  aneurism,  547 

Stanley:  rupture  of  ureter,  234  ;  phagedenic  ulceration  of  bone,  433;  ulcers  of  bone, 
441  ;  cystic  tumors  of  bone,  451;  hypertrophy  of  bone,  458 

Startin  :  impetiginous  lupus,  884 

Stolies :  gunshot  wound  of  spine,  339 

Stromeyer :  subcutaneous  surgery,  505 

Sivayne  :  diagnosis  of  dissecting  aneurism,  527 

Syme:  injury  to  vein  in  tying  artery.  111  ;  wound  of  artery,  113;  torsion,  123;  ojso- 
phagotomy,  216  ;  caries,  440;  old  operation  for  aneurism,  532  ;  old  ojieration  for 
axillary  aneurism,  546;  ligature  of  internal  iliac,  553;  external  urethrotomy, 
795;  amputation  of  foot,  926;   excision  of  elbow,  935 

Tatiim :  whitlow,  498 

Taylor,  A.  S. :  tetanus,  86 

Taylor  :  extension  in  hip  disease,  479 

Tcnle :  loose  cartilage,  470  ;  macroglossia,  609  ;  rectangular  amputation,  924 

Teale,  Jr.:  injection  of  perchloride  of  iron  in  nsevus,  361;  enucleation  of  nasvus, 
361  ;  suction  operation  for  cataract,  719;  operation  for  symblepharon,  741 

Thotnas  :  fracture  of  jaw,  199 

Tliornpson,  Sir  H. :  urinary  diseases,  ch.  xxxvii, passiwt;  division  of  the  entire  pros- 
tate in  lithotomy,  813;   lithotrity,  822 

Thudiclaiin  :  nasal  douche,  599 


xl  INDEX    OF    AUTHORS. 

Tourdes:  wound  of  internal  mammary  artery,  227 

Toynbee  :  treatment  of  nervous  deafness,  7G4 

Travel- s :  gangrene,  70;  collapse,  128;  cysts  of  bone,  452;   orbital  aneurism,  544; 

excision  of  clavicle,  9o2 
Travers,  Jr.  :  absorption  of  neck  of  femur,  244 
Trousseau:  hydrophobia,  101 
Tufnell:  medical  treatment  of  aneurism,  531 

Vanzetti :  uncipression,  125;  digital  pressure  in  aneurism,  536 

Velpeau :  foreign  body  in  chest,  225  ;  injection  of  spina  bifida,  49() 

Venning :  treatment  of  gonorrhoea,  392;  diagnosis  of  syphilis,  398;  cancer  of  upper 

lip,  582 
Veimeu'd :  foreipressitin,  125;   varicose  veins,  564 
V'idal  dc  Cassis  :  bilateral  lithotomj',  815 

Virchow  :  glanders,  99  ;  nomenclature  of  tumors,  348  ;  ulceration  of  cartilage,  468 
Vulkmann  :  antiseptic  surgery,  52 

Wagstaffe :  transfusion,  127  ;  sarcoma  of  jaw,  591 

Walker,  of  Liverpool:  compression  in  popliteal  aneurism,  537 

Waller:  migration  of  leucocytes,  36 

Walton,  Hagnes:  orbital  aneurism,  544 

Wardrop :  anastomotic  circulation,  116;  distal  ligature,  540 

Watso7i,  P.  H.  :  aneurism  of  profunda,  554;  excision  of  knee,  939 

Watson,  Sir  T.  :  foreign  bod}'  in  bronchus,  213 

Weber:  ulceration  of  cartilage,  468;  nasal  douche,  598 

Wells,  Spencer:  ovariotomy,  857 

Willan :  porrigo,  879 

Williams:  migration  of  leucocytes,  36 

Wilson:  removal  of  spina  bifida,  496 

Wilson,  Erasmus:  treatment  of  urticaria,  871 

Wolfe:  transplantation  of  excised  portions  of  skin,  912 

Wood:  trusses,  629;  radical  cure  of  hernia,  630  ;  extroversion  of  bladder,  770 

Wormald:  dissection  of  dislocation  of  hip,  319;  reduction  of  dislocation  of  hip, 

320  ;  treatment  of  varicocele,  840 
Wunderlich:  temperature  in  injury  of  the  spine,  187 

h- 
Yuuatt :  hydrojjhobia,  101 


SURGERY: 

ITS  PRINCIPLES  AND  PRACTICE. 


CHAPTER    I. 

INFLAMMATION  AND  THE  PROCESS  OF  UNION  IN  SOFT  PARTS- 
TRAUMATIC  FEVER— DRESSING  OF  WOUNDS. 

Inflammation  is  the  name  given  to  a  perverted  vital  action,  one  of 
the  leading  features  of  which,  as  the  name  implies,  is  the  production  of 
unnatural  heat  in  the  part.  Although  the  researches  of  modern  pathol- 
ogists have  greatly  advanced  our  knowledge  of  the  essential  phenomena 
of  the  process  of  inflammation,  yet,  for  practical  purposes,  I  think  it  is 
better  to  commence  the  study  of  inflammation  from  the  old  definition  ol 
it  by  its  four  great  s_ymptoms,  "  redness,  swelling,  heat,  and  pain.'" 

Redneas. — The  redness  depends  on  cungedion,  or  the  loading  of  the 
inflamed  part  with  blood  ;  and  this  congestion  is  spoken  of  in  surgical 
language  as  active^  i.e.^  due  to  an  increased  supply,  or  passive,  i.e.,  due 
to  diminished  power  of  circulation  or  impeded  return  of  blood.  Conges- 
tion is  best  studied,  either  in  a  superficial  part  of  the  human  body,  or  in 
the  web  of  a  frog's  foot,  or  otlier  transparent  part,  spread  out  under  the 
microscope.  Thus,  in  the  ocular  conjunctiva,  after  the  lodgment  of  a 
grain  of  dust  in  the  eye,  red  vessels  will  be  seen  shooting  over  parts 
which  before  were  perfectly  white,  and  soon  the  membrane,  which  in  its 
natural  state  was  transparent  and  imperceptible,  is  converted  at  the  part 
injured  into  a  pulpy  mass  of  dilated  vessels,  from  which  a  copious  dis- 
charge of  fluid  exudes.  In  the  frog's  foot,  on  the  application  of  an  irri- 
tant, the  small  arteries  dilate,  the  stream  of  blood  flows  more  rapidly,  the 
dilatation  extends  to  the  capillaries  and  then  to  the  veins;  next  the  stream 
of  blood  moves  more  slowly,  and  finally  it  oscillates  and  stops  entirely. 
The  period  of  dilated  arteries  and  increased  stream  is  that  of  "active 
congestion  ;"  that  of  dilated  veins  and  diminished  movement,  "  passive 
congestion  ;"'^  The  stoppage  of  the  stream  receives  the  name  of  "  the 
inflammatory  stasis." 

1  This  is  Celsus's  definition  :  "  Nota3  inflammationis  sunt  quatuor,  rubor  et  tumor, 
cum  calore  et  dolore." 

2  Passive  congestion,  however,  is  not  always,  nor  indeed  usually,  an  inflammatory 
symptom.  Any  cause  which  prevents  the  return  of  the  venous  blood — a  lifi^ature 
round  the  limb,  a  tumor  in  the  course  of  the  vein,  even  prolonged  standing  or 
exposure  to  heat,  besides  innumerable  other  similar  conditions — may  determine  pas- 
sive congestion. 


34  INFLAMMATION. 

Swelling. — The  increased  supply  of  blood  in  the  part  must  necessarily 
cause  siceUiug.,  but  another  and  the  main  cause  of  swelling  is  the  extrav- 
asation which  takes  place  in  the  parenchyma  of  the  inflamed  part  as  the 
impediment  to  the  blood-stream  increases.  When  the  blood  is  flowing 
naturally,  through  a  transparent  web,  there  will  always  be  seen  around 
the  central  column  of  the  blood-corpuscles  an  external  part  of  the  ves- 
sel's area,  which  looks  as  if  it  were  empt}' — z.e.,  where  only  the  trans-, 
parent  serum  is  circulating — and,  if  the  individual  blood  disks  can  be 
seen,  they  will  be  observed  to  be  separate  from  each  other.  On  what 
cause  this  mutual  repulsion  between  the  blood-corpuscles  and  the  wall 
of  the  vessel  depends  we  do  not  know,  but  it  is  abolished  by  inflamma- 
tion. The  corpuscles  adhere  to  each  other  and  to  the  wall  of  the  vessel, 
and  soon  the  white  corpuscles  of  the  l)lood  are  seen  to  have  passed  through 
the  membrane  and  to  have  moved  into  the  parenchymatous  tissue.  The 
serum  also  transudes,  and  the  red  globules  are  here  and  there  found  to 
be  cxtravasated.  The  name  of  lymph  is  given  to  this  inflammatory  exu- 
dation, consisting  mainly  of  the  cells  which  are  formed  out  of  the  leuco- 
cytes in  their  various  stages  of  development,  and  partly  of  serous  fluid. 
Red  blood-globules  ma}'  be  intermingled,  but  this  is  accidental.  The 
terra  "fibrin"  is  also  often  employed  as  synonymous  with  lymph. 

Tem2:)erature. — The  temperature  of  an  inflamed  part  is  raised,  to  the 
sensations  of  the  patient  himself  generally,  and  always  to  the  thermometer. 
This  is  familiar  to  everybody  from  his  own  experience,  and  some  increase 
of  temperature  must  evidently  be  caused  by  the  mere  loading  of  the  part 
witli  blood.  But  it  seems,  from  recent  experiments,  that  not  only  is  the 
part  more  richly  supplied  with  blood  at  the  usual  temperature  of  healthy 
blood,  but  that  lieat  is  generated  in  the  inflamed  part,  and  thus  the  tem- 
perature of  the  blood  at  the  focus  of  inflammation  is  raised  above  that 
of  the  rest  of  the  blood.  John  Hunter  taught  the  reverse  of  this  doc- 
trine. He  quotes  some  experiments  which  he  made'  to  prove  that  the 
temperature  of  an  inflamed  part  never  raises  above  tiiat  of  the  blood  in 
the  heart ;  but  these  experiments  were  not  made  with  sufficiently  delicate 
means  of  observation  ;  and  Mi*.  Simon''  has  put  on  record  a  series  of 
thermo-electrical  observations  of  inflamed  parts,  wherel\y  he  has  proved: 
"  1.  That  the  arterial  blood  supplied  to  an  inflamed  limb  is  less  warm  tlian 
the  focus  of  inflammation  itself.  2.  That  tlie  Lienou.H  blood  returning 
from  an  inflamed  limb,  though  less  warm  than  the  focus  of  inflammation, 
is  warmer  than  the  arterial  blood  supplied  to  the  limb ;  and,  8,  that  the 
venous  blood  returning  from  an  inflamed  limb  is  warmer  than  the  cor- 
responding current  on  the  o])posite  side  of  the  body;"  that  is  to  say,  that 
the  lieat  generated  at  the  inflamed  part  raises  the  blood  returned  IVom 
that  part  above  the  usual  tem))eratnre  of  the  mass  of  the  blood.  Wlien 
this  increase  of  heat  is  so  considerable  that  the  natural  loss  of  tempera- 
ture b}' perspiration,  etc.,  is  insufficient  to  counteract  it,  the  temperature 
of  the  whole  body  rises,  and  tlie  other  phenomena  of  "  inflammatory 
fever"  ensue.'' 

Fain. — The  pain  of  inflammation  varies  very  considerablj'.     Even  in 

'  See  Hunter's  works,  l)y  Palmer,  vol.  iii,  pp.  388-340.  In  the  hist  cxpfriinent 
there  detiiiled,  however,  the  reader  will  observe  that  Hunter  noticed  an  increase  of 
the  tri'ueral  temperature  of  the  hody  in  inflammation. 

'■^  Holmes's  .System  of  Suri^ery,  "Ad  (;d.,  vol.  i,  p    18, 

'  I  do  not  mean  that  all  tlie  phenomena  of  inllainmalory  oi-  traumatic  fevei-  depend 
on  th(!  n)ere  rise;  of  tcmipcirature  of  the  blood,  but  as  the  inllammatory  heat  rises  so 
arc  these  phenomena  developed.  Whether  they  depend  on  the  rise  of  temperature, 
or  whether  they  and  it  have  a  common  cause,  is  another  question. 


INFLAMMATORY    FEVER.  35 

inflammation  of  the  largest  and  the  most  vital  organs  there  may  be  little 
or  no  j)ain,  while  in  some  of  the  smallest  (such  as  the  fingers)  tlie  i)ain 
may  be  intolerable.  Much  depends  on  the  extensibility  of  the  inflamed 
part;  thus  the  acute  pain  in  wliitlow  and  in  orchitis  is  explained  by  tlie 
resistance  offered  to  the  increase  of  swelling  by  the  sheath  of  tlie  tendon, 
and  by  the  tunica  albuginea  respectively.  Still  more  depends  on  the 
peculiar  sensibility  of  tlic  organ.  The  physical  cause  of  pain  it  is  often 
impossible  to  ascertain.  Pain  is  often  greater  in  diseases  when  there  is 
no  evidence  of  inflammation  (as  in  neuralgia)  than  when  inflammation 
is  not  only  dangerou'^  but  even  fatal  (as  in  gangrene  of  the  lung);  and 
most  severe  pain  may  be  experienced,  as  every  one  knows,  in  conditions 
of  the  body  which  are  compatible  with  perfect  health.  Yet  this  does  not 
destroy  the  great  importance  of  pain  as  a  symptom  of  disease  in  general, 
and  of  inflammation  in  particular.  It  only  shows  tliat  in  clinical  investi- 
gations it  is  necessary  to  take  account  of  all  the  circumstances  of  the 
case,  not  of  one  only.  The  persistence  of  pain  in  any  given  part  ought 
to  induce  tlie  surgeon  to  examine  closely  the  condition  of  the  general 
system  (pulse,  tongue,  temperature,  and  secretions)  and  of  the  part  itself 
(as  to  redness,  swelling,  heat,  and  the  functions  of  the  organ),  and  on 
such  an  examination  a  secure  diagnosis  can  almost  always  be  founded. 

InJlaDLmcUory  Fever. — Inflammation,  when  extensive  or  very  violent, 
is  accompanied  by  general  fever,  which  is  variously  designated  as  "  in- 
flammatory," "traumatic,"  "surgical,"  "irritative,"  etc.  The  condition 
necessary  for  its  production  appears  to  be  the  overheating  of  the  blood, 
as  stated  above,  and  its  leading  symptom,  therefore,  is  the  rise  of  tem- 
perature of  the  whole  body.  Hence  the  importance  of  the  thermomet- 
rical  observations  which  are  now  so  generally  taken  in  surgical  as  well 
as  in  medical  cases. 

As  typical  of  inflammatory  fever,  for  surgical  purposes,  I  shall  select 
that  form  which  follows  on  a  severe  wound. ^ 

Traumalic  fever  commences  usually  within  twenty-four  hours  of  the 
receipt  of  the  injury,  and  sometimes  dates  almost  from  the  moment  of 
its  receipt.  The  jiatient  feels  hot  and  uncomfortable,  with  occasional 
intervals  of  chilliness,  sometimes  amounting  to  definite  rigor.  He  is 
thirsty  and  reslless,  with  a  rapid  and  perhaps  hard  and  bounding  pulse, 
furred  tongue,  hot  and  dr}'  skin,  scanty  and  high-colored  urine,  consti- 
pated bowels,  flushed  face,  headache,  and  loss  of  appetite.  The  symp- 
toms are  aggravated  towards  night,  when  a  definite  rise  of  temperature 
can  usually  be  noted.  Coincident  with  any  abrupt  and  very  considerable 
elevation  (say  more  than  2"  F.)  of  the  heat  of  the  blood  there  is  almost 
certain  to  be  a  rigor.  In  uncomplicated  cases  of  traumatic  fever  the 
symptoms  will  probably  begin  to  decline  from  about  the  second  day  after 
its  commencement,  and  will  have  entirely  subsided  by  the  fifth,  sixth,  or 
seventh  day;  l)ut  there  is  much  variety  both  as  to  the  period  at  which  it 
attains  its  climax  (or  "fastigium,"  as  it  is  technicallj^  called)  and  as  to 
its  total  duration.  The  first  appearance  of  decrease  is  very  generally 
coincident  with  the  occurrence  of  supi)uration.  After  the  subsidence  of 
the  primary  attack  of  fever  a  secou(lary  attack  sometimes  occurs,  apart 

1  A  good  opportunity  of  watching  tlie  phenomena  of  traumatic  fever  is  furnished 
by  any  great  operation,  such  as  an  amputation,  undertaken  for  the  removal  of  a 
chronic  disease  on  a  person  previously  in  good  general  health.  The  state  of  the 
pulse,  tongue,  and  secretions,  and  the  normal  temperature,  should  be  carefully  noted 
for  the  two  or  three  days  preceding  the  operation  ;  and  morning  and  evening  obser- 
vations should  be  regularly  taken  after  it  until  the  temperature  and  all  other  matters, 
observed  have  returned  to  the  condition  of  health. 


36  INFLAMMATION. 

from  a.uy  other  complication,  but  iisuall}'  the  reappearance  of  fever  de- 
notes the  occurrence  of  some  of  the  comi)lications  of  wounds,  as  deep- 
seated  abscess,  erysipelas,  phagedrena,  or  pyiemia.  When  the  fever  does 
not  subside  at  the  ordinary  time  the  presence  of  some  concealed  source 
of  irritation,  such  as  lodged  foreign  body  or  obstructed  discharge,  is 
probable,  and  should  be  carefully  sought  for. 

We  shall  consider  this  subject  of  traumatic  fever  more  fully  in  its  sur- 
gical bearings  presently. 

Pathology  of  Inflammation. — The  above  is  intended  for  a  rough  sketch 
of  the  leading  symptoms  of  inflammation  as  seen  in  practice.  The  pa- 
thology or  essential  nature  of  the  process  must  next  be  briefly  discussed. 
It  has  long  been  a  controversy  whether  the  phenomena  which  we  term 
inflammation  are  due  to  changes  in  the  nervous  s^'stem,  the  vessels,  the 
blood,  or  the  tissues  ;  nor  is  the  question  one  which  seems  to  admit  of 
any  conlident  answer.  Bnt  the  first  changes  which  are  perceptil)le  to 
the  eye  utfect  the  vessels  and  their  contents  at  once.  The  arteries  dilate;^ 
the  blood-stream  moves  with  greater  rapidity ;  the  red  and  white  blood- 
corpuscles,  which  in  the  natural  state  are  quite  separate  from  each  otlier 
as  well  as  from  the  wall  of  the  vessel,  begin  to  adhere  together  and  to 
stick  to  the  arterial  wall.  As  the  dilatation  extends,  first  to  the  capil- 
laries and  then  to  the  veins,  the  blood-stream  moves  more  and  more 
slowly,  the  vessels  becoming  more  obstructed  by  blood-globules.  Next, 
a  very  remarkable  phenomenon  is  noticed,  i.e.,  the  "-emigration  "  of  tlie 
white  corpuscles,  or  "leucocytes,"  as  they  are  now  usually  called.  The 
experiment  bj?^  whicli  this  emigration  may  be  actually  rendered  visible  is 
very  difficult  to  carry  out  successfully.-  It  leaves  no  doubt  that  the 
white  corpuscles  begin  to  adhere  to  the  wall  of  the  vessel  before  the 
axial  current  (i.e.,  the  current  of  red  l)lood-globules  along  the  centre  of 
the  vessel)  stops  ;  that  the  wall  of  the  vessel  then  exhibits  buds  or  pro- 
jections, as  if  the  leucocyte  were  pushing  its  way  through  ;  that  these 
buds  or  projections  become  connected  with  the  wall  of  the  vessel  l\y  a 
sort  of  tongue  or  string,  which  then  gives  wa}-,  and  leaves  a  body  exactly 
similar  to  a  leucocyte  in  the  parenchyma  external  to  the  vessel;  and  that 
the  vvallof  the  vessel  shows  no  alteration  at  the  part  where  the  leucocyte 
has  thus  passed  through  it.  In  what  precise  manner  this  may  take  place 
it  is  needless  here  to  discuss.  We  may  suppose,  even  if  only  for  the  sake 
of  hypothesis  and  to  render  the  thing  conceivable,  that  the  leucocyte, 
which  is  a  mass  of  prot()i)lasm,  rebuilds  the  wall  of  tlie  vessel  that  it  is 
perforating  (which  is  also  a  mass  of  proto[)hism;  as  fast  as  it  destroys  it.^ 
The  leucocytes  display  the  same  amoeboid  ujovements  after  their  emigra- 
tion which  the}'  are  known  to  do  within  the  vessels,  and  which  seem  to 
be  connected  witii  their  further  development.     (See  Fig.  I.) 

1  It  seems  doubtful  whether  or  not  this  dih^tation  is  preceded  by  ii  period  of  active 
contraction  or  spasm  of  the  vessel.  If  it  be  so,  that  jieriod  is  so  transient  that  it  has 
not  been  found  possible  as  yet  to  afBrm  its  constant  occurrence. 

2  Tills  cxiicrinicnt  was  prohahly  first  performed  by  Dr.  Waller,  before  18-JG;  but 
his  observations  did  not  attract  the  attention  they  deserved.  Coiinheiin  devised  a 
more  |)erfi'Ct  form  of  tin;  exiieriinent,  on  a  frog  paralyzed  by  curare.  It  will  be 
found  ver}'  clearly  described  by  Dr.  Sanderson,  in  Holmes's  System  of  Surs^ery,  p. 
751,  2d  ed.  At  pp.  741-2  of  the  same  volume  will  be  found  an  account  of  the  re- 
searches and  leaching  of  our  distinguislied  countrymen,  Dr.  C.  J.  H.  Williams  and 
Dr.  Addison,  who  so  nearly  anticipated  Cohnheim's  discovery,  in  spite  of  tin;  im- 
perfection of  the  instruments  with  which  at  that  lime  they  were  obliged  to  work. 

'  Some  authors  teach  that  there  are  openings  or  "stomala"  in  the  capillary  wall, 
throui;h  which  the  corpuscles  pass.  It  this  is  tlie  case,  the  corpuscles  must,  "  emi- 
grate "  al.«o  in  the  healthy  processes  of  nutrition. 


PATHOLOGY. 


37 


So  far  the  changes 
observed  refer  wholly 
to  the  vessels  and  their 
contents.  But  that  the 
tissues  around  the  ves- 
sels have  an  independent 
and  most  important  part 
in  the  process  cannot 
be  doubted.  Professor 
Lister^  has  observed 
changes  going  on  in 
the  pigment-cells  lying 
in  the  intervascular 
spaces  of  the  frog's  web 
which  testify  to  an  ac- 
tion entirely  indepen- 
dent of  that  in  the 
blood  or  the  vessels ; 
and  the  action  of  irri- 
tants on  the  non-vascu- 
lar tissues,  such  as  the 
cartilages,  will  be  found 
illustrated  in  subse- 
quent pages.  Again, 
as  the  blood  -  stream 
becomes  retarded,  the 
blood  begins  to  oscillate 
backwards  and  forwards 
in  the  vessels,  and  finally 
stops.  This  inflamma- 
tory stasis  can  be  pro- 
duced even  when  the 
vessels  have  been  en- 
tirely emptied  of  blood 
and  filled  with  milk  in 
place  of  blood.  It  can- 
not, therefore,  entirely 
depend  upon,  though  it 
must  doubtless  be  influ- 
enced by,  the  qualities 
of  the  blood.  Nor  can 
we  imagine  that  the 
mere  vascular  wall  can 
be  the  sole  cause  of  so 
remarkable  a  phenome- 
non. It  must,  there- 
fore, be  caused  in  some 
measure  by  the  vital  ac- 
tions which  are  going 
on  in  the  part  generally. 
And  the  same  conclu- 
sion results  from  many 
of  the  other  recorded 
facts,  for  which  I  must 


\    V. 


C^JES^J^ 


Cohnheim's  experiment  showing  the  emigration  of  the  leuco- 
cytes out  of  a  vein  in  the  mesentery  of  a  frog.  The  times  of  the 
successive  observations  are  marked  on  each  figure,  and  the  indi- 
vidual leucocytes  are  distinguished  by  different  letters,  r  and  g 
denote  two  leucocytes  which  were  external  to  the  vein  at  the  com- 
mencement of  the  observation,  a  was  only  just  attached  to  the 
outside  of  the  wall  of  the  vein  at  the  commencement,  and  was  free 
from  it  at  the  second  observation,  c  had  almost  passed  through 
tlif  wall  at  the  first  observation,  was  only  just  attached  at  the  sec- 
ond, and  was  free  at  the  third.  6  had  commenced  to  adhere  to  the 
interior  of  the  wall  of  the  vein  at  tlje  first  observation,  had  par- 
tially penetrated.it  at  the  second,  was  adhering  to  its  outer  wall  at 
the  third,  and  was  becoming  pedunculated  and  preparing  to  detach 
itself  at  the  fourth.— From  an  experiment  made  for  me  by  my 
friend  and  pupil,  Mr.  J.  R.  W.  Webb. 


1  Pbil.  Trans  ,  1858,  p.  678. 


38  INFLAMMATION. 

refer  to  works  of  more  detail.  The  latest  researches  seem  to  show  that 
irritants  which  do  not  affect  the  walls  of  the  vessels,  though  they  may 
cause  dilatation  of  the  capillaries  and  stagnation  of  the  blood-current, 
are  not  followed  b}^  emigration  of  leucocytes,  or  by  transudation  of  the 
colored  blood-disks  ;  while  if  an  irritant  be  applied  which  acts  so  deeply 
and  so  continuously  as  to  affect  the  wall  of  the  vessel  itself  an  abundant 
emigration  of  colorless  and  colored  blood-disks  ensues — the  former  pass- 
ing chiefly  out  of  the  veins  and  the  latter  from  the  capillaries.^  The 
question  therefore  above  alluded  to  would  be  answered  by  saying  tliat 
the  essential  phenomena  of  inflammation  depend  on  changes  in  all  the 
structures — the  blood,  the  bloodvessels,  and  the  parenchyma  of  the  part 
simultaneously. 

Terminations  of  the  Inflamniatory  Process. — The  process  of  inflam- 
mation maj^  be  regarded  as  destructive  or  constructive,  according  to  its 
terminations.  If  the  process  above  described  should  cease  at  the  point 
to  which  the  description  has  just  been  carried,  the  blood-stream  will  re- 
sume its  movement,  the  vessels  their  normal  size,  the  effused  serum  and 
the  leucocytes  will  disappear  from  the  intervascular  spaces,  and  the  part 
will  resume  in  all  respects  the  functions  and  appearance  of  health.  This 
termination  is  known  in  surgical  language  as  '^  Resolution."  But  if  this 
does  not  occur,  the  inflammatory  exudation  may  become  organized  into 
new  tissue  forganization,  adhesion),  or  it  maj^  break  down  into  pus  (sup- 
puration, abscess),  or  the  tissue  of  the  part  may  become  softened  and 
disintegi'ated  (ulceration),  or  the  whole  part  may  die  (gangrene). 

Effusion  and  Organization. — The  production  of  new  tissue  may  be  re- 
garded as  the  curative  termination  of  inflammation.  It  is  true  that  in 
many  instances  this  newly  formed  tissue  impairs  the  functions  of  the 
part  and  constitutes  in  itself  a  kind  of  disease.  Thus  the  utility  of  joints 
is  destroyed  by  soft  anchylosis,  the  result  of  inflammatory  adhesions  ;  or 
bands  of  adhesion  are  formed  in  the  peritoneum  which  may  fatally  inter- 
fere with  the  movements  of  the  Intestines.  But  it  is  none  the  less  true 
also  that  it  is  upon  such  reproductive  properties  that  all  the  repair  of 
wounds  and  fractures  depends,  and  that  the  greater  part  of  the  practice 
of  surgery  is  directed  to  the  production  and  regulation  of  this  repro- 
ductive process. 

It  will  he  most  convenient,  I  think,  to  study  here  this  curative  termi- 
nation of  inflammation  as  it  is  seen  in  the  soft  parts ;  while  the  chapter 
on  the  union  of  fractures  will  contain  a  description  of  inflammatory  or- 
ganization in  the  hard  tissues.  I  therefore  turn  to  the  general  subject 
of  wounds  and  the  process  of  their  union,  in  order  to  illustrate  the  re- 
sults of  inflammation. 

Wounds  and  Contusions. — A  forcible  solution  of  continuity  in  the  soft 
tissues  of  the  body  is  called  a  wound  ;  but,  in  ordinary  language,  the  ex- 
posure of  the  injured  part  to  the  air  is  implied,  and  the  action  of  some 
weapon  is  also  understood.  When  the  subcutaneous  tissues  are  merely 
bruised,  i.e..,  more  or  less  lacerated  without  the  skin  being  divided,  the 
injury  is  called  a  "  Contusion."  In  a  contusion  there  is  pro1)ably  always 
some  laceration  of  the  fibres  of  the  cellular  tissue,  tiie  vessels  are  more  or 
less  ruptured,  and  blood  is  extravasated  proportionally  into  the  subcuta- 
neous or  parenchymatous  tissue,  or  into  any  of  the  neighboring  cavities  of 

^  See  Dr.  Klein's  account  of  Cohnhoim's  Ifxtest  rosearchos  in  the  London  Mod. 
Record,  December  31st,  1873,  and  January  7th,  1874. 


ORGANIZATION    OF    CI.OT.  39 

the  body.  In  very  severe  contusions,  such  as  are  produced  by  re])eated 
injuries,  the  skin  is  very  extensively  separated  from  the  subjacent  fascia,' 
and  is  consequently  liable  to  perish  for  want  of  blood-supi)ly.  Into  this 
space  blood  is  effused,  which,  showinj};  through  the  skin,  gives  the  familiar 
black  and  blue  appearance  of  a  bruise,  the  color  varying  witli  the  deli- 
cacy of  the  skin,  the  quantity  of  blood  effused,  and  the  structure  of  the 
part.  Thus,  in  the  eyelids,  s(;rotum,  and  vulva  a  bruise  is  black ;  on  the 
scalp,  where  the  skin  is  strengthened  by  the  tendon  of  the  occipito-fron- 
talis,  it  shows  hardly  any  color  at  all ;  on  the  globe  of  the  eye,  where 
the  conjunctiva  allows  the  free  passage  of  the  air,  it  is  scarlet.  The 
black  color  of  an  ordinary  bruise  on  the  surface  of  the  bod}^  fades  away 
into  green  or  yellow  as  the  blood  is  absorbed.  Very  frequently,  when 
the  laceration  has  been  great,  the  blood  remains  for  an  indefinite  time 
collected  in  a  cavity,  the  walls  of  which  are  formed  of  blood-clot  and  con- 
densed tissues,  while  its  contents  consist  of  serum  mixed  with  more  or 
less  of  the  coloring  matter  and  broken-down  corpuscles.  To  such  a  col- 
lection the  name  Hematoma,  or  "blood-tumor,"  is  given.  Blood-tumors 
are  distinguished  from  abscess  by  the  history,  appearing  as  they  do  at 
once  after  the  contusion  ;  by  the  thinner  character  of  the  fluid,  contained 
in  a  wall  of  solidified,  but  not  inflamed,  tissues  ;  and  by  the  uninflamed 
and  unengorged  condition  of  the  integuments.  They  are  comparatively 
common  on  the  scalp  in  infancy  and  childhood,  sometimes  extending 
over  half  or  the  whole  head.  They  usually  subside  spontaneously,  even 
when  of  very  large  size,  though  their  absorption  is  generally  considered 
to  be  accelerated  by  some  of  the  stimulating  lotions  or  embrocations 
usually  ordered,  among  which  arnica  is  perhaps  the  most  in  favor.'^  But 
such  stimulating  applications  should  not  be  made  use  of  immediately 
after  the  injury.  The  application  of  cold  is  indicated  at  first,  so  long  as  it 
seems  probable  that  fresh  blood  is  being  effused  ;  unless  the  skin  is  so  ex- 
tensively separated  that  gangrene  is  to  be  feared,  in  which  case  moderate 
warmth  (as  b}^  water-dressing  or  warm  opiate  lotion)  is  more  advisable. 
In  some  cases,  when  the  effused  blood  shows  no  tendency  to  disappear, 
it  has  been  removed  by  puncture  with  impunity ;  but  as  this  is  usually 
unnecessary,  it  should  not  be  done  except  in  the  last  resort,  and  then  the 
"aspirator"  of  Dieulafoy,  or  some  such  invention  for  avoiding  the  en- 
trance of  air,  should  be  employed.  If  the  tissue  around  inflames,  form- 
ing pus,  the  bloody  fluid  becomes  decomposed  and  a  serious  form  of  fever 
may  be  generated.  In  such  a  case,  as  in  that  of  inflammation  of  the  sac  of 
an  abscess,  it  becomes  necessary  to  lay  open  the  cavity  freely,  wash  it  out 
with  carbolic  lotion  daily,  and  support  the  patient's  strength  through  the 
ensuing  fever.  Thus  we  see  that,  as  a  rule,  contusions  do  not  require 
any  inflammatory  process  for  their  cure;  and  that  when  inflammation 
follows  on  a  contusion  it  is  usually  as  a  complication,  and  one  which, 
when  it  reaches  the  stage  of  suppuration,  may  prove  a  formidable  one. 
But  the  hardening  which  sometimes  remains  permanently  in  a  contused 
part  is  also  very  probably  in  many  cases  the  result  of  chronic  inflamma- 
tion, leading  to  the  formation  of  a  low  form  of  fibrous  tissue. 

The  question  as  to  the  organization  of  blood-clots  is  one  of  much  inter- 

1  In  examining  the  body  of  a  schoolboj'  who  had  been  beaten  to  death  by  his 
schoolmaster,  Mr.  Prescott  Hewett  and  I  found  the  skin  so  extensively  separated 
from  the  fascia  lata  that  a  common  walking-stick  could  easily  be  laid  between  them. 

^  The  applications  in  common  use  in  cases  of  contusion  are:  Tincture  of  arnica, 
gently  rubbed  in,  either  pure  or  diluted  with  its  own  bulk  of  water,  or  as  a  lotion 
•with  five  to  ten  parts  of  water;  or  poultices  of  black  briony-root  (much  valued  by 
pugilists) ;  or  Friar's  balsam  or  soap  and  opium  liniment. 


40  INFLAMMATION. 

est,  both  in  a  pathological  and  a  practical  point  of  view.  John  Hunter 
tauglit  unreservedl}'  that  coagulated  blood  "either  forms  vessels  in  itself, 
or  vessels  shoot  out  from  the  original  surface  of  contact  into  it,  forming 
an  elongation  of  tliemselves,  as  we  have  reason  to  suppose  they  do  in 
granulations;"  and  in  order  to  define  his  meaning  more  precisely,  he  im- 
mediately adds,  "I  have  reason,  howcA'er,  to  believe  that  the  coagulura 
has  the  power,  under  ordinary  circumstances,  to  form  vessels  in  and  out 
of  itself;"  and  of  this  supposition  he  proceeds  to  give  proofs,  for  which 
I  must  refer  the  reader  to  the  original.^  On  this  supposed  property  of 
extravasated  blood  to  take  on  active  processes  of  organization  in  its  own 
substance,  independent  of  the  structures  amongst  which  it  was  lying, 
depended,  amongst  many  other  surgical  doctrines  and  precepts,  the 
treatment  so  much  recommended  by  Sir  A.  Cooper,  and  still  occasion- 
ally practiced,  of  laying  a  piece  of  lint  steeped  in  the  blood  of  the  part 
over  the  wound  of  a  compound  fracture,  in  order  that  the  blood  might 
form  a  bond  of  union,  and  convert  the  compound  into  a  simple  fracture. 
It  seems,  however,  to  say  the  least,  highly  dubious  whether  any  such 
self-organization  of  clots  is  possible.  The  practical  result  is  doubtless 
the  same,  viz.,  that  in  the  substance  of  the  clot  vessels  are  formed,  and 
ultimately  the  coagulum  is  replaced  by  a  membrane  or  fibrous  tissue 
more  or  less  complete,  and  including  in  its  substance  the  remains  of 
the  blood-corpuscles.  But  it  seems  more  probable,  as  Rindfieisch  has 
pointed  out,^  that  the  efficient  agents  in  this  organization  are  leucoc^'tes, 
whicli  are  derived,  not  from  the  white  corpuscles  of  the  clot  itself,  but 
by  immigration  from  the  neighboring  tissues.  "Artificial  thrombi," 
says  this  author,  "  have  been  produced  by  tying  arteries  in  the  lower 
animals  ;  cinnabar  has  then  been  injected  into  the  blood,  and  its  leu- 
cocytes impregnated  with  this  fine  granular  material,  which  is  easil}'' 
recognizable  under  the  microscope.  It  was  found  that  those  cells  from 
which,  on  the  second  or  third  day  after  the  occurrence  of  coagulation, 
the  organizing  process  appeared  to  set  out,  contained  cinnabar — the 
inevitable  inference  being  that  they  had  emigrated  into  the  clot  from 
without."  He  then  describes  the  branching  out  and  communication  of  the 
leucocytes  to  form  "  a  delicate  protoplasmic  network  with  nuclei  in  its 
nodal  points,"  through  which  capillary  cliannels  are  afterwards  opened 
out,  these  channels  ultimately  anastomosing  with  the  vasa  vasorum ; 
while  in  the  interspaces  a  connective  tissue  is  formed  from  the  fibrin  of 
the  clot,  involving  in  its  meshes  the  remains  of  the  blood-corpuscles, 
wiiich  at  first  entirely  obscure  it ;  and  then,  a>  the  clot  shrinks  and 
hardens,  they  wither  away,  lose  their  coloring  matter,  and  there  remains 
instead  of  every  red  corpuscle  a  flake  of  colorless  protoplasm. 

All  tliis  applies  to  the  organization  of  non-laminated  thrombi  contained 
within  the  vessels.  Of  tlie  minute  phenomena  of  organization  in  extra- 
vascular  and  laminated  coagula  nothing  is  known.  More  will  be  found 
on  the  changes  which  intervascular  thrombi  undergo  in  the  chapters 
treating  of  the  diseases  of  the  Arteries  and  Veins. 

Treatment. — The  treatment  whicli  is  to  l)e  selected  in  any  case  of  con- 
tusion depends  on  tiie  severity  of  tlie  injury.  When  the  blow  (as  is  often 
the  case)  entails  much  loss  of  power  and  pain  in  attempted  movement,  it 
is  obvious  that  rest  is  the  main  recpiisite.  Warmth  sliould  be  ai)plied, 
as  by  a  piece  of  heated  spongio-piline,  or  warm  lotion,  covered  with  oiled 


'  On  tho   Blood,  Inflamrniilion,  hihI   (Jiiiisliot  Wounds.     Works,   by  PahiK;!-,  iii, 
^  Piithological  Histology,  trans,  for  tho  New  Syd.  Soc,  vol.  i,  p.  225. 


UNION     BY     FIRST    INTENTION.  41 

silk.  In  smaller  and  less  disabling  injuries  some  active  movement  is 
desirable,  and  gentle  rubbing  will  relieve  the  pain  and  promote  absorp- 
tion of  the  effused  blood. 

Wounds  are  divided  for  purposes  of  description  into  incised,  i.  6.,  simple 
cuts  in  whicli  the  length  bears  a  considerable  proportion  to  the  depth  ; 
jjuncfured,  in  which  the  deptli  much  exceeds  the  length,  the  latter  being- 
more  of  the  nature  of  a  prick  than  a  cut;  subcutaneous,  which  are  surgi- 
cal wounds  in  which  a  considerable  extent  of  tissue  (generally  including 
one  or  more  large  tendons  or  muscles)  is  divided  through  a  mere  punc- 
ture of  the  skin,  and  which  are  therefore  examples  of  one  kind  of  punc- 
tured wounds  ;  contused,  in  which  tlie  divided  tissues  and  those  around 
are  contused  as  well  as  cut ;  and  lacerated,  in  which  the  whole  or  a  por- 
tion of  the  solution  of  continuity  is  caused  by  tearing  and  not  by 
cutting. 

The  incised  are  the  most  common,  and  those  from  which  the  process  of 
union  is  best  studied. 

Tlie  processes  by  which  wounds  are  united  illustrate  very  aptly  the 
various  events  of  inflammation,  regarded  both  in  its  curative  and  in  its 
destructive  aspect. 

1.  Immediate  Union. — When  the  surfaces  of  a  clean-cut  wound,  such 
as  that  made  in  the  operation  for  harelip,  are  careful!}^  adapted  to  each 
other,  and  supported  for  a  sufficient  lengtli  of  time  in  apposition,  they 
will  probably  be  found  to  present  no  sign  of  inflammation  appreciable  by 
the  senses,  and  in  the  course  of  from  twenty-four  to  forty-eight  hours  the 
wound  will  be  so  soundly  united  as  to  require  no  further  attention,  nothing 
being  left  except  a  linear  mark,  which  at  first  looks  more  or  less  red,  but 
gradually  fades  awa}',  and  in  the  case  of  small  cuts  disappears  altogether. 
This  metliod  of  union  is  called  immediate  union  or  primary  adhesion.  In 
this  form  there  is  little  or  no  evidence  of  inflammatory  eftusion,  and  some 
pathologists  have  tauglit  that  the  tissues  merel}'  adhere  and  grow  togetlier. 
Tliis,  however,  is  hardly  an  intelligible  account  of  the  action  of  living 
tissues,  and  it  seems  more  probable  that  the  process  difers  in  no  respect 
from  that  to  be  next  described,  except  in  that  the  symptoms  are  less 
obvious. 

2.  Union  by  First  Intention. — Tlie  next  process  is  that  of  union  by  first 
intention,  or  primary  union.  In  this  the  cut  surfaces  pour  out  a  certain 
quantity  of  blood  which,  if  in  small  quantit}^  is  probably  entirely  ab- 
sorbed, although  it  is  a  very  common  opinion  that  a  portion  of  it  becomes 
organized,  i.  e.,  that  the  leucocytes  become  developed  into  permanent 
tissue  in  the  extravasated  blood,  as  they  do  in  the  inflammatory  effusion. 
In  the  latter  the  process  of  development  goes  on  by  the  amoeboid  leuco- 
cytes attracting  to  themselves  and  absorbing  into  their  tissue  the  pabulum 
appropriate  for  their  nutrition  from  the  neighboring  plasma.  Thus  masses 
of  protoplasm  are  formed,  around  which  a  cell-wall  is  developed.  The 
nuclei  of  these  cells  divide  and  multiply  to  form  new  cells,  of  "  prolife- 
rate," as  it  is  called.  The  rounded  cells  then  elongate  into  fibre-cells, 
out  of  which  are  formed  the  fibrous  elements  of  the  connective  and  vas- 
cular tissues  ;  the  neighboring  vessels  shoot  out  processes  into  the  grow- 
ing tissue,  the  unused  serum,  etc.,  is  reabsorbed,  and  thus  the  wound  is 
closed  by  new  material,  with  no  formation  of  pus. 

For  the  minute  details  of  this  process  I  must  refer  the  reader  to  the 
works  which  treat  specially  of  pathology.  It  will  be  sufficient  here  to 
say  that  as  far  as  is  known  at  present  both  the  vessels  and  the  connective 
tissue  are  formed  out  of  leucocytes,  and  that  the  latter  may  be  furnished 


42 


INFLAMMATION. 


either  by  emigration  out  of  the  vessels,  or  from  the  connective  tissue  of 
the  part;  that  some  of  these  leucocytes  are  converted  into  cells  which 
communicatini);  with  each  other  form  vascular  channels,  wiiile  others  are 
elongated  into  si)indle-shaped  cells,  the  rudiment  of  libres  ;  and  that  the 
vessels  are  formed  in  one  of  two  ways,  either  by  channels  (as  above) 
formed  out  of  leucocytes  and  afterwards  opening  into  the  capillary  tube, 
and  receiving  a  layer  of  endothelium  from  it,  oi"  by.  a  budding  out  of  the 
endothelial  tube  of  the  capillaiT,  which  i)ud  elongates  into  a  loop  and 
opens  into  another  part  of  the  capillary  tube.  The  former  is  called  by 
Billroth  necondari/  and  the  latter  tertiary  vascularization,  in  contradis- 
tinction to  the  primari/  vascularization  seen  in  the  embryo,  in  whicli  the 
vessels  are  directly  formed  by  the  differentiation  of  previously  indifferent 
cells,  others  of  which  are  developed  into  blood-corpuscles. 

Lymphatic  vessels  are  observed  in  the  cicatrix  after  the  formation  of 
the  fibres  of  which  it  is  composed,  and  nerves  are  also  probabl}'  produced 
in  it.  Muscular  tissue  is  never  reproduced,  but  the  interspace  caused  in 
a  muscle  by  a  wound  is  filled  up  with  fibrous  tissue. 

3.  Union  by  Second  Intention. — If  the  infiammation  passes  this  point, 
then  we  have  the  phenomena  of  iii(ppu7-ation,  one  of  the  destructive  ter- 
minations of  the  inflammntory  action,  and  the  method  of  union  is  that 
M-hich  is  known  b}'  the  technical  name  of  union  by  the  second  intention. 
The  inflammatory  leucocytes  instead  of  developing  into  fibre-cells  and 
forming  tissue  become  developed  into  pia^-globules,  and  the  exudation 
breaks  down  more  or  less  completely  into  a  creamy  ttuid  called  pus, 
which  consists  of  these  globules  floating  in  serum,  the  liquor  puris.  Pus- 
globules,  as  seen  out  of  the  bod\',  are  but  little  different  in  appearance 

from  leucocytes.  The  leucocyte  when  treated 
with  acetic  acid  displays  the  appearance  of 
a  nucleus  in  its  interior,  that  appearance 
being  usually  regarded  as  the  result  of  a 
shrinking  of  the  i)rotoplasm  of  which  it  is 
composed.  The  pus-globule  shows  more 
distinct  trace  of  a  membrane,  and  is  fre- 
quently many-nucleated  when  treated  with 
acid,  a  condition  which  Kindfleisch  regards 
as  indicating  a  tendency  to  degenerate  and 
break  down.  But  tiie  same  author  says  that 
many  of  the  corpuscles  of  pus  displa}'  no 
difierence  whatever  in  character  from  the 
blood  leucocytes,  having  only  single  nuclei^ 
showing  the  same  auKcboid  movements,  and 
being  in  fact  obviously  the  same  things,  both 
in  structure  and  function.  This  should  be 
borne  in  mind  in  connection  with  the  fact  that  suppuration  is  not  in  most 
cases  wholly  a  destructive  process,  but  serves  also  as  one  of  the  usual 
modes  of  repair. 

The  result  then  of  the  process  of  suppuration  is  twofold.  Tiie  greater 
part  of  the  pus  is  sooner  or  later  cast  out  of  the  body.  When  the  suppu- 
ration is  in  tiie  interior  of  tin!  body  this  is  effected  usually  by  the  forma- 
tion of  an  abscess  ;  the  pus-globules  make  their  way  to  a  common  centre, 
and  the  matter  becomes  inclosed  in  a  cyst  or  cavity  formed  by  inflamed 
tissue.  As  the  inflammation  progresses  the  tissues  soften  and  break  down 
in  some  definite  direction,  usually  towards  the  surface  of  the  skin  or  one 
of  the  cavities  of  the  body,  and  the  pus  shows  tiirough  the  thin  tissue 
which  is  raised  up  by  the  fluid  underneath  it,  allowing  perhaps  even  the 


P'IG.  2. 


Pus-corpusoles.  a.  From  a  lioaltliy 
graDuhitins  woniiil.  6.  From  an  »]>- 
scess  in  tlie  areolar  tissue,  c.  The 
same  treated  with  dilute  acetic  acid. 
tl.  From  a  sinus  in  bone  (necrosis),  e. 
Migratory  pns-corpiiseles.  From  Rind- 
flei-sch's  Pathological  Histology. 


INFLAMMATORY    SOFTENING. 


43 


color  of  the  pus  to  be  distinguished.  Then  the  abscess  is  said  to  point, 
and  will  shortly  burst,  if  not  opened  by  the  surgeon.  In  some  cases, 
however,  no  such  collection  of  the  pus  takes  place,  the  matter  is  difi'used 
with  no  definite  limit  through  the  interstices  of  the  part — cliffiixe  injiam- 
matiim.  When  suppuration  occurs  on  the  internal  surface  of  one  of  the 
cavities  of  the  body,  as  in  i)urulent  inflammation  of  a  synovial  membrane, 
it  forms  what  is  often  spoken  of  as  abscess  of  the  cavity,  altliough  the 
matter  is  really  contained,  not  in  a  cyst  formed  by  the  inflamed  tissues, 
but  in  the  natural  bag  of  the  serous  or  synovial  membrane,  which  in 
some  cases  may  be  free  from  inflammation  at  the  part  where  the  pus  is 
found. 

In  flammatory  Softening. — As  the  tissues  inflame,  and  as  the  leucocytes 
multiply,  the  normal  cells  of  the  part  proliferate,  that  is  to  say,  they 
give  rise  to  fresh  cells  by  the  multiplication  of  their  nuclei,  while  they 
themselves  become  indistinguishable.     Coincidently  with  this  the  fibres 


Vertical  section  through  the  edge  of  a  gnuuilating  surface  in  process  of  repair  (after  Rindfleisch).  a. 
Secretioii  of  pus.  6.  Granulation-tissue  (embryonic  tissue)  with  capillary  loops,  whose  walls  consist  of 
a  layer  of  cells  longitudinally  disposed  ;  their  thickness  decreases  as  we  approach  the  surface,  c.  Cica- 
trization beginning  at  the  base  (spindle-cell  tissue),  d.  Cicatricial  tissue,  e.  Fully  formed  cuticle,  its 
middle  layer  consisting  of  grooved  cells.   /.  Young  epithelial  cells,    g.  Zone  of  ditferentiation. 


of  which  the  part  is  composed  soften,  and  in  many  parts  a  considerable 
amount  of  oil  is  produced  in  their  interior.  All  this  is  quite  consistent 
with  absence  of  suppuration,  and  the  inflammatory  softening  may  be  re- 
placed, or  succeeded.  b>Mnflammatoi'y  organization,  and  the  part  become 
much  more  dense  and  solid  than  natural,  as  we  constantly  see  in  inflam- 
mation of  bones.     But  if  it  proceeds  a  step  further  the  softened  and  de- 


44  I  N  F  L  A  ]\r  M  A  T I  O  N. 

generated  tissues  begin  to  melt  away  in  suppuration,  and  the  condition 
of  uhrrafion  ensues,  denominated  by  Hunter  "  molecular  gangrene,"  in 
which  minute,  imi)erceptible  portions  of  the  tissues  die,  and  are  either 
carried  ott"  with  the  discharges  or  removed  by  the  absorbent  vessels  (the 
veins  or  lymphatics),  causing  a  breach  of  surface,  which  when  on  a  free 
surface  is  filled  up  by  granulation  and  cieatrizaHon. 

GranulaUom^. — When  the  pus  is  formed  on  a  free  surface  much  of  it 
is  merely  discharged,  but  the  surface  of  the  wound  is  all  the  time  under- 
going a  process  of  organization  called  granulatiun.  To  the  naked  eye, 
or  under  a  lens  of  low  power,  the  surface  of  a  wound  or  ulcer  covered 
with  granulations  ("a  granulating  surface,"  as  it  is  usually  called)  looks 
something  like  coarse  red  velvet,  that  is,  it  is  studded  with  innumerable 
small  red  projections  which  are  concealed  by  the  pus  and  serous  fluid  ex- 
uding from  the  wound,  but  are  brought  into  sight  by  gently  drying  it. 
If  one  of  these  granulations  be  examined  in  tlie  microscope,  after  having 
been  artificially  hardened,  it  will  be  seen  to  be  composed  chiefly  of  a  col- 
lection of  large  granular  cells  (exudation-cells,  as  they  used  to  be  called) 
with  pus-cells  on  the  surface  and  fibre-cells  at  the  deeper  parts;  intermin- 
gled with  these  cells  there  are  new  vessels  which  shoot  into  tiie  granula- 
tions from  the  capillaries  of  the  wounded  or  inflamed  surface,  and  the 
whole  is  permeated  by  fluid.  The  cells  on  the  surface  may  occasionally 
be  seen  to  be  developed  into  epithelium.  The  cavity  of  the  wound  is 
closed  by  the  constant  organization  of  the  deep  parts  of  these  granulations, 
as  the  superficial  parts  melt  away  into  pus,  and  ultimately  by  the  forma- 
tion of  epithelium  over  their  surface,  "  skinning  over,"  as  it  is  popularly 
called. 

Cicalrization. — The  cuticle  is  formed  mainly  by  the  differentiation  of 
the  outermost  cells  of  the  granulating  surface;  l)ut  it  seems  probable  that 
the  proximity  of  the  natural  epithelium  of  the  edge  of  the  ulcer  or  wound 
has,  to  say  the  least,  a  considerable  effect  in  producing  or  disposing  to 
the  production  of  this  new  epithelium.  For  though  in  an  ulcer  new  for- 
mations of  epithelium  may  often  be  seen  far  away  from  the  edges,  yet  the 
skinning  over  far  more  commonly  spreads  from  the  edge,  i.e.^  from  the 
old  e[)idermis;  and  the  piienomena  of  skin-grafting  also  show  how  much 
the  production  of  epidermis  is  hastened  b}'  applying  a  healthy  epidermal 
tissue  on  healthy  granulations. 

The  formation,  then,  of  the  cicatrix  in  union  by  second  intention  differs 
veiy  widely  in  its  external  phenomena  from  that  which  is  seen  in  union 
by  first  intention,  and  alltlie  differences  are  in  favor  of  the  latter  process. 
In  the  su])purative  union  there  is  greatly  more  destruction  of  tissue,  much 
more  time  is  required,  all  the  symptoms  afl'ecting  tiie  palient's  health  are 
far  more  severe;  and  the  newly  formed  bond  of  union  is  more  lowly  or- 
ganized, more  prone  to  various  degenerations,  and  more  inadequate  to 
replace  the  tissue  in  whose  place  it  has  been  deposited.  Yet,  as  will  be 
seen  from  the  above  sketch,  the  essence  of  botli  processes  is  the-same. 
'Both  depend  on  the  organization  of  leucocytes  into  cellular  tissue,  and 
the  development  of  new  vessels;  and  the  essential  features,  both  of  vas- 
cularization and  of  organization,  are  similar,  only  that  in  the  secondary 
union  nu\ny  of  the  leucocytes  lie  too  far  from  the  vessels  to  obtain  the 
nourisliment  which  is  necessary  for  their  growth,  and  therefore  break 
down  into  pus. 

4.  Union  by  ^^ Secondary  Adhesion.'''' — Besides  the  common  process  of 
repair  l)y  supi)uration,  i.e.,  union  by  granulati'ju,  or  liy  second  intention, 
tliere  are  two  other  pi'ocesses  dcscrilied  by  Paget  analogous  tf)  and  in  lact 
to  a  great  extent  identical  with  it  essentially',  Ijiit  dillering  in  some  ini- 


CICATRICES.  45 

povtant  practical  details  ;  they  are  union  l)y  s^econdary  adhesion ^  or  by 
the  third  intention.,  and  union  under  a  scab.  The  former  process  is  best 
illustrated  by  the  wound  of  an  operation  for  harelip  in  which  the  attempt 
to  obtain  primary  union  has  failed,  and  the  surfaces  of  the  wound  have 
begun  to  granulate.  If  the  ordinary  process  of  union  by  second  intention 
were  allowed  to  go  on  to  its  termination,  these  granulations  would  grad- 
ually fill  the  wound  up  until  the  whole  cavity  was  closed  more  or  less 
Imperfectly  by  a  dense  cicatrix ;  or,  as  would  most  likely  be  the  case  in 
the  instance  supposed,  the  two  surfaces  of  the  lip  would  scar  over,  and 
the  cavity  would  not  be  filled  at  all.  But  sometimes,  when  the  granula- 
tions are  perfectly  healtliy,  if  the  surfaces  be  brought  evenly  together 
throughout,  they  will  adhere  without  any  further  suppuration,  the  grow- 
ing tissue  at  the  base  of  one  set  of  granulations  coalescing  witli  tliat  at 
the  base  of  those  on  the  opposite  side,  and  thus  the  wound  will  be  closed 
perfectly  and  at  once. 

The  advantages  of  this  process  are  that  it  leaves  ranch  less  scar  beliind  ; 
that  the  scar  is  much  more  nearly  equal  in  size  to  the  cavity  wliich  it  fills, 
and  that  it  is  completed  in  a  very  short  space  of  time,  so  that  any  bone  or 
otlier  important  part  which  has  been  exposed  in  the  wound  gets  rai)idly 
covered  over  and  defended  from  the  inflammatory  action.  The  two  former 
points  are  of  interest  in  wounds  of  the  face  or  other  exposed  part ;  the 
last  is  of  great  importance  in  scalp  wound,  where  exposed  bone  can  often 
be  rapidly  covered  by  bringing  the  granulating  edges  (if  perfectly  healthy) 
into  contact  by  means  of  one  or  two  silver  sutures,  and  thus  all  risk  of 
necrosis,  or  inflammation  of  the  exi)osed  cranium,  will  be  avoided. 

5.  Union  under  a  svab.i  or  union  by  scabbing,  takes  place  either  in  fresh 
wounds  or  in  those  wliich  have  Iteen  previously  grautdating.  In  fresh 
wounds  the  surface  is  covered  by  a  laj'er  of  dried  l)lood,  or  of  the  inspis- 
sated secretion  (serum  and  lymph),  which  will  ooze  from  the  divided 
vessels  just  after  the  bleeding  has  ceased;  and  when  this  comes  away  the 
surface  is  found  to  be  skinned  over.  The  exact  nature  of  this  process 
does  not  seem  to  be  altogether  understood.  It  is  constant  in  animals, 
but  very  rare  in  man,  though  Sir  J.  Paget  relates  two  instances  in  which 
even  so  large  a  surface  as  that  left  after  removal  of  the  breast  has  been 
thus  healed. 

In  the  case  of  a  granulating  wound  the  surface  of  the  granulations  is 
coated  over  either  naturally  with  inspissated  secretion  (pus  and  serum), 
or  ai'tificially  with  some  semi-fluid  substance  which  excludes  the  air ;  the 
superflcial  portion  of  the  granulations  is  then  at  once  converted  into  epi- 
thelium, and  the  cicatrization  is  completed  without  further  su})puration. 
When  the  scab  falls  off  a  scar  is  found  below  it. 

Cicatricex. — The  material  by  which  a  wound  is  united  is  called  a  cica- 
trix. It  differs  from  the  normal  tissue  which  it  has  replaced  in  man}' 
important  particulars.  As  Rindfleisch  says:  "The  cicatricial  tissue  is 
far  from  being  a  connective  tissue  of  ideally  high  quality.  On  the  con- 
trary, its  fibres  are  stiff,  inelastic,  and  misshapen  ;  its  cells  are  represented 
b}'  shrunken,  staff-shaped  nuclei,  and  its  vital  capacity  is  proportionally 
reduced.  Moreover,  the  cicatricial  tissue  exhibits  an  extreme  proneness 
to  contract  in  all  its  dimensions.  ...  It  need  hardly  be  said  that  this 
general  diminution  in  bulk  is  a  physical  rather  than  a  vital  phenomenon. 
The  removal  of  water  has  a  great  deal  to  do  with  it,  for  the  white  glis- 
tening tissue  of  a  cicatrix  is  dry,  compact,  and  harder  to  cut  than  any 
other  variety  of  connective  tissue."  These  remarks  of  Rindfleisch  are 
applied  by  him  to  the  cicatrix  produced  by  primary  union  ;  but  they 


46  INFLAMMATION. 

apply  still  more  forcibly  to  that  of  tiie  union  by  second  intention  ;  and 
generally  it  may  be  said  that  the  longer  a  cicatrix  is  in  forming,  the  more 
imperfect  will  be  its  organization,  the  more  will  it  be  likely  to  fall  short 
in  bulk  of  the  parts  which  it  replaces,  and  the  more  liable  will  it  be  to 
all  the  various  diseases  which  affect  scars,  sucii  as  contraction,  ulceration, 
cheloid,  and  cancerous  degeneration.  All  these  diseases  will  be  Ibund 
treated  in  the  chapter  on  Ulcers. 

Traumatic  Fever. — We  have  spoken  incidentally  of  traumatic  fever  as 
one  of  the  occasional  phenomena  of  inflammation,  but  this  subject  is  so 
important  in  |)ractical  surgery  that  it  demands  a  very  careful  study. 
The  inflammatory  process  involves,  as  we  have  seen  (p.  iU),  as  one  of  its 
necessary  results,  the  generation  of  heat  in  the  blood  of  the  inflamed 
part.  When  that  part  is  small  and  insignificant  the  slight  additional 
heat  thus  imparted  to  the  total  mass  of  the  blood  is  easil_y  got  rid  of  by 
the  natural  processes  of  transpiration  through  the  skin  and  lungs.  But 
if  the  inflammation  is  very  extensive  the  bodily  powers  may  not  be  suHfi- 
cient  to  clisi)os.e  of  the  excess  of  heat — the  whole  mass  of  blood  then  rises 
in  temperature,  and  the  phenomena  of  fever  result.  This  is  the  simplest 
theory  which  can  be  formed  of  the  causation  of  fever,  and  that  it  is  true 
in  part,  I  think,  can  be  hardly  douI)ted,  though  it  is  far  too  simple  to  be 
acce[)ted  as  a  solution  of  all  the  complicated  facts  of  inflammatory  fever. 
Besides  this  mere  increase  of  heat  from  simple  inflammation,  it  seems 
necessary  to  admit  tliat  the  blood  is  also  poisoned  by  the  imbibition  of 
some  product  of  inflammation  ;  and  hence  the  intimate,  not  to  say  indissol- 
nble,  connection  between  traumatic  fever  and  that  constitutional  infec- 
tion now  commonly  called  septicaemia. 

That  traumautic  fever  ma_y  originate  independently  of  absorption  of 
any  of  the  products  of  decomposition,  or  even  of  inflammation,  is  proved 
by  the  fact  that  it  arises  occasionally  almost  immediately  alter  the  injury, 
and  nearlj"  as  soon  as  tlie  inflammation  itself  does.  Since,  in  these  cases, 
there  has  been  no  time  for  the  imbibition  of  decomposing  matters  into 
the  blood,  there  are,  as  far  as  I  can  see,  only  two  hypotheses  l)y  which 
the  occurrence  of  fever  can  be  explained,  viz.,  either  tiie  simple  one  of 
increase  in  the  heat  of  the  blood,  or  the  supposition  (which  is  onl^^  slightly 
different)  that  such  overheated  blood,  circulating  through  the  nervous 
centres,  disturbs  the  chief  functions  of  respiration,  circulation,  etc.  But 
since,  commonly  speaking,  fever  does  not  set  in  till  a  period  at  which  the 
products  of  inflammation  have  formed  and  have  had  time  to  decompose 
or  ferment,'  since  similar  phenomena  niay  doubtless  be  excited,  in  a  pre- 
viously healthy  animal,  l>y  the  injection  into  the  circulating  blood  of  va- 
rious putrefying  matters  ;  and  since  the  gravity  of  the  traumatic  fever 
seems  often  to  bear  a  proportion  to  the  amount  of  decomposition  present 
in  tlie  wound,  it  appears,  to  say  tiie  least,  probable  in  the  highest  degree 
that  tiie  ellicient  cause  of  the  fever  is  in  most  cases,  tliougli  not  in  all, 
the  imbiitition  of  some  of  the  pioducts  of  inflammation  into  tlie  blood. 
On  this  point  Billroth  speaks  as  follows  : 

"  .Since,  from  the  nature  of  the  process  in  the  inflamed  part,  some  of 
the  tissue  is  destroyed,  while  some  new  tissue  is  formed,  it  is  notiraprob- 

1  Billroth  SHys  that  in  hi.*  numerous  observations  the  fever  has  usually  been  found 
to  coiTim(;noe  before  tlie  end  of  the  >coond  day.  Mr.  Pick  (St.  George's  Ho.spital 
Reports,  vol.  iii)  says  that  out  of  108  cases  "  in  no  single  instance  did  it  occur  after 
the  fifth  day,  and  in  some  cases  it  occurred  within  the  first  twenty-four  or  forty- 
eiirht  hours." 


TRAUMATIC    FEVER.  47 

able  tliat  some  of  the  products  of  this  <lestruction  enter  tlie  blood,  partly 
through  the  bloodvessels,  partly  through  the  lymph  vessels;  such  material 
acts  as  a  ferment,  excites  change  in  the  l)lood,as  a  consequence  of  which 
the  entire  amount  of  blood  may  be  warmed.  We  might  also  admit  a  more 
complicated  mode  of  development  of  warmth,  which  by  including  the 
nervous  system,  might  in  some  respects  he  more  serviceal)le  theoretically  ; 
the  blood,  changed  by  taking  up  tiie  products  of  irritation,  migiit  prove 
irritant  to  the  centres  of  the  vaso-motor  nerves,  and  thus  induce  increased 
production  of  warmth.  The  decision  between  these  different  hypotheses 
is  diflicult ;  they  are  all  about  equally  justifiable,  and  all  have  the  common 
factor  of  pollution  of  the  blood  by  material  from  the  seat  of  inflammation 
or  the  wound,  which  is  recognized  as  having  an  effect  on  the  production 
of  heat ;  these  substances  must  have  the  effect  of  exciting  fever  (a  pyro- 
genous  action).  This  was  to  be  proved.  It  has  been  proved  by  experi- 
ments of  0.  Weber  and  myself,  which  I  can  notice  only  briefly  here.  In 
most  open  wounds,  especially  in  contused  wounds,  shreds  of  tissue  are 
always  decomposed  ;  in  many  idiopathic  inflammations  the  circulation  is 
arrested  at  different  points  in  the  inflamed  tissue,  and  there  is  partial 
decomposition  of  these  dead  portions.  Decomposing  tissue,  then,  was 
an  object  to  be  examined  in  regard  to  its  pyrogenous  action.  If  you 
inject  filtered  infusions  of  this  substance  into  the  blood  of  animals  they 
have  high  fever,  and  not  unfrequently  die  with  symptoms  of  debility,  of 
somnolence,  with  coincident  bloody  diarrlioea.  The  same  effect  is  induced 
by  fresh  pus  injected  into  the  blood  ;  a  weaker  effect  follows  the  employ- 
ment of  juice  and  pus-serum  pressed  out  of  the  inflamed  part.  Hence 
the  products  of  decomposition,  as  well  as  those  of  new  formation,  have  a 
pyrogenous  action  in  the  blood.  These  products  are  of  a  very  compli- 
cated and  variable  nature;  some  of  the  chemical  substances  in  them  have 
been  independently  tested  in  regard  to  their  fever-exciting  qualities  :  we 
may  induce  fever  by  injecting  leucin,  sulphuretted  hydrogen,  sulphides 
of  ammonium  and  carbon,  and  other  chemical  substances  resulting  from 
the  decomposition  of  tissue,  or  even  by  injecting  water;  decomposing 
vegetable  matter  also  has  a  fever-exciting  effect.  Hence  there  are  no 
specific  fever-exciting  sulistances,  but  the  number  of  pyrogenous  mate- 
rials is  innumerable.  A  considerable  amount  of  them  is  usually  contained 
in  tlie  inflammatory  foci. 

"After  the  pyrogenous  effect  of  the  products  of  inflammation  and  de- 
composition had  been  absolutely  confirmed,  it  remained  to  be  proved  that 
this  material  could  be  taken  from  the  tissue  into  the  blood,  and  to  be  shown 
how  this  took  place.  For  this  purpose  it  was  injected  into  the  subcuta- 
neous cellular  tissue,  where  it  spread  around  in  the  meshes  of  the  tissue; 
the  effect  as  to  fever  was  the  same  as  when  the  injection  was  made  directly 
into  the  blood:  hence  the  pyrogenous  material  is  absorbed  from  the  cel- 
lular tissue.  Here  there  is  another  observation  to  be  made.  After  a  time, 
at  the  point  where  decomposing  fluid  or  fresh  [nxs  has  been  injected,  there 
is  severe  and  not  unfrequently  rapidly  progressive  inflammation.  For  in- 
stance, I  injected  half  an  ounce  of  decomposing  fluid  into  the  thigh  of  a 
horse:  in  twenty-four  hours  the  whole  leg  was  swollen,  hot,  and  painful, 
and  the  animal  very  feverish.  1  did  tlie  same  thing,  with  the  sameresult, 
with  fresh  (not  decomposing)  abscess  pus,  in  a  dog.  This  action  of  pus 
and  putrefying  matter  in  exciting  local  inflammation  I  call  phlogogenous. 
All  pyrogenous  substances  are  not  at  the  same  time  phlogogenous  ;  some 
are  more  so  than  others,  and,  especially  in  the  putrefying  fluids,  it  makes 
a  great  deal  of  difference  whether  the  poisonous  power,  which  we  do  not 


48  INFLAMMATION. 

know  accurately,  is  present  in  greater  or  less  quantities.  It  is  not  certain 
whether  the  pyrogenons  materials  enter  the  blood  through  the  lymph  or 
bloodvessels."  ^ 

Effect  of  Inflammation  on  the  Blood. — The  condition  of  the  blood  in 
infiamniation  must  be  profoundh^  modified  from  tlie  state  of  health.  Yet 
little  is  really  known  about  it  Iieyond  the  fact  that  it  appears  to  be  very 
commonly  more  rich  in  filirin  than  it  was  before.^  Thus  is  explained  the 
remarkable  appearance  known  as  the  "  buffy  coat"  and  "the  cupping" 
of  the  blood.  "  Perhaps  no  point  is  better  established  in  the  pathology 
of  the  blood,"  says  Simon,  "  than  a  connection  between  i{,s  yield  of  librin 
and  the  presence  of  acute  inflammation.  In  rlieumatic  fever,  in  pneu- 
monia, in  bronchitis,  in  pleurisy,  in  peritonitis,  in  quinsy,  in  erysipelas, 
the  blood's  normal  yield  of  fibrin  has  been  found  doubled,  tripled,  quad- 
rupled, quintupled."  And  in  all  such  conditions  there  is  usually  to  be 
found  the  buffy  coat  (i.  e.,  the  upper  stratum  of  the  clot  is  nearly  or  quite 
destitute  of  color,  consisting  almost  entirel}^,  or  entirely,  of  fibrin),  and 
it  is  also  "  cupped,"  the  upper  surface  being  depressed,  while  the  lower 
strata  of  the  clot  are  somewhat  more  bulky,  so  that  the  whole  clot  is  more 
or  less  conical.  These  appearances  depend  doubtless  in  part  on  the  greater 
fibriniferousness  of  the  blood,  but  partly  also  on  its  slower  coagulation, 
for  an  appearance  resembling  the  buffy  coat  can  be  produced  in  healthy 
blood  by  retarding  its  coagulation.  The  butting  and  cupping  of  the  blood 
used  to  be  taken  as  the  chief  indication  of  the  sthenic  character  of  the  in- 
flammation, and  of  the  necessity  of  bleeding;  but  this  error  is  now  quite 
exploded.  It  is  known  that  the  relative  quantity'  of  fibrin  in  the  blood  is 
increased  instead  of  diminished  by  bleeding  and  starvation;  and  it  seems 
highly  probable,  to  sa_y  the  least,  that  the  greater  fibriniferousness  of  in- 
flamed blood  is  a  proof  of  its  degeneration  ;  '-that  an  increased  yield  of 
fibrin  portra3'S  not  perfection,  but  postperfection  of  the  blood ;  that  it 
corresponds,  not  to  the  rise,  but  to  the  decline  of  albuminous  material ; 
that  its  relations  are  not  with  repair  but  with  waste  "  (Simon) ;  and,  con- 
sequently, that  all  idea  of  bleeding  or  depletion  in  order  to  diminish  the 
quantity  of  fibrin  in  the  blood,  and  so  to  obviate  the  tendency  to  inflam- 
matory exudation,  and  the  formation  of  new  tissue,  which  the  superficial 
resemblance  between  the  fibrin  of  the  blood  and  the  exuded  lymph  (the 
fibrin  of  inflammation)  suggested  to  the  elder  [)athologists,  is  delusive. 
The  more  i)rol)able  theory  is  that  the  blood  in  inflammation  is  more 
^charged  with  fibrin  because  it  is  less  perfectly  freed  from  the  elements  of 
r  decomposition.  I  must  refer  the  reader  to  Mr.  Simon's  account  of  the 
I  "  Blood  in  Inflammation,"  in  the  Si/t^t.  of  Surg.,  vol.  i,  pp.  28,  et  seq. 
I  The  symptoms  of  traumatic  fever  may  be  thus  briefly  sununarized. 
There  is  increased  temperature  at  the  seat  of  the  wound  and  increase  in 
the  heat  of  the  whole  body,  as  proved  by  the  thermometer,  vvith  chilliness 
and  perhaps  (but  not  usual!}')  rigors  as  the  heat  rises;  quick,  sharp  pulse, 
furred  tongue,  more  or  less  sleeplessness,  and  the  sleep  which  is  obtained 
is  unrefreshing;  the  urine  is  high-colored,  and  the  amount  of  urea  ex- 
creted is  above  the  normal  standard  and  exceeds  the  quantity  which 
could  be  furnished  by  the  nitrogenous  aliment;  the  bowels  are  often  slug- 
gish, and  the  motions  offensive.  This  fever  ought  to  pass  away  as  the 
local  inflammation  declines,'  and  in  uncomplicated  cases  generally  disap- 


'  Billroth's  Surgical  Pathology,  translated  by  HacUlcy,  jip.  89,  90. 

'^  It  has  been  assorted  al.-o  that  the  proimrtioti  of  thi;  wliile  to  the  red  corpuscles  is 
increased,  l)Ut  this  is  as  yet  unproved. 

3  Mr.  Pick  says  :  "In  most  cases  it  will  be  found  tliat  tlu;  ucrao  or  greatest  inten- 
sity of  the  febrile  attack  usually  pi'eccdes  some  imjiortaut  ciiange  in  the  condition  of 


DRESSING    OF    WOUNDS.  49 

pears  about  the  seventh  day  ;  but  in  unhealthy  subjects  it  may  continue 
beyond  the  usual  time,  and  then  usually  passes 
into  some  of  ti)e  specific  inflammatoi-y  compli-  ^^°-  *• 

cations,  such  as  er\  sipelns,  phagedaena,  or  py- 
flemia,  or  may  even  persist  until  it  passes  into 
hectic.  Again,  after  the  complete  subsidence 
of  the  fever  it  may  be  lighted  up  again  by 
some  secondary  complication,  such  as  deep- 
seated  abscess  ;  and  to  this  form  the  name  of 
secondary  traumatic  fever  has  been  given  ; 
but  the  reader  will,  of  course,  understand  that 
the  word  secondary  is  used  here  in  no  con- 
nection with  the  idea  of  secondary  deposits.  Thermograph  of  traumatic  fever 

Some  amount  of  traumatic  fever  geuerall}', 
though  by  no  means  ahvaj's,  occurs  after  grave  operations  and  severe  in- 
juries, and  its  persistence  beyond  the  usual  period  is  an  evil  omen. 

Beyond  sedulous  attention  to  the  general  state  of  tlie  patient,  cautious 
inspection  of  the  part  to  see  that  no  discharges  are  confined  in  the  wound, 
and  cleanly  and  skilful  dressing,  I  know  of  no  treatment  for  traumatic 
fever.  The  treatment  of  traumatic  fever  resolves  itself  mainly  into  the 
treatment  of  the  injury  from  which  the  fever  springs.  Its  prophylaxis  is 
a  matter  of  very  grave  importance,  and  this  is  clearly  connected  with  the 
question  of  the  best  means  of  avoiding  putrefaction.  If  it  be  true,  as 
Billroth's  experiments  prove,  that  decomposing  matter  injected  into  the 
healthy  cellular  tissue  will  produce  fever,  it  is,  to  say  the  least,  highly 
probable  that  the  production  of  decomposition  in  inflamed  cellular  tissue 
will  have  the  same  etlect.  Everything,  then,  which  tends  to  make  a 
wound  ''do  well" — that  is,  which  favors  rapid  union  with  the  least  possi- 
ble amount  of  suppuration,  and  as  perfect  an  immunity  from  putrefaction 
as  possible — wiW  pro  tan  to  diminish  the  liability  to  traumatic  fever.  It 
is  of  primary  imi)ortance,  in  surgical  operations,  so  to  contrive  the  inci- 
sions that  the  parts  ma)-  lie  in  apposition  without  tension  or  discomfort, 
and  that  the  bloody-  serum  and  the  products  of  inflammation  which  will 
soon  exude  from  the  cut  surfaces  may  find  a  ready  exit;  or,  if  this  is 
impossible,  to  provide  an  artificial  exit  for  them  by  means  of  a  drainage- 
tube.  Tiie  position  of  the  patient  or  of  the  limb,  and  all  the  details  of 
careful  and  cleanly  nursing,  are  also  to  be  sedulously  attended  to;  and 
then  occurs  the  important  question  of  how  to  dress  the  wound. 

Dre^ii<ing  of  Wounds;. — It  certainly  may  seem  strange  that  after,  at  any 
rate,  more  than  a  century  of  careful,  diligent,  and  scientific  observation, 
from  the  da^s  of  Hunter  to  the  present  time,  surgeons  are  far  further  from 
agreement  as  to  what  is  the  best  i)lan  for  dressing  a  common  incised 
wound  than  they  probabl}'  were  in  the  days  of  Podalirius  and  Machaon, 
when  such  points  were  settled  b}'  traditional  authority.  Yet  so  it  is. 
One  distinguished  surgeon  (Professor  Lister)  sees  in  the  atmospheric  air 
the  universal  medium  of  contagion,  and  the  vehicle  by  which  all  the  germs 
of  corruption  are  conveyed  to  the  wound.  Another  (Dr.  Humphry) 
teaches  that  wounds  do  best  wlien  freely  exposed  to  the  air  without  any 
material  of  dressing  whatever.  A  third  (Sir  W.  Fergusson),  after  per- 
haps a  more  extensive  operative  experience  than  that  of  any  other  sur- 
gical authority  of  his  day,  repudiates  all  special  methods  of  treating 


the  wound.  In  most  of  the  cjises  in  which  the  wound  suppurated,  the  highest  tem- 
perature preceded  the  establishment  of  suppuration  by  about  twelve  hours." — 0|).  cit., 
p.  75. 

4 


50  INFLAMMATION. 

wounds,  and  thinks  that  as  a  general  rule  they  do  better  with  water-dress- 
ing than  with  any  other  application.  I  have  no  claim  to  dogmatize  on  a 
question  on  which  such  eminent  surgeons  differ,  but  there  is  one  point  of 
extreme  importance  on  which  I  think  all  would  be  agreed,  i.  e.,  that  scru- 
pulous care  in  the  dressing  of  a  wound,  to  see  that  all  the  materials  used 
are  clean,  and  that  no  accidental  impurity  can  afterwards  find  access  to 
it,  will  go  far  to  insure  its  safe  and  rapid  union.  When  we  get  beyond 
this,  and  inquire  into  the  value  of  special  plans,  we  are  met  by  the  diffi- 
cult}' that  in  carefully  managed  hospitals  (by  which  1  mean  not  only 
hospitals  where  all  sanitary  details  are  properly  cared  for,  but  also  where 
the  surgeons,  house-surgeons,  and  dressers  are  careful  to  dress  all  wounds 
themselves,  and  to  avoid  everything  that  could  even  produce  any  risk  of 
contamination)  almost  all  plans  of  dressing  wounds  will  succeed  so  often 
that  it  is  hard  to  classify  the  exceptions  for  the  purpose  of  comparison, 
while,  under  the  opposite  conditions,  all  plans  will  equall}^  fail.  Allowing 
for  this,  I  cannot  but  express  my  own  strong  conviction  of  the  value  of 
the  method  of  dressing  wounds  which  Mr.  Lister  has  introduced.  1  have 
frequently  ascertained  by  thermometric  and  other  observations,  and 
pointed  out  to  others,  tlie  perfect  immunity  from  traumatic  fever  which 
in  some  cases  follows  even  the  gravest  injuries  or  operations  thus  treated;* 
and  although  I  quite  admit  that  a  similar  immunity  follows  after  other 
methods  of  dressing,  yet  I  think  it  is  more  common  after  that  which  is 
called  "the  antiseptic  system"  than  any  other,'^  and  on  that  account  I 
advocate  the  use  of  that  system,  as  well  as  on  account  of  its  utility  in 
hospital  practice,  as  necessitating  the  dressing  of  important  cases  by  the 
surgeons  or  house-surgeons  themselves,  and  almost  excluding  the  possi- 
bility of  any  subsequent  inoculation. 

Professor  Lister's  directions  for  this  dressing  may  be  summarized  as 
follows:  The  principles  of  the  method  are:  (1)  to  destroy  any  germs  of 
putrefaction  which  may  have  been  accidentally  implanted  in  the  wound 
before  it  is  dressed,  or  to  guard  against  an}'  such  implantation  :  (2)  never 
to  allow  the  access  of  air  to  the  wound  except  filtered  through  the  anti- 
septic ;  and  (3)  to  provide  for  the  drainage  of  decomposable  fluids  from 
the  wound  without  admitting  the  entrance  to  it  of  unfiltered  air. 

1.  In  cases  which  are  not  seen  till  some  time  after  the  injury  the  first 
indication  is  fulfilled  by  washing  out  the  wound  freely  with  a  lotion  of 
carbolic  acid — 1  part  in  40^ — and  in  an  operation  either  by  performing 

^  An  instance  which  much  struck  me  was  the  following :  A  man  was  admitted  into 
hospital  with  a  most  formidable  compound  fracture  of  the  leg.  I  thought  it  neces- 
sary to  resect  more  than  two  inches  of  both  bones,  in  oi  Jer  to  avoid  amputation,  and 
was  greatly  blamed  by  a  senior  colleague  for  not  choosing  the  latter  alternative. 
The  wound  was  dressed  according  to  Lister's  method.  I  asked  the  house-surgeon  to 
construct  for  me  a  thermograph  of  traumatic  fever  from  this  case,  wanting  it  for  a 
lecture.  But  the  most  careful  morning  and  evening  observations  failed  to  detect  the 
least  rise  of  temperature,  nor  were  there  any  other  symptoms.  The  wound  healed 
kindly  and  rapidly,  and  the  man  was  discharged  with  a  perfectly  sound  and  strong 
though  shortened  limb. 

*  The  opinion,  if  true,  does  not  of  necessity  involve  any  adhesion  to  the  "germ 
theory"  of  disease,  nor  to  the  doctrines  as  to  the  presence  of  such  germs  in  the  atmos- 
phere under  ordinary  circumstances.  As  far  as  I  am  competent  to  form  an  opinion 
on  such  matters  the  opponents  of  these  theoretical  doctrines  seem  to  me  hitherto  to 
have  had  the  best  of  the  controversy.  But  however  putrefaction  is  produced,  tiiere 
can  be  no  question  that  carbolic  acid,  amongst  other  substances,  stops  it.  Nor  do  I 
think  there  will  be  much  doubt  in  the  mind  of  any  surgeon  who  will  give  a  really 
patient  and  extensive  trial  to  the  use  of  this  and  possibly  other  antiseptic  substances 
as  dressings,  of  the  great  utility  of  the  plan,  especially  in  hospital  wards,  where 
numerous  wounds  are  soriHitimes  collected  together. 

*  If  the  putrefaction  has  attained  a  considerable  height   it  is  best  to  sponge  the 


ANTISEPTIC    DRESSINGS.  51 

the  operation  in  a  cloud  made  by  pulverizing  this  lotion  in  a  spray  pro- 
ducer, or  by  wasliing  the  wound  out  with  it  freely  as  soon  as  the  operation 
is  over ;  and  it  is  a  useful  additional  precaution  to  wash  the  part  to  be 
operated  on,  the  hands,  and  the  instruments  in  the  same  lotion,  and  to 
carbolize.any  oil  used  for  saws  or  other  purposes. 

2.  The  second  indication  is  accomplished  by  wrapping  the  wound  up 
in  a  medium  saturated  with  carbolic  acid,  and  providing  that  this  medium 
shall  extend  far  enough  on  all  sides  of  the  wound  to  obviate  the  access 
of  any  air  which  has  not  been  thoroughly  filtered  through  the  disinfectant. 
The  medium  now  generally'  used  is  "antiseptic  gauze" — alight  cotton 
cloth  of  open  texture,  impregnated  with  a  mixture  of  carbolic  acid,  resin, 
and  paraffin,  in  which  the  resin  serves  as  a  vehicle  for  the  acid,  while  the 
paraffin  is  added  to  prevent  inconvenient  adhesiveness.'  Six  or  eight 
layers  of  this  are  wrapped  about  the  wound,  and  these  are  covered  with  a 
light  mackintosh  cloth,  which  surrounds  and  overlaps  the  whole,  in  order 
to  prevent  the  discharge  from  saturating  the  gauze,  and  so  bringing  about 
a  direct  communication  with  the  outer  air.  The  mackintosh  compels  the 
discharge  to  travel  through  the  whole  of  the  antiseptic  atmosphere,  and 
thus  insures  the  disinfection  of  the  air  which  comes  along  its  track.  In 
other  cases  it  may  be  more  convenient  to  wrap  the  part  in  lint  saturated 
with  carbolized  oil,  supported  by  the  carbolic  lac-plaster.  In  order  to 
avoid  the  irritating  action  which  the  stronger  solutions  of  carbolic  acid 
exert  on  the  raw  edges  of  the  wound,  it  is  well  to  protect  them  with  oiled 
silk  dipped  in  a  weak  solution  of  the  acid,  or  with  a  peculiar  preparation 
of  oiled  silk  termed  "the  protective,"  which  is  dipped  in  the  weak  lotion 
1  :  40.  The  object  is  to  defend  the  wound  and  at  the  same  time  to  guard 
against  the  implantation  of  fresh  germs  of  putrefaction.  In  changing 
the  dressings  the  most  convenient  plan  and  the  surest  is  to  surround  the 
whole  with  the  carbolized  spray.  If  this  is  not  at  hand,  a  thin  rag  steeped 
in  carbolic  lotion — "antiseptic  veil,"  as  it  is  called — must  be  slipped  over 
the  wound  as  the  dressings  are  removed  ;  and  if  it  is  necessary  to  expose, 
examine,  or  otherwise  manipulate  any  part,  it  must  be  irrigated  during 
the  whole  time  with  the  same  lotion  dropped  from  a  syringe.  The  pres- 
ence or  absence  of  putrefaction  is  judged  of  partly  by  the  odor,  partly 
by  the  color  of  the  "protective,"  which  turns  from  a  light-green  to  a  black 
by  contact  with  putrefying  matters. 

3.  Drainage  of  putrefiable  matters  is  secured  by  insertion  into  the 
wound,  in  any  convenient  part  or  parts,  of  a  drainage-tube,  or  a  piece  of 
lint,  rendered  antiseptic  by  immersion  in  carbolized  oil,  which  must  not 
project  beyond  the  antiseptic  dressing  an}'  more  than  the  protective  must, 
otherwise  they  would  serve  to  conduct  the  undiluted  atmosphere  to  the 
wound ;  and  any  collections  of  matter  must  be  opened  under  the  spray 
or  the  antiseptic  veil,  while  all  putrefying  sinuses  must  be  freely  injected 
with  the  antiseptic  lotion. 

In  this  method  of  dressing  the  vessels  must,  of  course,  be  secured  with 
the  carbolized  catgut,  as  described  in  the  chapter  on  Haemorrhage.  Some 
operators  also  use  this  gut  for  the  sutures,  but  I  think  metal  superior,  as 
being  perfectly  free  from  any  liability  to  putrefaction,  and  able  to  hold 
for  an  unlimited  time.     I  often  leave  the  sutures  in  place  for  a  fortnight 

whole  surface  thoroughly  with  a  lotion  of  chloride  of  zinc,  20-40  grains  to  the  ounce 
of  water,  as  recommended  by  Mr.  Campbell  De  Morgan. 

'  The  gauze  is  generally  supplied  ready  made,  as  is  also  the  antiseptic  lac-plaster, 
the  protective  oiled  silk,  and  the  catgut  ligature;  but  those  who  are  at  a  distance 
from  the  instrument-makers  will  find  all  necessary  directions  in  Professor  Lister's 
article  in  System  of  Surgery,  vol.  v,  pp.  621  et  seq.,  2d  ed. 


62  INFLAMMATION, 

or  more,  while  the  carbolized  gut  will  become  so  far  melted  in  four  or  five 
days  as  to  break  with  the  weight  of  the  flap.  If  strapping  be  wanted  in 
dressing  the  wound,  it  slionld  be  dipped  in  a  liot  solution  of  carbolic  acid, 
to  render  it  antiseptic  before  it  is  applied,  or  at  any  rate  passed  through 
an  atmospliere  of  carbolic  acid. 

The  chief  olijection  to  the  caibolizcd  dressings  is  doubtless  the  irritat- 
ing property  of  the  acid,  and  tiiis  will  generally  necessitate  the  abandon- 
ment of  the  method  alter  the  fii'st  tliiee  or  four  weeks.  If  the  carl)olic 
acid  be  employed  longer,  and  the  part  slill  wrapped  up  in  macinlosli,  it 
seems  that  the  heat  so  generated  and  the  irritating  quality  of  the  acid 
will  keep  up  too  much  action  and  prevent  union,  wliich  will  then  go  on 
rapidly  if  common  water-dressing  l)e  substituted.  But  by  that  time  even 
the  largest  and  deepest  wounds  have  usually  become  nearly  superficial.^ 

I  have  thought  it  right  to  bestow  so  much  space  upon  this  method  of 
dressing  wounds  partly  from  its  success  in  my  own  and  others'  hands,'* 
and  partly  as  it  illustrotes  most  of  the  general  principles  which  in  England 
are  admitted  as  governing  this  part  of  surgery.  These  general  principles 
are,  to  place  the  edges  of  wounds  in  accurate  and  easy  contact,  with  no 
strain  on  tiie  parts  composing  the  flaps  and  no  undue  pressure  on  those 
in  the  neighborhood  ;  to  provide  adequate  exit  in  a  dependent  situation 
for  the  products  of  inflammation  ;  to  give  as  much  support  to  the  parts 
as  will  assist  in  maintaining  them  in  apposition;  and,  finally,  to  protect 
them  from  the  air.  The  latter  indication,  however,  as  I  have  stated  al)ove, 
is  not  uiiiver.-<o,llt/  admitted.  In  some  foreign  countries  wounds  are  sys- 
tematicall}'  dressed  so  as  to  exclude  the  possibility  of  primary  union,  the 
cavil}-  l)eing  stuffed  with  charpie  until  suppuration  has  set  in  ;  but  this 
seems  to  us  to  involve  a  needless  aggravation  of  the  traumatic  fever,  a 
needless  length  of  the  healing  process,  an  additional  risk  of  unhealthy 
action  in  the  wound,  and  a  less  healthy  cicatrix.  There  are  wounds, 
however,  such  as  the  deep  and  large  cavities  left  after  excision  of  a  large 
joint  or  bone,  or  the  cavity  pioduced  by  trephining  or  gouging  inflamed 
b(^ne,  in  which  it  would  be  useless  to  seek  primary  union,  and  in  which, 
if  the  skin  be  closely  united  over  the  whole  cavity,  it  might  adhere  suflB- 
ciently  to  obstruct  the  exit  of  the  i)us  which  must  ultimately  form.  The 
best  plan  in  such  cases  is  to  stuff'  the  cavity  with  a  long,  broad  piece  of 
dry  lint,  leaving  the  end  of  it  to  project  from  the  wound,  which  is  left 
ununited  in  any  convenient  situation  for  that  purpose,  the  rest  being 
closed.  The  dry  lint  absorbs  any  blood  or  other  fluid  which  may  ooze 
from  the  surfaces,  and  can  be  gently  drawn  out  after  twenty-four  or  thirty- 
six  hours,  leaving  the  flaps  clean  and  free  from  clot,  and  allowing  a  suffi- 
cient exit  for  the  discharge  which  must  ensue. 

Irrigalion  of  Woxindx. — A  very  comfortable  way  of  dressing  almost 
any  kind  of  wound  is  by  irrigalum^  either  with  pure  water  or  with  car- 
bolic lotion,  or  with  some  perfumed  water.    The  fluid  ma^'^  be  either  warm 

'  Proff'ssor  Lis^ter  has  reoontly  recomrnondt'd  anntlier  Jinlispptic  drcssinjr — lint 
saturated  with  horacio  acid — as  cqiially  efficient  and  less  irritating  (Lancet,  May  1, 
IHTO).  M  V  (i\vn  very  limited  cx))eri(Miee  oC  ihis  substanc(!  d<i(!s  not  lend  ni«  to  lliink 
that  it  will  ever  siiiwr^edc  tJH!  carbolized  dressini^s  ;  and  I  niay  say  tho  same  of  sali- 
cvlie  acid  (sec;  Moore,  in  fcjt.  George's  Hospital  Reporls,  vol.  vii,  and  the  London  Med. 
liecud,  May  2'ith,  1870). 

*  German  teslinionies  to  the  value  of  Lister's  principles  are  found  recorded  by 
Ke\  lieriri  Lang.  Archiv  ,  vol.  xvii,and  by  Volkrnann  — ljeitrag(!zur  Cliirurgie,  1875. 

1  believe  the;  method  is  alsi;  succe.s<fully  used  in  Ilaly.  In  France  the  snbsUince 
which  Professor  LisU-r  chiefly  employs  was  first  introduced  into  practice  under  the 
name  of  "  phi^nic  ai^d,"  but  1  am  not  awuie  that  the  antiseptic  method  itself  has  had 
any  fair  t."ial  there. 


DRESSING    OF    AVOUNDS,  53 

or  cold.  It  is  suspended  in  a  Florence  flask  from  the  bed-cradle,  and  a 
skein  of  lamp-wick  cotton  hanginsj  out  of  the  flask  allows  it  to  drip  over 
tlie  wound.  By  regnlatiii,<>;  the  size  of  the  wick  the  supply  of  fluid  can 
be  almost  exactly  i)roportioned  to  the  evaporation,  and  a  gutter  made 
in  a  macintosh  siieet  laid  under  the  wound  will  convey  away  any  super- 
fluity. 

It  would  be  endless  if  I  were  to  endeavor  to  discuss  all  the  details  of 
dressing  wounds,  as  to  every  one  of  which  the  widest  diflference  of  opinion 
prevails,  even  among  surgeons  of  tlie  same  school.  But  a  few  words  on 
some  of  the  chief  ])oints  may  be  useful.  Thus  with  regard  to  sutures. 
Some  surgeons  insist  on  the  supposed  necessity  for  withdrawing  them 
very  early  after  the  operation  ;  others,  of  whom  I  am  one,  believe  that  if 
an  adequate  exit  has  been  provided  /"rom  Ihe  first  for  the  discharges  (for 
which  purpose  a  drainage  tube,  laid  in  the  wound  during  tlie  operation, 
is  very  convenient)  the  sutures  can  hardly  be  retained  too  long — they 
keep  the  parts  in  easy  contact,  and  obviate  the  necessity  for  the  constant 
reapplication  of  strapping,  whicii  is  in  general  very  painful  and  irritating 
to  the  patient,  especially  to  children.  1  have  often  treated  cases  of  ampu- 
tation to  the  end  without  removing  the  sutures  till  the  patient  left  the 
hospital;  and  the  stumps  so  formed  have  generally  been  the  most  satis- 
factorj'.  This,  of  course,  does  not  apply  to  wounds  of  the  f[\ce,  or  any 
other  part  where  the  marks  of  the  suture  would  be  objectionable.  Again, 
with  respect  to  the  material  and  kind  of  the  suture.  The  silver  sutures 
are  now  in  universal  use,  and  are  incontestably  superior  to  any  other,  if 
they  are  to  be  allowed  to  remain  long  in  ;  but  if  the  sutures  are  to  be  re- 
moved soon  after  tlie  operation,  silk  is  better,  since  it  can  be  removed 
without  any  pain  or  difficulty,  whereas  the  withdrawal  of  a  metal  suture, 
whatever  care  be  used,  must  as  a  general  rule  give  a  little  pain.  That 
pain,  however,  may  be  reduced  to  a  minimum  by  carefully  straightening 
the  suture  after  it  is  cut,  and  flattening  <lovvn  the  cut  end  witli  forceps 
before  drawing  it  out.  Catgut  sutures  are  very  convenient,  and  need  no 
withdrawal,  since  their  buried  part  melts  away,  and  then  the  suture  di-ops 
off  of  itself;  but  for  the  same  reason  they  are  of  no  use  after  the  first  few 
days.  Many  surgeons  use  the  continuous  suture  ;  and  it  answers  very 
well  if  the  stitches  are  only  to  be  retained  a  few  days,  in  which  case  it  is 
perhaps  best  made  of  the  carbolized  catgut.  The  objection  to  it  is  that 
it  is  difficult  to  cut  out  a  portion  of  it,  if  necessary  for  relief  of  tension  or 
exit  of  discharge,  without  loosening  the  whole  suture  ;  its  advantage  is 
the  accurate  apposition  which  it  insures. 

Strapping. — Other  means  for  keeping  the  edges  of  a  wound  in  apposi- 
tion are  bandages,  strapping,  and  compresses.  Strapping  is  alisolutely 
necessary  in  many  cases  where  the  sutures  have  been  removed  or  the 
weight  of  the  flaps  is  so  dragging  upon  them  as  to  make  it  desirable  to 
assist  them  by  taking  off  tlie  strain ;  and  for  small  wounds  which  can  be 
kept  in  exact  apposition  strapping  is  more  useful  than  sutures.  In  such 
cases  the  straps  should  be  very  rarely  disturbed — only  when  it  is  plainly 
required.  So,  also,  when  strapping  is  used  to  produce  pressure  in  order 
to  restrain  haemorrhage,  the  longer  it  is  left  on  the  better,  |)rovided  no 
oedema  of  the  lower  part  of  the  limb  is  present,  and  the  bleeding  is  eflTec- 
tually  commanded.  But  in  large  wounds,  such  as  those  of  amputation, 
I  cannot  say  that  I  am  myself  very  fond  of  strapping,  though  1  am  aware 
that  some  very  good  surgeons  use  it  from  the  first  to  the  total  exclusion 
of  sutures.  The  chief  reason  why  I  prefer  the  latter  as  a  means  of  keeping 
the  edges  together  is,  that  the  wound  thus  requires  hardly  any  dressing, 
and  frequentl}'  need  never  itself  be  touched  ;  while  strapping  gets  so  soon 


54  COMPLICATIONS    OF    WOUNDS. 

disturbed  b}'  the  discharges  that  it  must  be  renewed  at  very  short  inter- 
vals, a  proceeding  involving  no  little  pain  in  an  inflamed  stump. 

Bandagefi  are  often  of  very  great  service  in  obviating  the  spasms  which 
are  so  painful  in  large  wounds,  such  as  those  of  amputation.  The  sup- 
port of  a  splint  and  bandage  lightly  and  evenly  applied  seems  to  me  a 
great  comfort  after  an  amputation,  and  in  a  severe  wound  on  the  thigh 
or  into  the  knee  I  think  it  a  very  good  plan  to  bandage  the  whole  limb 
evenly  from  the  toes.  Again,  bandages  are  ver}^  often  used  to  prevent 
the  retraction  of  the  flaps  which  sometimes  ensues  after  amputation, 
though  this  end  is  perhaps  better  secured  by  a  loop  of  strapping  well 
secured  to  the  stump  and  acted  on  by  a  weight.  Compresses  are  some- 
times necessary,  and  especially  in  wounds  which  are  the  seat  of  venous 
bleeding,  or  bleeding  from  a  number  of  minute  vessels.  They  should  be 
carefully  adapted  to  the  shape  of  the  wound,  the  first  compress  (made  of 
about  four  folds  of  lint)  exactly  covering  the  part  on  which  pressure  is 
to  be  made  and  no  more.  This  is  supported  by  another  a  little  larger, 
and  a  third  of  still  larger  size,  is  laid  on  the  top,  and  the  whole  secured 
in  its  place  by  long  strips  of  strapping  crossed  over  the  compress,  star- 
wise,  and  a  firm  bandage  over  all. 


CHAPTER  11. 

THE  COMPLICATIONS  OF  WOUNDS  AND  INJURIES— ABSCESS— SINTJS 
AND  FISTULA— PYEMIA— HECTIC— ERYSIPELAS— GANGRENE— 
TETANUS— DELIRIUM  TREMENS. 

Abscess. — We  must  now  consider  the  complications  which  interfere 
with  the  regularity  of  the  healing  process,  and  the  specific  diseases 
which,  taking  their  rise  in  unhealthy  inflammation  or  disturbed  innerva- 
tion excited  by  the  injury,  affect  the  whole  system,  and  too  often  render 
what  at  first  seemed  a  trivial  accident  very  serious  or  even  fatal.  All  of 
these  complications  also  originate  spontaneously  from  diseases  of  all 
sorts;  but  they  are  most  conveniently  studied  in  relation  to  wounds. 
We  will  begin  with  abscess,  a  frequent  concomitant  of  all  kinds  of  inju- 
ries and  an  equally  frequent  idiopathic  affection. 

An  abscess  is  defined  as  a  collection  of  pus  inclosed  in  a  cavity.  This 
cavity  is  formed  by  the  parts  around  (usually  the  cellular  tissue)  con- 
densed by  infiammation,'  and  lined  b}^  a  layer  of  flocculent  lymph,  which 
has  received  the  name  of  the  "p3'0genic  membrane" — a  name  which  is  so 
far  appropriate  that  the  layer  is  chiefly  formed  b^^  the  aggregation  of  the 


1  By  "condensed  "  I  mean  matted  together  and  thickened.  The  consistence  of 
thosf;  matted  and  thickened  tissues  varies,  chiefly  according  to  the  acuteness  of  the 
inflammation.  In  acute  abscess  the  parts  are  softened  and  lacerable ;  in  chronic 
abscess,  on  the  contrary,  they  are  hardened. 


ABSCESS.  55 

inflammatory  leucocytes  which  are  breaking  down  into  pus,  and  there- 
fore is  the  part  from  which  the  pus  proceeds. 

In  studying  abscess  we  must  speak  briefly  of  the  contents  of  the  cav- 
it}?^,  of  its  mode  of  progress,  of  the  kinds  of  abscess,  their  symptoms  arid 
treatment. 

Kinds  of  Pus. — The  contents  of  the  abscess  cavity  is  pus,  or  "matter," 
the  nature  of  which  has  ah'eady  been  spoken  of.  Healthy  pus  is  a  creamy, 
inodorous,  yellow,  homogeneous,  alkaline  fluid.  This  was  called  by  the 
old  authors  pus  laudahile.  When  mixed  with  blood,  as  it  often  is  in  acute 
abscess,  it  is  called  sanious  ;  when  it  has  putrefied  from  acute  inflamma- 
tion or  from  gangrene  of  the  parts  in  which  it  is  formed,  it  is  termed 
offensive  or  putrid;  when  mixed  with  flakes  of  solid  matter,  cwrcZy  or 
flaky;  and  when  those  flakes  are  believed  to  be  fragments  of  crude 
tubercle,  strumous;  when  excessively  thin,  as  in  chronic  abscess,  serous 
or  watery;  when  thin  and  acrid,  so  as  to  irritate  the  skin  in  the  neigh- 
borhood, ichorous.  Finally,  in  rare  cases,  pus  presents  various  colors — 
blue,  green,  or  black.^ 

Abscess  Cavity.  —The  cavity  consists  internally  of  the  la^yer  of  pus  and 
lympli  called  the  pyogenic  membrane  (which  is  more  distinct  in  chronic 
abscess  of  bone  than  in  any  other  kind),  immediately  external  to  which 
is  tissue  degenerated  by  inflammation,  and  containing  a  large  number  of 
dilated  vessels,  then  oederaatous  cellular  and  other  tissues  gradually  fading 
away  into  healthj'  parts.  The  enlargement  of  the  vessels  around  the 
abscess  is  often  so  great  as  to  give  rise  to  pulsation  obvious  to  the  eye  as 
well  as  perceptible  to  the  patient.  As  the  surrounding  tissues  soften  and 
break  down,  the  abscess  cavity  extends;  and  this  usually  occurs  more 
towards  the  nearest  surface  than  in  other  directions,  until  the  tissues 
over  the  pus  become  so  much  thinned  that  it  projects  and  its  color  can 
be  seen,  when  the  abscess  is  said  to  point,  and  this  immediately  precedes 
its  bursting. 

Kinds  of  Abscess. — The  kinds  of  abscess  are  acute  and  chronic,  or 
cold,  to  which  French  authors  add  abscesses  by  congestion.  The  latter 
are  such  as  are  in  contact  with  a  diseased  surface  of  bone,  from  which 
their  matter  is  furnished,  as  is  the  case  in  spinal  abscess. 

The  most  common  are  the  acute  abscesses  which  depend  on  some 
definite  irritation  giving  rise  to  inflammation.  They  advance  rapidly, 
with  pain,  and,  if  large,  with  constitutional  symptoms.  A  large  abscess 
is  usually  preceded  by  rigors,  and  probably  accompanied  by  perceptible 
fever.  The  parts  around  are  swollen,  hot,  and  painful,  often  very  tense 
and  pulsating;  the  pus  is  generally  healthy,  or  sanious.  A  cold  abscess 
advances  very  slowly  and  gradually  to  a  large  size,  with  no  fever,  and 
generally  little  or  no  pain  ;  the  parts  around  are  somewhat  thickened  and 
hardened  by  inflammatory  eff"usion  and  chronic  organization,  but  other- 
wise hardly  altered,  except  by  mere  distension  ;  the  pus  is  usuall}'  watery 
or  curdy. 

Diagnostic  Signs. — The  diagnosis  of  abscess  has  to  be  made  from  mere 
inflammation  with  oedema,  from  soft,  solid  tumors  (such  as  soft  cancers), 
from  cystic  tumors,  and  from  extravasations  of  blood.'^  The  first  point 
in  the  diagnosis  of  abscess  is  to  become  perfectly  familiar  with  the  sensa- 
tion of  fluctuation.  The  particles  of  fluid  in  a  cavity,  if  not  too  tightly 
bound  down  by  its  walls,  are  displaced  in  any  direction  by  the  slightest 

^  See  System  of  Surgery,  vol.  i,  p.  119,  2d  ed. 

*  Abscesses  may  also  be  confounded  with  aneurism  ;  but  this  will  be  treated  of 
with  the  latter  subject. 


56  COMPLICATIONS    OF    WOUNDS. 

force,  and  immediately  return  again  to  their  former  position.  Thus,  if 
one  hand  or  one  finger  be  placed  on  a  dropsical  abdomen  while  any  other 
part  of  the  belly  is  tapped  gently  with  the  other  hand  or  another  tinger, 
the  wave  of  flnid  will  be  plainly  felt  to  impinge  on  the  hand  or  finger  which 
is  at  rest;  or  if  the  thumb  be  sharply  pressed  down  on  a  small  deep- 
seated  collection  of  fluid,  the  fluid  yields  and  will  be  felt  to  surge  up 
again  against  the  thumb.  The  perception  of  fluctuation,  in  either  of 
these  ways,  distinguishes  a  limited  collection  of  fluid  like  an  abscess  from 
the  indefinite  softness  of  fluid  diffused  in  the  meshes  of  the  tissues  and 
also  from  solid  tumors  ;  and  the  history  of  the  case,  with  the  presence  of 
inflammation  in  its  neighborhood,  will  distinguish  an  alxscess  from  a  cyst 
or  a  collection  of  extravasated  blood  ;  but  in  case  of  doubt  the  grooved 
needle,  exploring  trocar,  or  Dieulaf'oy's  aspirator  will  settle  the  question. 
The  fallacies  in  detecting  fluctuation  arc  numerous.  Tiiere  may  be  fluid, 
but  it  may  be  so  tightly  bound  down  that  its  displacement  is  imper- 
cep(il)le.  This  is  very  common  in  small  tense  cysts  and  in  hydrocele,  less 
so  in  abscess,  except  in  thecal  and  perinaeal  al)scesses.  There  may  be 
fluid,  and  in  considei'able  quantity,  permeating  the  tissues  so  extensively'' 
as  to  give  the  sensation  of  fluctuation,  though  there  is  no  cavity.  Thus 
inflamed  soft  parts  are  sometimes  incised,  under  the  impression  that 
there  is  an  abscess,  when  it  turns  out  to  be  only  inflammatory  oedema. 
This  argues,  to  that  extent,  a  deficiency  in  the  tactus  eruditua  on  the 
part  of  the  surgeon,  l)ut  it  is  not  uncommon  even  with  the  most  experi- 
enced. A  still  greater  difficidty  is  to  distinguish  the  sensation  of  deep- 
seated  fluid  from  that  of  a  soft  tumor,  such  as  a  rapidly  growing  cancer; 
in  fact,  it  is  hardly  possible,  so  permeated  with  fluid  is  the  texture  of 
such  tumors.     Here,  again,  exploration  is  essential. 

Treatment  of  Abace^^. — The  diagnosis  of  abscess  having  been  made, 
the  question  occurs  of  opening  it.  As  a  general  rule  all  abscesses  are 
better  opened  at  once,  except  large  abscesses  by  congestion,  and  those 
which  are  very  deeply  seated.  The  former  are  less  likely  to  inflame  if 
left  to  burst,  and  the  latter  will  require  less  extensive  incision  if  allowed 
to  come  nearer  to  the  surfacie.  In  parts  also  where  deformity  is  espe- 
cially to  be  avoided,  as  in  the  neck,  it  may  be  better  to  wait  until  a  mere 
puncture  will  sufHce,  and  till  the  surgeon  can  see  exactly  which  is  the 
most  depending  part  of  tlie  fluid. 

There  are  many  different  kinds  of  abscess  knife.  One  of  the  best  is 
that  which  goes  by  the  name  of  Syme,  a  e-ickle-shaped  blade,  which  is 
plunged  into  the  al)scess  and  cutting  rapidly  outwards  makes  a  suflk-ient 
incision  with  very  little  pain.  A  small  knife,  which  is  called  Pollock's 
knife,  at  St.  George's,  but  has  different  names  with  difl'erent  instrument- 
makers,  is  very  useful,  as  it  makes  hardly  a  larger  puncture  than  an  ex- 
ploring needle,  and  so  can  be  withdrawn,  if  there  be  no  pus,  without 
doing  any  damage,  3'et  is  strong  enough  to  oi)en  any  ordinary  abscess. 
In  many  situations  (e.  <;.,  the  neck)  abscesses  may  be  very  usefidly  opened 
by  means  of  a  seton.  A  stout  thread  is  driven  through  the  abscess,  and 
kept  in  till  the  puncture  is  permanently  established,  and  thus  the  al)sces3 
is  drained  (jff  with  very  little  mark.  A  fine  drainnge-tube  is  still  more 
convenient  for  the  same  purpose.  Some  deepseated  abscesses  (as  tliose 
in  the  liver)  are  still  occasionally  opened  by  destroying  the  tissues  over 
them  with  caustic  jjotash,  though  this  plan  is  nearly  antiquated.  A  very 
useful  method  of  opening  large  abscesses  is  under  carl)olic  acid.  A  veil 
or  thin  rag  steeped  in  the  ordinary  cai'bolic  lotion  (1  part  in  40)  is  laid 
over  the  part,  the  knife  is  passed  under  this  veil,  and  as  the  incision  is 
made  tiie  veil  is  smoothed  down  over  it,  so  that  no  air  enters.     The  pus 


A  BSCESS. 


57 


is  allowed  to  ooze  out  through  this  veil,  and  in  about  an  hour,  when  the 
dischar«-e  has  pretty  well  ceased,  the  wound  is  dressed  after  the  ordinary 
antisei)tic  method. 

When  the  al)scess  is  very  deeply  seated  or  lies  in  the  neighborhood  of 
important  structures,  as  in  the  neck,  a  very  safe  and  valuable  method  is 


Fig.  5. 


Fig.  6. 


"Symi's"  abicoss  knife. 


Paset's"  or  "  Pollock's  "  abscess  knifo. 


that  which  is  especially  recommended  by  Mr.  Hilton'  of  laying  aside  the 
knife  after  the  supeificial  parts  have  been  freely  incised  and  breaking 
into  the  cavity  of  the  abscess  with  the  end  of  a  director.  A  pair  of  for- 
ceps can  then  be  inserted  into  the  small  liole  so  made,  and  b}^  opening 
the  blades  the  orifice  may  be  enlarged  as  far  as  needful. 

Inflammation  of  the  cavity  of  a  large  abscess  after  incision  is  attended 
witli  very  grave  symptoms — rigors,  fever,  a^lema  of  the  parts,  and  jjutre- 
faction  of  the  matter.  The  wound  must  now  be  freely  enlarged,  and  the 
cavity  washed  out  constantly  with  some  antiseptic,  while  the  patient's 
strengtli  is  supported  with  stimulants  and  tonics,  and  opium  used  as  may 
be  indicated. 

Hsemorrhage  from  Wall  of  Abscess. — Another  matter  which  should  be 
noticed  in  connection  with  abscess  is,  that  when  opened  the  sides  of  the 
cavity  begin  to  granulate  freely;  and  often  if  the  oi)ening  is  not  free 
enough,  the  granulations  will  become  congested  and  a  continuous  oozing 
of  blood  {hxmorrhagie  en  nappe,  as  the  French  term  it)  will  take  place. 
Styptics,  pressure,  etc.,  are  constantly  used  in  such  cases,  and  aggravate 
the  mischief.  If  the  cavity  be  laid  freely  open  from  one  end  to  the  other, 
and  if  need  be  by  a  crucial  incision,  the  admission  of  tlie  air  to  the  gran- 
ulations will  at  once  suppress  tlie  bleeding. 

Disappearance  of  Abxcesxes. — Finally,  it  should  be  added  that  ab- 
scesses sometimes  entirely  disappear  without  bursting.  If  an  opportunity 
offers  for  examining  the  part  after  this  has  taken  place,  a  caseous,  semi- 
solid substance  called  "adipocere"  is  found  occu|)ying  the  diminished 
cavity  and  surrounded  by  traces  of  the  wall  of  tlie  abscess.  Ultimately 
even  this  may  disappear,  and  there  may  be  left  either  a  little  chalky  mass 
or  nothing  but  a  confused  induration  of  the  tissues. 

Residual  Abscess. — In  the  remains  of  old  dried-up  abscesses,  or  in 
other  residues  of  inflammation  which  has  never  advanced  to  suppuration, 


'  See  Paget,  Clinical  Lectures  and  Essays,  p.  333. 


58  COMPLICATIONS    OF    WOUNDS. 

abscess  is  very  likely  to  occur  a  considerable  time  after  apparent  recov- 
ery. Sir  J.  Paget  has  called  especial  attention  to  these  ''  residual  ab- 
scesses "  in  a  work  lately  published.'  They  are  most  common  after  spinal 
abscesses,  and  are  also  common  after  abscesses  connected  with  diseased 
joints,  but  the}'  occur  in  any  part  wliicli  remains  altered  and  degenerated 
in  texture — ''  in  the  thickenings,  adhesions,  or  other  lowl^'  organized 
products  of  inflammation  long  past."  The  prognosis  of  these  abscesses 
is,  as  a  rule,  better  than  that  of  the  original  disease  on  which  they  super- 
vene. They  are  best  opened  at  once,  and  their  occasional  occurrence  in 
the  residues  of  abscesses  which  have  dried  up  without  opening  forms  no 
valid  objection  to  the  practice  of  abstaining  as  long  as  possible  from 
incising  spinal  or  articular  abscesses,  since  it  is,  after  all,  only  in  a  small 
proportion  of  such  cases  that  residual  abscesses  are  noticed. 

Very  commonly  after  it  has  burst  the  abscess  remains  open,  but  its 
cavit}'  narrows  into  what  is  called  a  "  sinus  "  or  fistula. 

Siiins  and  Fistula. — These  two  terms  are  sometimes  used  as  synony- 
mous, meaning  a  long  channel  like  that  of  a  pipe  running  through  the 
soft  or  hard  parts,  but  at  other  times  some  differences  are  made  in  the 
use  of  the  words.  Speaking  generall}',  three  kinds  of  sinus  or  fistula  are 
described,  viz.:  1.  Long  narrow  suppurating  canals  (e.g.,  fistula  in  ano, 
mammary  sinus);  2.  Canals  giving  unnatural  exit  to  secretions  (e.g., 
gastric  fistula,  biliary  fistula);  and  3.  Unnatural  apertures  of  communi- 
cation between  mucous  canals  or  cavities  (e.g.,  vesico-vaginal  fistula). 
"If  a  distinction  is  to  be  made  between  the  terms,  fistula  should  be  ap- 
plied to  the  second  and  third  of  the  abovenamed  three  forms  of  disease, 
and  to  those  examples  of  the  first  form  in  which  the  suppurating  canal 
has  two  openings  ;  and  sinus  should  be  applied  exclusively  to  those  of 
the  first  form  in  which  the  canal  has  but  one  opening."  (Paget.)  The 
special  forms  of  fistula  will  be  considered,  so  far  as  the}'  are  the  subjects 
of  surgical  treatment,  in  subsequent  chapters,  as  fistula  in  ano  with  Dis- 
eases of  the  Rectum,  vesico-vaginal  fistula  with  Diseases  of  the  Female 
Generative  Organs.  We  need  only  here  occupj'  ourselves  with  those 
sinuous  or  fistulous  passages  which  result  from  the  imperfect  healing  of  old 
abscesses.  Tliis  imperfection  results  most  commonly  from  some  abiding 
source  of  irritation  either  at  the  bottom  or  in  the  track  of  the  abscess, 
such  as  a  piece  of  diseased  bone  or  a  lodged  foreign  body ;  sometimes 
from  muscular  action  disturbing  the  parts,  sometimes  from  imperfect 
exit,  causing  retention  of  the  matter  and  consequent  inflammation  of  the 
walls  of  the  abscess  ;  sometimes,  as  it  seems,  by  mere  ill-health,  inter- 
fering with  the  tendency  of  the  cavity  to  fill  up.  The  walls  of  an  old 
sinus  will  alwaj's  be  found  more  or  less  inflamed,  condensed,  and  un- 
healthy, and  very  frequently  secondary  pouches,  or  suppurating  cavities, 
exist  in  tlie  walls,  or  the  sinus  divides  into  two  or  more  channels  which 
open  independently  of  each  other. 

The  main  points  in  the  surgical  treatment  of  sinuses  are  :  First,  to  as- 
certain whether  au}'  foreign  body  is  present,  and  if  so  to  remove  it ;  next, 
to  ascertain  whether  tlie  sinus  depends  on  disease  of  some  bone,  and  in 
that  case  to  remove  the  bone  if  loose,  and  if  carious  to  treat  the  disease 
according  to  the  rules  laid  down  in  the  chapter  on  Diseases  of  Bone. 
Simple  sinuses  whicii  are  kept  up  by  the  action  of  muscles  may  be  cured 
by  the  division  of  those  muscles,  of  which  the  division  of  the  sphincter 
in  anal  fistula  is  a  familiar  example.    Sometimes  the  morbid  action  of  the 

'  Clinical  Lectures,  p.  810. 


PYEMIA.  59 

parietes  of  the  sinus  may  be  modified  by  injecting  it  with  some  irritating 
fluid,  as  the  tincture  of  iodine  or  of  cantharides,  or  by  lightly  cauterizing 
it  with  the  galvanic  cautery  ;  and  the  same  effect  may  in  other  cases  be 
produced  by  a  seton  or  a  drainage-tube.  In  some  few  cases  pressure  may 
act  advantageously,  the  deeper  or  remoter  parts  of  the  sinus  being  kept 
in  contact  till  they  unite  and  thus  close  the  sinus  gradually  from  the  bot- 
tom. Sometimes  the  dilatation  of  the  sinus  with  the  sea-tangle  tent  con- 
verts it  into  a  simple  abscess  which  fills  up.  But  the  surest  plan,  when 
it  can  be  thoroughly  carried  out,  is  to  lay  open  the  whole  sinus  and  every 
branch  of  it,  and  make  the  entire  wound  granulate  from  the  bottom. 

Pyaemia  is  usually  defined  as  an  affection  of  the  mass  of  the  blood, 
characterized  by  a  peculiar  form  of  fever,  and  resulting  in  the  formation 
of  abscesses  (secondary  deposits)  in  various  parts  of  the  body.  The  cause 
of  this  affection  of  the  blood  is  probably  the  absorption  into  it  of  putre- 
f3'ing  material,  and  it  is  by  no  means  impossible  that  some  molecular 
change  in  the  blood  itself  may  cause  a  similar  affection  (spontaneous 
pyaemia). 

Septicaemia. — The  best  writers  on  pysemia  speak  of  two  forms  or  modi- 
fications of  the  disease:  (1)  the  systemic  infection,  and  (2)  the  true  pyae- 
mia, characterized  by  local  changes  or  "  secondary  deposits."  To  the 
former  the  name  septicaemia  is  now  very  commonly  applied.  It  is  regarded 
by  some  pathologists  as  a  different  affection  from  pyaemia,  though  closely 
allied  to  it ;  by  others  (and  I  think  with  more  reason)  as  the  same  disease 
under  a  somewhat  different  form. 

Septicaemia  is  sometimes  even  more  fatal  than  ordinary  pyaemia,  but  at 
others  it  is  so  little  dangerous  as  hardl}^  to  be  distinguished  from  common 
traumatic  fever,  if,  indeed,  there  be  any  distinction.  Many  diseases  are 
now  recognized  as  being  similar  in  essence  to  pyaemia  and  septicaemia, 
and  are  grouped  with  them  under  the  generic  name  of  blood  poisoning, 
notably  all  the  erysipelatous  affections,  the  putrid  sore  throat  of  dissect- 
ors or  hospital  attendants,  and  puerperal  fever.  Mr.  Callender  thus  de- 
scribes the  most  characteristic  and  most  acute  form  of  septicaemia : 

"  Within  twenty-four  hours  in  acute  cases  there  are  rigors,  vertigo,  and 
general  uneasiness.  Then  follow  heat,  perspiration,  and  increased  rapidity 
of  pulse.  The  seat  of  inoculation  is  dusky,  indurated,  often  pustular; 
or  if  it  had  been  before  secreting  pus,  the  discharge  ceases.  Radiating 
from  this  centre,  the  integument  is  distending  with  a  serous  effusion, 
presently  to  be  mingled  with  thin  sanious  pus.  The  swelling,  generally 
somewhat  elastic,  is  hard  and  tense  over  enlarging  and  painful  glands. 
The  blood,  deranging  the  heart's  action,  is  circulated  violently  and  rapidly 
through  the  system;  exuding  from  its  vessels,  as  in  purpura,  it  stains  the 
surrounding  tissues,  forms  ecchymoses  in  internal  organs,  or  is  poured 
out  upon  mucous  surfaces,  and  is  then  chiefly  removed  by  purging  or 
vomiting.  In  another  twenty-four  hours  the  patient,  flushed,  anxious, 
restless,  even  delirious,  is  in  a  hopeless  condition,  with  prostration  and 
rapid  sinking."  ^ 

This  is  an  excellent  and  faithful  description  of  the  most  rapid  and  most 
hopeless  cases  of  blood  poisoning,  such  as  occasionally  follows  on  dissec- 
tion-wounds. In  less  acute  cases,  the  symptoms  are  those  of  ordinary, 
but  severe,  traumatic  fever  ;  and  sometimes  in  these  less  acute  cases  of 
what  is  at  first  diagnosed  as  septicaemia,  secondary  deposits  occur,  proving 
the  identity  of  septicaemia  and  pyaemia. 

1  System  of  Surgerj-,  2d  ed.,  vol.  i,  p.  254. 


60 


COMPLICATIONS    OF    WOUNDS. 


The  disease,  liowever,  to  which  the  term  pyaemia  is  universally  applied 
is  one  of  so  very  wt'll-niarked  a  cliaracter,  so  frequently  fatal,  and  when 
fatal  usually  marked  hy  such  unmistakable  morbid  appearances,  that  it 
is  very  stranoe  liow  it  could  have  escaped  the  ol'servatiou  of  so  many 
famous  plnsicians  and  suro;eons  down  to  the  time  of  Mr.  Arnott.^  Its 
accession  is  usually  marked  by  very  definite  symptoms  of  fever — rigors, 
recurring  at  intervals  sometimes  so  regular  as  to  be  mistaken  for  :igne, 
colliquative  perspirations  very  commonly  following;  bilious  aspect  of  the 
countenance,  occasionally  amounting  to  jaundice  (and  this  usuall3-  when 
the  liver  is  ntfected),  frequent  and  small  pulse,  and  numerous  other  symp- 
toms, varying  with  the  part  on  which  the  stress  of  the  disease  falls. 
Thus,  when  the  circulation  of  the  brain  is  affected,  there  ma^'  he  delirinui; 
of  the  intestines,  diarrhoea;  of  the  lungs,  dyspncea,  and  so  on  ;  but  very 
commonly  the  recurring  rigors  and  the  consecutive  perspirations,  mark- 
ing a  persisting  fever  for  which  there  is  no  explanation  in  the  local  con- 
diti.)ns,  are  the  oidy  prominent  symptoms.  The  local  conditions,  iudeed, 
as  shown  by  the  state  of  the  wound,  are  often  indistinguishable  from 
those  of  an  ordinnry  healing  ulcer,  though  there  are,  no  doubt,  cases  in 
which  the  granulatious  turn  gray  and  wither,  and  the  discharge  becomes 
ichorous.  The  state  of  the  tongue  is  also  very  variable.  But  the  per- 
sistence of  a  considei'able  amount  of  fever  from  day  to  day,  such  as  is 
shown  in  the  accompanying  thermograph,  after  a  wound  or  injury,  is 
always  suspicious,  and  nsually  indicates  the  absorption  of  poisonous 
matter  into  the  blood.  In  fact,  unless  there  is  some  specific  affection,  or 
some  evidence  of  deepseated  suppuration,  it  is  difficult  to  explain  the 
occurrence  of  this  fever  otherwise.  A  comparison  of  the  thermometrio 
chart  ou  the  margin  with  those  of  simple  traumatic  fever  (on  p.  49)  aud 


3     +     5  I  6,    7      8     9     10  In 


Hirai 
inn 

^~JlfllTl_ 

niuniiiiaii 

MIMHIIJil 


m 


ThtTinograpli  of  i)y£einia  terminuling  in  recovery. 

of  hectic  (on  p.  05)  will  show  the  following  differences.  In  traumatic 
fever,  which  depends  on  the  application  of  a  definite  "stimulus"  to  the 
blood,  whereby  its  heat  is  raised  above  the  normal,  there  is  a  more  or 
less  abriq)t  rise  so  long  as  this  stimulus  acts  until  the  climax  is  reached, 
when  it  is  succeeded  by  a  gradual  defervescence,  and  the  temperature 
comes  l)ack  to  the  normal,  and  so  remains.  In  hectic  there  is  a  recur- 
rence of  the  feverish  condition  regularly  once  or  twice  a  day,  quickly 
followed  by  sweating  and  a  fall  to  the  normal  temperature.     In  pyjiemia 


'  The  accuriite  study  of  pyajmia  mny  be  said  to  date  from  the  essay  published  by 
this  Rurjxenn,  On  the  KHecls  of  Inflammation  of  Veins,  in  the  Med.  Clin.  Trans., 
vol.  x\,  in  the  year  1828. 


PYEMIA.  61 

there  is  a  constant  exaltation  of  the  natural  temperature,  bnt  witli  irreg- 
ular exacerbations  (at  the  times  of"  tlie  rigors),  the  temperature,  however, 
remaining  aliove  the  normal  all  the  time. 

The  local  suppurations  come  on  at  most  irreguhir  periods,  and  affect 
the  most  various  organs.  There  is  proltalily  no  organ  of  the  body  which 
is  not  sometimes  attacked  by  the  |)y8emic  inflammation,  tiiougli  the  liver, 
lungs,  and  joints  are  those  fai-  most  commonly  implicated.  The  symp- 
toms caused  by  these  local  inflammations  are  often  very  slight.  Dysp- 
~ncea  may  be  present  to  a  less  or  greater  extent  when  tlie  pleural  cavity 
or  lung  is  inflamed,  pain  under  the  ribs  or  jaundice  in  affection  of  tlie 
liver,  pain  and  redness  in  the  neighborhood  of  affected  joints;  but  such 
symptoms  are  usually  much  slighter  than  in  healthy  inflammations,  and 
pyasmic  abscess  is  constantly  found  after  death  in  organs  where  there  has 
been  no  reason  to  suspect  it  during  life. 

Pathulogy  of  Pysemia. — There  are  several  different  explanations  of  the 
pathology  or  generation  of  pyaemia,  but  of  these  the  one  whicli  was  first 
accepted,  and  which  rested  on  the  great  authority  of  Crnveilhier — viz., 
that  it  depended  on  the  })assage  of  pus-globules  into  the  blood — is  now 
exploded.^  The  known  fact  that  py.iemia  can  originate  spontaneously 
when  no  pus  is  present  in  any  part  of  the  body  would  alone  disprove 
this  idea,  which  is  also  inconsistent  with  the  early  morbid  anatomy  of 
the  deposits. 

It  appears  now  to  be  admitted  that  the  essence  of  pyjiemia  consists  in 
the  imbibition,  by  the  blood,  of  matters  in  a  state  of  putrefaction,  which 
act  as  a  ferment  on  the  blood,  and  cause  it  to  stagnate  in  the  capillaries. 
To  this  fermentation  is  due  the  feverish  condition  which  is  present  during 
the  whole  period  of  the  disease.  To  the  stagnation  of  the  blood  in  the 
capillaries  of  the  part  is  due  the  formation  of  the  secondary  deposits. 

Secondary  Depomts. — The  original  stage  of  a  secondary  (leposit  is  that 
in  which  the  capillaries  or  veins  of  the  parts  are  loaded  with  coagulated 
blood  (tliroml)osis),  and  to  this  succeeds  an  inflammatory  stage  in  which 
the  parenchyma  becomes  loaded  with  the  products  of  inflammation  and 
with  blood  ("  haemorrhagic  infarct"),  to  which  succeeds  suppuration, 
and  so  an  abscess  results.  The  process  on  a  free  surface  is  the  same, 
thougli  the  details  ma}'  be  somewhat  different,  the  inflammatory  products 
being  poured  out  on  to  the  surface  of  the  mucous  or  serous  membrane, 
soon  succeeded  by  a  collection  of  thin  pus  in  the  cavity. 

So  much  is  admitted  on  all  hands;  the  more  diflicult  questions.  What 
is  the  putrefying  material?  and.  How  does  it  get  into  the  mass  of  blood? 
are  hardly  as  yet  settled.  It  seems  certain  that  it  frequently  results  from 
plugging  or  "•thrombosis"  of  some  distant  vein,  the  effect  of  injury  or 
irritation.  This  thrombus  may  decompose  and  break  down,  when  the 
disintegiated  and  decomposed  fibrin  may  be  carried  into  the  venous 
current,  as  shown  by  the  annexed  diagram.  It  is  also  quite  conceivable 
that  the  putrefying  discharges  on  the  free  surface  of  a  wound  may  be 
absorbed  into  the  blood  and  thus  excite  the  same  consequences.  This, 
however,  does  not  explain  the  cases  of  spontaneous  pyaemia,  where,  with- 

1  Cnivpilfiier's  explanation  was  foundod  on  an  oxperisncnt  in  which  he  injected  a 
globule  of  niorcnry  into  a  vein  in  a  l)one ;  tlie  nlobiiie  was  detained  in  the  lutii;  and 
became  the  nucleus  of  an  abscess.  He  concluded  from  thi>  ;ind  other  experiments 
that  the  pus-iilubules  pass  from  the  supfiurating  surface  up  the  veins  in  the  same  way 
as  thiis  globuhi  of  mercury  did,  and  are  detained  in  the  capillaries  of  remote  organs, 
generally  the  lung. 


62 


COMPLICATIONS    OF    WOUNDS. 


Fio.  8. 


out  any  known  injury  or  anj'  ulcerating  surface,  symptoms  of  blood  poi- 
soning come  on,  followed  by  secondary  abscesses  in  various  parts. 
On  this  subject  Billroth  speaks  as  follows: 

"  At  present  there  is  probably  no  doubt  that 
it  is  usuall}'  due  to  reabsorption  of  putrid  fluid 
or  pus ;  that  it  is  always  so  is,  indeed,  disputed. 
Man}^  surgeons  assert  that  pyaemia  very  fre- 
quently results  from  miasma,  especiall}^  from  a 
miasma  which  develops  from  the  wounds  of  many 
patients  lying  together.  This  view  is  based  chiefly 
on  the  fact  that  where  many  severe  surgical  cases 
lie  together  (as  in  large  hospitals,  especially 
army  hospitals),  many  of  them  die  of  pysemia, 
and  that  even  mild  cases,  patients  with  cicatriz- 
ing granulating  wounds,  become  pysemic  under 
such  circumstances.  This  is  no  place  for  po- 
lemics, hence  I  must  be  content  with  giving  you 
my  own  views  on  the  subject.  I  can  entirely 
agree  to  the  miasmatic  origin  of  pj'aemia,  if  by 
miasma  is  understood  what  I  understand  by  it 
in  the  present  and  some  other  cases,  namely, 
dustlike,  dried  constituents  of  pus,  and  possibly 
also  accompanying  minute,  living,  very  small  or- 
ganisms, which  in  badly  ventilated  sick-rooms 
are  suspended  in  the  air  or  adhere  to  the  walls, 
bedclothes,  dressings,  or  carelessly  cleaned  in- 
struments. These  bodies,  which  are  in  some 
respects  of  difl:'erent  nature,  are  usually  phlogo- 
genous,  all  pyrogenous,^  when  they  enter  the 
blood.  Of  course  they  will  collect  chiefly  where 
there  is  the  best  opportunity  for  their  develop- 
ment and  attachment,  that  is,  in  badly  ventilated 
sick-rooms,  where  the  patients  are  carelessly  at- 
tended, where  there  is  deficient  cleanliness,  and  the  patients  remain  some 
time  in  the  same  apartments.  It  is  impossible  to  say  whether  all  pus, 
moist  or  dr}',  is  alike  injurious;  experiments  on  animals  give  us  no  in- 
formation on  this  point.  It  is  possible  that  dry  pus,  as  well  as  moist, 
acquires  peculiarly  injurious  qualities   from  certain  minute  organisms, 

animal  or  vegetable 

"  We  are  here  floating  entirely  in  the  region  of  hypothesis :  even  as- 
suming the  action  of  these  small  organisms  in  the  development  of  pysemia, 
the  question  as  to  the  mode  of  their  action  arises.  Possibly  they  induce 
a  sort  of  fermentation  in  the  pus  of  the  wound,  inflammation  and  destruc- 
tion of  the  granulations;  possibly  they  force  their  way  into  the  granula- 
tions ;  possibly,  also,  as  previously  mentioned,  they  enter  the  blood 
through  the  lungs;  possibly  even  when  in  the  blood  they  are  not  alike 
dangerous  to  all  persons — all  these  things  are  unknown.'" 

The  pathological  analonnj  of  septicaemia  and  pyaemia  maj'  be  thus  very 
summarily  described  :  1.  In  some  cases  (septicseraia)  no  distinctly  local- 
ized appearances  are  discovered;  the  spleen,  the  solitarj^  glands  of  the 
intestine,  and  the  lymphatic   glands  may   be  found  swollen,  the  blood 


Diagram  of  a  thrombus  in 
a  vein.  From  Billroth,  Surg. 
Path.,  p.  337.  a.  Central  end 
of  a  venous  thrombus  project- 
ing into  a  large  trunk.  6.  A 
branch  without  thrombus  ;  the 
blood  flowing  through  it  may 
detach  and  carry  into  the  cir- 
culation the  end  of  the  throm- 
bus a. 


1  By  "  plilogogenous  "  is  meant  "capable  of  exciting  local   inflammation;" 
pyrogenou.s,"  "CMpable  of  exciting  general  fovor."     See  pp.  47,  48. 
*  Billroth.     Surgical  Pathology,  trans,  by  Hackloy,  pp.  358-9. 


by 


PYEMIA.  63 

hardly  coagulated,  and  the  tissues  prone  to  rapid  decomposition,  and 
thereby  somewhat  altered  in  microscopic  appearance.  2.  In  other  cases 
(more  distinctly  pyiiemic)  the  appearances  are  localized  in  the  synovial 
and  serous  cavities,  as  diffuse  sero-purulent  inflammation  of  the  pleura, 
pericardium,  peritoneum,  or  endocardium,  without  any  perceptible  in- 
flammation of  the  organs  which  they  cover,  or  as  similar  affections  of  the 
joints.  Heiberg  notices  that  when  tlie  pysemia  follows  on  childbirth 
(puerperal  fever)  sucli  inflammation  may  be  found  in  the  peritoneum 
"without  an}'  aff'ection  of  the  walls  or  lining  of  the  uterus.  3.  In  the  third 
form  the  morbid  material  shows  its  aflinity  for  the  mucous  membranes, 
and  chiefly  that  of  the  alimentary'  canal,  by  which  it  seems,  as  it  were,  to 
seek  for  elimination.  The  appearances  are  those  of  catarrh  of  the  mem- 
brane, with  swelling  of  the  solitary  and  agminate  glands.  This  is  the 
form  which  is  usually  seen  in  animals  after  the  injection  of  putrid  matter 
into  the  blood.  4.  The  fourth  form  is  tliat  in  which  numerous  metastatic 
abscesses  are  formed,  such  metastatic  abscesses  being  usually,  but  not 
always,  preceded  by  embolic  clots  in  the  minute  vessels. 

Bacteria  in  Blood  Poisoning. — The  above  is  summarized  from  a  very 
able  tract  by  Heiberg,  of  Christiania,^  which  may  also  be  consulted  for  a 
demonstration  of  the  presence  of  bacteria  in  these  p3'ffimic  deposits  and 
in  all  the  parts  where  the  pyfemic  or  septicaemic  process  is  perceptible.  He 
appears  to  regard  these  bacteria  as  in  some  way  an  integral  part  of  the 
matter  (the  "materia  peccans,"  as  he  terms  it)  which  sets  up  the  fermen- 
tative action  in  the  blood  ;  and  he  endeavors  to  trace  the  bacteria  along 
the  venous  and  the  lymphatic  system  from  the  point  of  inoculation  into 
the  general  mass  of  the  blood,  i.  e.,  to  the  great  veins  and  the  heart.  This 
view  would  explain  the  cases  of  apparently  spontaneous  pyaemia  as  being 
instauces  where  the  morbid  matter  was  accidentally  implanted  on  some 
part  of  the  external  integument,  or  alimentary  mucous  membrane,  or 
respiratory  tract  accidentally  denuded  of  its  normal  epithelium  ;  so  that 
the  "peccant  substance"  (the  presence  of  which  is  indicated  by  the  bac- 
teria) is  allowed  to  find  its  way  into  the  lymph-channels,  and  so  into  the 
blood. 

At  the  same  time  it  must  be  admitted  that  our  knowledge  of  the  con- 
nection which  may  exist  between  the  bacteria  which  are  found  extensively 
in  decomposing  fluids  and  tissues,  and  the  symptoms  (called  septicaemia, 
pyaemia,  etc.)  which  ma\'  be  caused  by  the  absorption  of  putrefying  pro- 
ducts, is  at  present  very  limited.  An  interesting  article  recently  pub- 
lished by  Panum,  of  Copenhagen,^  may  be  referred  to  as  showing  that 
such  putrid  fluids  retain  their  poisonous  properties  after  undergoing  pro- 
cesses by  which  all  bacteria  must  be  destroyed,  and  that  the  mode  of  their 
action  is  much  more  analogous  to  that  of  some  compound  chemical  pro- 
duct than  to  the  propagation  of  an  animal  or  vegetable  parasite.  But  even 
if  the  bacteria  themselves  be  not  the  vehicles  of  the  poison,  there  remains 
the  possibilitj'  that  the  bacteria  may  have  been  in  some  way  the  cause  of 
the  poisonous  property  of  the  matter.  And  this  possibility  Panum  ad- 
mits, representing  it  hypothetically  by  the  assumption  that  the  "•  putrid 
poison  "  may  be  the  secretion  of  the  bacteria  ;  and  he  points  to  the  prac- 
tical fact,  which  is  alone  of  extreme  importance,  that  the  same  precau- 
tions which  will  prevent  the  development  of  bacteria  will  hinder  the  forma- 
tion of  the  poison. 

1  Die  Puerperalen  und  Pyamischen  Processe.     Leipzig,  1873. 
*  Das  putride  Gift,  die  Bakteiien,  die  putride  Infection  und  die  Septicsemie. — Lan- 
enbeck's  Archiv,  vol.  xvi,  1874. 


64  COMPLICATIONS    OF    WOUNDS. 

The  reader  who  wishes  to  see  the  opposite  views  as  to  the  connection 
between  the  lowest  forms  of  animal  life  and  the  development  of  inflamma- 
tory disorders  ably  and  fully  stated  may  be  referred  to  the  discussion  re- 
cently held  at  the  Pathological  Societ}-^,  and  reported  in  the  British 
Medical  Journal^  for  April  10,  24,  and  May  8,  1875,  or  in  tlie  other  medi- 
cal papers  of  similar  dates. 

The  diagnosis  of  pyaemia  is  not  by  any  means  easy  in  all  cases,  or  even 
possil)le  at  lirst,  since  its  early  symptoms  are  identical  or  near!}'  so  with 
those  of  the  severer  forms  of  traumatic  fever.  Indeed,  tliere  can  be  little 
doubt  that  since  they  are  due  to  simiUir  causes  there  is  no  essential  differ- 
ence between  a  case  of  acute  traumatic  fever  and  one  of  the  so-called 
septiciemia,  nor  does  post-mortem  examiuation  detect  an\'  difference  in 
their  effects.  But  the  characteristic  difference  between  these  three  forms 
of  wound  fever  is  this,  that  in  the  simple  traumatic  fever  there  is  a  distinct 
rise  up  to  the  climax  and  a  distinct  defervescence  and  return  to  health. 
Recurring  traumatic  fever  is  onl}'  a  repetition  of  this  process  usually  due 
to  a  repetition  of  the  irritation,  as  from  retained  matter  or  impacted 
foreign  bod^'.  In  the  constitutional  infections,  on  the  other  hand,  to 
which  the  names  of  septicaemia  and  pysiemia  have  been  given,  there  is  no 
such  definite  course  of  the  fever.  The  temperature  maintains  itself  above 
the  normal  and  is  exacerbated  from  time  to  time  when  the  I'igors  take 
place,  falling  again  as  tlie  sweating  goes  on.^  It  is,  tlien,  by  tliis  course 
of  the  temperature,  or  by  the  recurring  rigors  and  sweats  wliicli  are  its 
more  palpal)le  indications,  that  we  diagnose  p^'a^uiia  previous  to  the 
occurrence  of  visible  deposits  or  internal  inflammations,  recognizable  by 
their  symptoms. 

Prognosis. — The  prognosis  of  pygemia  is,  as  a  general  rule,  very  bad  ; 
that  recovery  does  ensue,  however,  we  have  the  most  ample  proof,  and  it 
appears  to  occur  more  frequently  in  cases  of  spontaneous  pysemia  than 
in  those  of  traumatic  origin,  and  is  always  more  probable  the  more  chronic 
is  the  course  of  the  symptoms. 

Causes. — In  surgical  practice  p,y?eraia  is  usually  caused  by  severe  in- 
juries to  bones,  and  especially  in  surgical  operations  and  compound  frac- 
tures, or  by  inflammation  of  veins.  Parturition  is  a  frequent  cause.  All 
visceral  diseases  and  exliaustiug  maladies,  as  well  as  atmosplieric  impuri- 
ties, act  as  predisposing  causes. 

Treatment. — Tlie  treatment  of  py.Temia,  like  that  of  traumatic  fever, 
really  resolves  itself  into  propiiylaxis,  as  to  which  enougii  has  been  said 
above.  None  of  tlie  various  plans  of  specific  treatment  wiiich  have  been 
proposed,  as  by  quinine,  mercury,  alcohol,  or  opium,  appears  to  exert  the 
least  real  influence  on  the  disease  itself.  All  that  can  l)e  done  is  to  sup- 
port the  patient's  strength,  and  treat  the  symptoms  as  they  occur.  When 
abscess  forms  in  an  accessible  situation  it  should  be  opened,  but  not  by 
too  free  an  incision. 

Chronic  Pyaemia. — The  above  description  applies  to  acute  i)y,Tmia  as 
we  ordinai'ily  see  it,  especially  in  surgical  practice,  as  occurring  after 
severe  injuries,  particular!}'  tiiose  in  wliicii  bones  are  involved.  It  is  an 
acute  disease,  and  its  course  is  usually  to  be  reckoned  liy  days,  rarely 
extending  to  some  weeks.  But  pyjemia  occurs  also  in  a  clironic  form,  of 
which  Sir  J.  Paget  has  given,  in  the  paper  which  commences  the  first 
volume  of  the  St.  Bartholomew's  Hospital  Brports,  an  excellent  descrip- 
tion, and  some  very  striking  instances,  in  one  of  which  the  symptoms 

'  iSee  the  thermograph  of  pyaemia,  nup.  p.  60;  and  of  traumatic  fever,  p.  49. 


HECTIC    FEVER. 


65 


were  protracted  over  three  years.  The  essential  features  of  this  form 
are  similar  to  those  of  acute  pynemia,  and  with  proper  attention  the 
diagnosis  can  usually  be  estal»lished  ;  but  tiie  resemblance  both  to  rheu- 
matism and  to  hectic  fever  is  much  greater  than  in  the  acute  disease, 
especially  to  hectic,  which  in  fact  may  sn{)ei'vene.  The  disease  is  not  so 
dangerous  as  the  acute  affection,  and  it  is  frequently  s[)ontanoous,  or  at 
least  independent  of  any  traumatic  cause.  Sir  J.  I'aget  has  noticed  that 
"■the  local  evidences  of  chronic  are  more  frequently  than  those  of  acute 
pyaemia  seated  exclusively  or  chiefly  in  different  parts  of  the  same  tissues 
[as,  for  instance,  if  occurring  as  a  consecjuence  of  disease  of  a  bone,  all 
the  secondary  inflammations  may  affect  tiie  osseous  system  only]  ;  that 
they  are  more  frequent  in  the  trunk  and  limbs  than  in  internal  organs, 
and  when  seated  in  tiie  veins  are  most  frequently  found  towards  tlie  close 
of  the  disease."  And  he  adds  a  most  important  practical  point,  in  which 
chronic  pyjemia  agrees  with  hectic,  viz.,  that  in  this  as  in  hectic  tiie  re- 
moval by  operation  of  the  seat  of  the  original  disease  is  frequently  so 
beneficial  that  it  becomes  the  surgeon's  duty  to  perform  the  operation, 
whilst  in  acute  pyaemia  operations  almost  always  deprive  the  patient  of 
the  faint  chance  of  life  he  might  otherwise  have. 


Hectic  Fever. — Clear 
which  all  run  a  definite 
or  "suppurative"  feve 
death  by  exhaustion 
tinned  suppuration,  bu 
greater  ex[)enditure  of 
the  blood. 

Its  symptoms  are  ar 
stages,  between  which. 


ly  distinguished  from  the  previous  forms  of  fever, 
course,  is  tiie  feverisli  condition  called  "  hectic" 
r,^  which  runs  no  definite  course,  and  tends  to 
It  is  generally  caused  by  profuse  and  long-con- 
t  may  be  occasioned  l)y  anything  which  causes  a 
the  elements  of  nutrition  than  can  be  supplied  to 

ranged  for  convenience  of  description  into  three 
however,  there  is  no  exact  separation  : 


Thermograijli  of  hectic  lever.     From  a  case,  recently  under  niy  care,  of  pelvic  inflammation  after 
parturition,  which  ultimately  ended  in  recovery. 

In  the  first  stage  there  is  loss  of  flesh,  varying  and  feeble  pulse,  the 
skin  is  dry  and  becomes  hot  towards  evening,  when  the  patient  feels 
chilly,  and  the  general  temperature  rises ;  there  are  profuse  night-sweats 
with  morning  remissions  ;  the  tongue  is  clean  and  red. 

In  tile  second  stage  the  emaciation  is  greater,  the  hectic  flush  begins 
to  appear  (that  is  to  say,  a  circumscribed  red  blush  on  the  cheek  strongly 
contrasted  with  the  clear  pallor  of  the  complexion,  and  lasting  so  long  as 
the  hot  state  continues),  the  night-sweats  are  much  more  profuse — "col- 
liquative," as  they  are  termed — and  there  is  often  diarrhoea;  the  rise  of 
temperature  at  night  is  more  marked  to  the  thermometer;  "the  urine 


Billroth  has  applied  the  term  "  suppurative  fever,"  also  to  pvfemia. 


66  COMPLICATIONS    OF    WOUNDS. 

after  the  sweating  will  be  found  to  contain  increased  quantities  of  urea, 
chloride  of  sodium,  sulphuric  acid,  and  water."     (Croft.) 

The  third  stage  is  one  of  still  more  marked  exhaustion  and  failing 
powers;  the  pulse  feebler  and  more  rapid,  the  skin  dry  and  scaling,  the 
motions  loose  and  sometimes  passed  involantaril3',  the  urine  offensive, 
the  mouth  aphthous  ;  the  cliills  and  sweats  are  more  frequent,  occurring 
sometimes  twice  in  the  twenty-four  hours;  the  legs  become  oedematous, 
bedsores  are  apt  to  form.  In  some  cases  consciousness  gradually  de- 
parts before  death.  The  patient  dies  very  graduall}',  sometimes  almost 
imperceptibly. 

This  condition  differs  entirely  from  traumatic  fever,  since  it  does  not 
depend  on  any  definite  irritation,  and  runs  no  definite  course  ;  and  from 
pyasmia  in  the  same  particulars,  and  also  in  the  absence  of  any  imbibition 
of  poisonous  materials  by  the  blood. 

The  treatment  of  hectic  must  generally  be  directed  merely  to  keeping 
the  patient  alive,  in  the  hope  that  the  source  of  suppui'ation  will  dry  up, 
and  on  the  cessation  of  the  cause  the  hectic  fever  will  sul)side.  But  there 
are  a  few  cases,  mainly  those  of  suppurating  joints  and  bones  of  the  limbs, 
in  wliich  the  source  of  suppuration  can  he  removed  by  operation,  and  if 
this  is  to  be  done,  it  should  always  be  done  as  early  as  possible  in  the 
disease.  At  later  stages  the  patient  is  too  weak  to  bear  the  shock  of  an 
operation.  In  the  majority  of  cases  where  the  source  of  this  disease  cannot 
be  removed  (of  wliich  the  hectic  ensuing  on  psoas  abscess  is  a  familiar 
example)  the  patient's  strength  must  be  supported,  and  albuminous  ma- 
terials supplied  to  the  blood  while  the  disease  is  passing  over.  Small 
quantities  of  nourishing  food,  wine  or  beer,  repeated  as  often  as  the 
patient  can  bear  it  without  making  too  strong  calls  on  his  digestion, 
quinine,  sulphuric  acid,  and  iron  to  check  the  feverish  exacerbations  and 
the  sweats,  and  opium  to  stop  the  diarrhoea  and  procure  sleep,  are  the 
chief  indications  of  treatment. 

Suppurative  Degeneration  of  Viscera. — Long-continued  suppuration 
may  also  prove  fatal  by  inducing  disease  of  the  alidominal  viscera,  chiefly 
the  kidneys,  liver,  and  spleen.  It  is  now  universally  admitted  that  the 
condition  which  was  originally  described  as  "waxy,"  or  "lardaceous" 
disease  af  tiiese  viscera,  and  afterwards,  not  very  correctly,  as  "  amyloid 
degeneration,"  is  often  caused  by  long-continued  suppuration,  and  this 
degeneration  of  the  liver  and  kidneys  is  a  frequent  cause  of  droiisy  and 
thereby  of  death  in  patients  laboring  under  exliausting  suppuration, 
whether  with  or  without  hectic  fever.  Dr.  Dickinson,  to  whoni  we  owe, 
I  believe,  our  first  accurate  statement  of  the  cause  of  this  degeneration,' 
traces  its  production  to  the  great  loss  of  the  alkaline  salts  of  potasli  and 
soda  from  the  blood  in  order  to  form  [)us.  He  points  out  that  the  alka- 
linity of  pus  is  due  to  its  containing  about  twice  the  quantity  of  the  salts 
of  potash  and  soda  which  are  contained  in  the  sei'um  of  blood  ;  that  the 
wax}'  or  lardaceous  viscera  always  contain  a  decidedl}'  smaller  quantity 
of  such  salts  than  are  contained  in  the  iieallhy  viscera,  and  that  the  so- 
called  "am3"loi<l"  reaction  may  be  ai'tiliciMlly  manufactured  by  depriving 
fibrin  of  the  alkali  with  which  it  is  naturally  c(Mnl)ined.  From  wliicli  he 
concludes  that  the  loss  of  alkali  from  the  itlood,  through  long-continued 
6Ui)pui'ation,  disposes  to  the  de|)osit  around  the  minute  vessels  in  the 
aflected  organ  of  the  substance  displaying  this  so  called  "amyloid  "  re- 

»  Med.-Chir   Trans.,  vol   1,  p.  39. 


ERYSIPEIvAS    AND    ERYTHEMA.  67 

action.  At  any  rate,  I  tliink  the  fact  is  now  certain  tliat  long-continued 
siip[)nration  does  produce  such  waxy  degeneration,  and  in  this  way  nia}' 
indirectly  cause  death — an  additional  motive  for  ridding  tiie  patient  of 
tlie  source  of  incurable  suppuration,  whenever  that  is  possible. 

Eri/sipclaft. — The  term  erysipelas  is  applied  to  a  spreading  inflamma- 
tion of  the  skin,  mucous  membrane,  or  connective  tissue  beneath  them  ; 
and  the  disease  is  divided  into  two  chief  varieties, — simple  or  cutaneous 
erysipelas,  in  which  only  the  skin  or  mucous  meml)rane  is  implicated,  and 
phlegmonous  erysii)elas  or  diffuse  inflammation,  in  which  the  connective 
tissue  is  the  part  mainly  involved.  Some  writers  also  describe  a  tiiird 
variety,  diffuse  cellulitis,  in  cases  where  the  integument  is  not  inflamed 
at  all;  for  instance,  the  diffuse  inflamtnation  of  tlie  pelvic  cellular  tissue 
which  sometimes  follows  surgical  operations. 

Erythema  is  an  affection  having  much  resemblance  to  erysipelas,  but 
differing  from  it  in  the  fact  that  in  erythema  there  is  no  necessary  con- 
stitutional complication,  and  that  the  redness  of  erythema  is  not  accom- 
panied by  any  definite  sign  of  inflammator}'  exudation,  which  is  always 
tlie  case  in  erysi[)elas. 

Erythema  is  usually  a  mere  local  affection,  and  might  perhaps  be  ap- 
propriately enumerated  amongst  the  skin  diseases;  but  as  it  is  advisable 
for  purposes  of  diagnosis  to  state  its  distinctive  features  in  this  place,  I 
will  here  mention  its  cliief  varieties  and  their  treatment.  Erythema  is 
defined  as  a  superficial  redness,  from  injection  of  the  capillary  vessels  of 
the  skin.  As  in  erysipelas,  the  redness  disappears  on  pressure,  and  in 
some  cases  it  is  accomi)anied  by  a  little  thickening  of  the  tissues  of  the 
skin.  In  some  forms  of  erythema,  however,  this  thickening  or  oedema  is 
the  cause  and  not  the  consequence  of  the  injection  ;  the  latter,  in  fact,  is 
due  to  passive  and  not  to  active  congestion.  Such  is  the  case  in  the  E. 
liKve  or  cedematosum,  the  redness  of  cedematous  skin  ;  and  this  is  to  be 
remedied  mainly  b^^  position,  the  removal  of  any  cause  of  obstruction, 
warm  astringent  lotions,  and  the  cautious  and  dexterous  application  of 
pressure.  E.  intertrigo  is  somewhat  allied  to  this  ;  it  is  the  redness  which 
attacks  the  surface  where  large  folds  of  the  skin  and  fat  rub  against  each 
other,  as  in  the  pendulous  bellies  of  very  fat  i)eo[>le,  or  in  the  groins  of 
infants.  The  scorch  of  a  sunburn  or  other  irritant  is  somewhat  of  the 
same  kind.  Cleanliness,  the  avoidance  of  friction,  powdering  the  part, 
and  brushing  it  with  nitrate  of  silver  lotion  or  some  other  astringent,  will 
relieve  it. 

Erythema  Fugax. — There  are  many  other  forms  of  erythema  which, 
thougli  they  are  in  themselves  local,  yet  own  a  general  cause.  The  most 
obvious  and  familiar  instance  of  tliis  is  the  "chloroform  rash,"  which  is 
so  often  seen  on  the  chest  and  other  parts  in  young  jjeople  of  delicate 
skin — a  slight  erythematous  eruption  which  very  quickly  fades  away.  The 
late  Dr.  Murray  observed  often  a  swollen  condition  of  the  thyroid  gland 
during  its  appearance.  This  of  course  requires  no  treatment.  In  other 
cases  erythema  fugax  appears  as  a  consequence  of  indigestion,  especially 
from  eating  shellfish  or  pork,  in  persons  to  whom  such  food  acts  in  a 
poisonous  manner,  or  as  a  complication  of  various  diseases  in  which  the 
digestive  system  is  disturbed.  The  knowledge  of  the  cause  points  out 
the  treatment. 

There  are  other  special  forms  of  erythema  which  are  more  persistent, 
and  which  more  nearly  approach  the  characters  of  the  definite  skin  erup- 
tions, especially  roseola.     Such  are  the  Erythema  circinatum  and  mar- 


68  COMPLICATIONS    OF    WOUNDS. 

ginatnm — definite  rings,  patclies,  or  spots  of  redness,  very  hardly  if  at 
all  distinguished  from  roseola  when  occurring  in  a  similar  form  ;  Ery- 
thema papulalum,  in  which  the  spots  are  raised  up  into  a  sort  of  pimple; 
Erythema  tuberculatum,  in  which  the  prominence  of  the  spots  is  greater, 
and  in  which  they  are  more  persistent.  This  form  is  usually  seen  as  a 
symptom  in  the  debility  of  fevers.  It  forms  the  transition  to  the  Erythema 
nodosum,  which  is  not  uncommon  as  a  substantive  disease. 

Erythema  nodosum  ditlers  so  much  from  the  usgal  forms  of  erythema 
that  it  is  doubtftd  whether  it  ought  to  be  included  among  them  or  classed 
with  afiections  of  the  lymphatic  system.  It  occurs  in  the  form  of  raised 
patches  or  tubercles  of  a  red  or  reddish-yellow  color,  and  somewhat  ten- 
der to  tlie  touch,  sometimes  accompanied  with  a  good  deal  of  smarting 
pain.  The  patches  are  generally  about  the  size  of  half  a  nut,  sometimes 
as  large  as  the  fist.  They  are  seated  most  commonly  on  the  legs,  but 
they  may  affect  an}^  other  part;  and  Hebra  speaks  of  cases  in  which  as 
they  disappear  at  one  part  they  occur  at  another  till  the  whole  body  has 
been  implicated.  They  never  suppurate,  and  the  redness  of  the  indi- 
vidual tubercles  never  spreads  to  the  skin  around  them,  a  character  which 
is  peculiarly  distinctive  of  erythema  nodosum.  "It  is  ver}' probable," 
says  Hebra, ^  "tliat  in  its  pathological  anatomy  E.  nodosum  is  allied  to 
absorbent  inflammation,  and  likewise  to  the  erysipelatous  diseases,''  and 
the  same  thing  may  periiaps  be  said  also  of  the  other  erythemata.  Indeed, 
it  admits  of  no  doubt  whatever  that  the  morbid  process  concerned  in  some 
cases  of  Erythema  nodosum  is  essentially  an  inflammation  of  the  lym- 
phatic vessels."  The  disease  more  often  aff'ects  young  women  suffering 
from  menstrual  irregularities  than  any  other  class  of  persons,  though  men 
suffer  from  it  also.  I  never  saw  a  case  in  childhood.  It  is  usually  con- 
nected with  some  obvious  disturbance  of  health,  and  may  be  accompanied 
with  more  or  less  symptomatic  fever.  The  treatment  consists  in  the  res- 
toration of  the  general  health,  and  in  alleviating  the  pain  by  position  and 
Ijy  mild  soothing  vvarm  applications. 

We  must  now  turn  to  the  varieties  of  erysipelas,  which  are  distin- 
gui^shed  from  these  various  forms  of  erythema  both  by  the  local  characters 
of  the  eruption  and  by  the  presence  of  a  definite  form  of  general  fever. 

The  cutaneous  or  simple  erysipelas  is  a  spreading  inflammation  of  the 
surface  of  the  skin,  with  thickening  of  its  tissue,  and  sometimes  consid- 
erable pulfiness  of  the  subcutaneous  parts.  This  puffiness  is  especially 
marked  in  erysipelas  of  the  face,  where  the  features  swell  so  much  and  so 
rapidly  that  tlie  patient  is  quite  irrecognizable  in  a  few  hours,  and  loses 
all  power  of  vision  from  the  swelling  of  his  eyelids.  The  redness  of  er}'- 
sipelas  is  usually  of  a  bright  tint,  often  mottled,  disappearing  on  pres- 
sure; it  has  a  defined  border,  wiiicli,  however,  shifts  continually  as  the 
eruption  advances  or  recedes,  and  the  surface,  especially  on  the  face,  is 
often  studded  with  vesicles  or  blebs.  There  is  often  a  good  deal  of  ting- 
ling pain  in  the  part,  and  swelling  of  the  absorbent  glands  is  a  very  com- 
mon plicuomenon.  In  fact,  the  glands  have  often  been  found  enlarged 
before  the  eruption  shows  itself;  and  if  these  enlarged  glands  be  more 
carefully  examined,  tenderness  will  often  be  detected  in  the  course  of  the 
lymphatics  which  lead  to  them.  These  symptoms  are  only  the  local  man- 
ifestations of  a  general  disorder  of  the  system  shown  by  fever.     There  is 

1  Diseases  of  the  Skin,  Iransliitod  for  the  New  Syd.  Soc,  vol.  i,  p.  291. 

2  We  chilli  see  iiri'seiilly  how  close  is  tlie  connection  between  erysipelas  and  influtn- 
mation  of  the  absorbents. 


ERYSIPELAS. 


69 


Fig.  K). 


Tlu'riiiogra|jli  of  erysipelas. 


almost  always  a  ri<^or,  often  several,  at  the  commencement  of  an  erysipel- 
atous attack  ;  the  tongue  is  usually  coated  and  often  dry,  the  pulse  rapid, 
the  patient  restless  and  feverish,  ap- 
petite bad,  bowels  consti|)ated,  urine 
hioh  colored  and  often   slightly  all)u- 
minous. 

The  rise  in  temperature,  as  seen  in 
the  annexed  thermograph,  is  often 
very  abrupt,  and  the  defervescence 
frecpiently  as  rapid.  The  course  of 
the  teni|)erature  in  uncomplicated  ery- 
sipelas (such  as  is  siiown  in  tiie  chart) 
differs  from  that  in  traumatic  fever  in 
running  a  much  less  regular  course, 
and  usually  subsiding  more  rapidly 
and  al>ruptly  ;  and  from  tliat  in  pyie- 
mia  in  not  presenting  those  constant 
exacerbations  and  depressions  which 
mark  the  rigors  and  sweats  of  pyHemia.  But  erysipelas  so  frequently 
supervenes  on  traumatic  fever,  and  is  so  frequently  complicated  with  local 
and  general  disturbances  (notably  with  the  formation  of  abscess  and  with 
the  transition  to  pyaemia),  that  its  tem[)erature  curves  vary  very  con- 
siderably. 

There  is  an  interval  between  the  first  feverish  symptoms  and  the  appear- 
ance of  the  rash  which  is  said  sometimes  to  be  as  long  as  four  days,  but 
which  I  think  is  rarely  more  than  twenty-four  hours.  The  fever  ought  to 
subside  considerably  in  a  few  days.  If  the  pulse  and  temperature  keep 
up  beyond  about  ten  days,  and  particularly  if  there  is  a  rapid  and  con- 
siderable rise  after  a  week,  the  case  may  be  expected  to  terminate  fatally, 
though  I  have  seen  exceptions  to  this  rule.  Disturbances  of  digestion 
are  very  common  in  erysipelas,  so  that  sometimes  the  rash  is  mixed  more 
or  less  with  the  color  of  bile,  and  the  conjunctivae  are  slightly  jaundiced, 
and  this  is  sometimes  descril)ed  as  "bilious  erysipelas,"  though  it  hardly 
seems  to  require  a  separate  name.  Conversely,  bilious  disturbance  is 
occasionally  an  exciting  cause  of  erysipelas,  so  that  persons  j)redisposed 
are  very  liable  to  have  an  attack  of  erysipelas  from  disturbance  of  the 
liver.  Erysipelas  lasts  an  uncertain  time,  generally  fading  gradually  and 
disappearing  with  desquamation  of  the  epidermis  ;  but  sometimes  vanish- 
ing suddenly  in  one  part  of  the  body  to  appear  in  another — erratic  ery- 
sipelas. Suppuration  often  follows  in  the  cellular  tissue,  or  in  the  glands 
which  were  originally  inflamed.  There  are,  again,  cases  in  which  no 
preliminary  affection  of  the  lymphatics  or  of  the  glands  precedes  the 
attack  of  erysipelas,  but  in  which  the  erysipelas  itself  originates  the  in- 
flammation of  the  absorbents.  In  fact,  the  connection  between  spreading 
erysipelatous  inflammation  of  the  skin  and  the  similar  inflammation  of 
the  absorbents  is,  as  might  have  been  anticipated,  an  extremely  close  one; 
and  this  illustrates  what  was  said  above  of  the  close  connection  between 
erythema  nodosum,  erysipelas,  and  absorbent  inflammation.  As  the  case 
progresses  the  constipation  often  passes  into  diarrhoea,  the  feverishness 
gives  way  to  lassitude  and  exhaustion,  and  death  by  asthenia  is  threatened. 

Kinds  of  Cutaneous  Erysipelas. — Numerous  varieties  have  been  de- 
scribed by  authors,  more  indeed  than  there  is  any  practical  necessity  for 
distinguishing.  I  see  no  oliject  in  describing  as  distinct  varieties  more 
than  the  E.  ambulans,  in  which  the  rash  spreads  rapidly  over  the  greater 
part  of  the  whole  body ;  the  E.  erraticum,,  in  which  it  leaves  one  part  to 


70  rOMPT^ICATIONS    OF    WOUNDS. 

appear  in  another;  and  the  E.  metastaticum,  in  which  after  the  subsidence 
of  erysipelas  of  tiie  skin,  an  affection,  presumed  to  be  of  an  erysipelatous 
nature,  is  developed  in  internal  organs,  which,  however,  is  certainly  very 
rare,  if  indeed  it  has  any  existence  apart  from  general  pyaemia. 

In  phlegmonous  erysipelas  the  skin  is  less,  and  the  subjacent  cellular 
tissue  much  more,  atlected  than  in  the  simple  cutaneous  form,  not  that 
in  the  latter  the  cellular  tissue  is  usually  quite  unaffected,  as  the  swollen 
features  of  erysipelas  of  the  face  show.  The  general  symptoms  of  phleg- 
monous erysipelas  or  ''diffuse  inflammation"  are  much  tlie  same  as  those 
of  cutaneous  erysipelas,  but  more  intense;  the  redness  is  usually  deeper 
in  color,  the  skin  more  brawny,  alid  the  part  is  oedematous  and  some- 
times very  tense.  In  a  few  days  it  becomes  boggy,  from  the  formation 
of  matter.  This  is  often  accompanied  by  renevved  rigors,  and  the  skin 
frequently  sloughs,  sometimes  to  a  very  great  extent  Thus  I  have  seen 
the  whole  scalp  perish,  exposing  the  entire  vertex  of  the  cranium  in  a 
case  of  diffuse  inllammation  of  the  head.  The  destruction  from  suppura- 
tion and  sloughing  often  extends  very  deeply  and  very  far,  opening  into 
the  joints,  destroying  muscles,  exposing  I)ones,  etc. 

Diffuse  cellulitis  is  a  variety  of  this,  in  which  the  skin  is  almost  or 
entirely  exempt,  or  which  attacks  the  cellular  tissue  in  a  part  where  there 
is  no  skin.  In  some  forms,  especially  in  those  rapidly  fatal  cases  which 
have  been  known  to  follow  dissection-wounds,  the  disease  evidently  has 
a  very  close  relaiionship  to  pyremia,  and  the  rapid  occurrence  of  death 
shows  that  the  general  mass  of  the  blood  is  affected.  In  such  cases  it 
does  not  necessarily  spread  from  the  wound,  Init  appears  at  a  remote  part 
of  the  limb,  or  even  on  the  opposite  side  of  the  body.  And  in  other  cases 
diffuse  cellulitis  accompanies  or  precedes  traumatic  gangrene,  the  limb 
being  mottled  with  patclies  of  a  dark-red  color,  which,  when  cut  into  (in 
amputation,  for  example),  are  seen  to  consist  of  patches  of  cellular  tissue 
loaded  with  serum  and  a  dark-colored  sanious  lymph.  The  inflamed  cel- 
lular tissue  in  such  cases  rapidly  sloughs,  involving  the  skin  in  its  destruc- 
tion. 

The  causes  of  erysipelas  may  be  separated  into  ihe  predisposing  and 
the  exciting.  The  most  common  predisposing  cause  seems  to  be  bad  air. 
Hence  the  great  prevalence  of  the  disease  in  ill-ventilated  hosi)itals,  and 
to  a  less  extent  even  in  those  whose  ventilation  and  other  arrangements 
are  as  good  as  our  present  knowledge  enables  us  to  make  them.'  Habitual 
intemperance,  bad  diet,  visceral  disease — especially,  as  it  ap|)ears,  disease 
of  the  kidneys — are  all  undoubted  predisposing  causes.  And  many  peo- 
ple, without  any  such  definite  predisi)Osing  causes,  have  a  constitutional 
predisposition  to  erysipelas  (  particularly  of  the  head  and  face),  wliich 
will  show  itself  in  them  on  the  slightest  exciting  cause,  or  even  with  no 
obvious  cause  whatever. 


'  1  cannot  but  protest  at:;!iin?t  the  n?sumption  involved  in  thct  terms  "  hos)iitiil  ery- 
sipelas "  and  "  hospital  diseases  "  as  descriptive  of  tlio  complications  of  wounds.  Such 
com]ili('ations  are  met  with,  it  is  true,  most  commonly  in  hospitals,  for  the  simple 
reason  that  wounds  are  also  met  with  most  commonly  there;  but  they  occur  very 
frequently  in  private  practice,  even  under  the  most  favorable  circumstances,  and  they 
have  never  really  bi'cn  jn-oved  to  be  relaiiv(dy  more  frcfjuent  in  good  liosjiitals  than 
in  pri\'ate  practice,  in  similar  cases.  There  is  much  need  ibr  us  all  to  do  our  best  to  im- 
prove in  every  way  theair,  the  treatm<-nt,  thedressing,  and  all  the  other  circumstances 
of  tlie  wounded  in  our  hospitals — and  thereby,  doubtless,  the  jirevalencc  of  these 
complications  will  be  lessened — but  it  is  n  sad  error  to  impair  the  re))utation  and  thus 
diminish  the  usefulness  of  our  hosjiitals  by  reckless  aspersions  on  their  salubrity. 


ERYSIPELAS.  71 

The  exciting  cause  of  erysipelas  is  very  commonly  a  wounrl,  and  it  is 
especially  common  after  lacerated  vvoiiiids  of  the  lower  extremities  and 
scali),  ill  the  latter  case  almost  always  in  the  pldegmonous  form  (see 
Injuries  of  the  Head).'  It  is  very  liable  to  occur  after  puncturin*if  or 
scarilyini^  dropsical  parts.  A  current  of  cold  air  on  the  head,  cold  to 
the  loins  during  menstruation,  any  sudden  chill,  overexertion  or  errors 
in  diet,  will  sometimes  be  followed  by  an  attack  of  erysipelas  in  tiiose 
predisposed  to  it.  Tliere  are  also  causes  which  are  sometimes  classed 
separately  as  efficient  causes,  inasmuch  as  they  are  looked  on  as  really 
producing  the  disease,  while  the  others  only  prej)are  the  system  for  it. 
Such  are  poisoned  states  of  the  atmosphere,  of  the  precise  nature  of  which 
we  are  ignorant,  but  where,  as  is  believed  by  some,  germs  are  conveyed 
by  the  air,  which  sow  the  disease,  as  it  were,  on  wounds  in  persons  pre- 
dis[)osed  to  it,  or  where  some  material  passes  into  the  blood  which  ex- 
cites the  disease  during  its  elimination.  Many  authors  have  believed 
that  the  etticient  cause  of  erysipelas  is  the  contagion  of  bacteria,  and 
their  passage  into  tiie  blood,  and  it  seems  at  least  certain  that  very  fre- 
quently bacteria  may  be  found  both  in  the  blood  and  in  the  tissues.  They 
are  found  also  in  the  discharges,  but  this  may  be  accounted  for  in  various 
ways.  A  very  interesting  i)aper  by  Dr.  Lukomsky,  a  pupil  of  von  Kech- 
lingsliausen,  may  be  found  in  the  sixteenth  volume  of  Langenbeck's 
Archives^  in  which  it  is  sought  to  be  proved  (1)  that  bacteria  may  be 
found  in  the  bloodvessels,  the  lympliatics,  and  the  lymph-cliannels  of  the 
skin,  the  cellular  tissue,  and  the  internal  organs  in  the  human  subject, 
when  deatli  takes  place  during  the  advance  of  the  attack  of  erysi[)elas; 
(2)  tiiat  the  bacteria  are  no  longer  found  in  cases  of  death  during  the 
retrocession  of  the  disease;  (3)  that  an  affection  exactly  similar  to,  if 
not  identical  with,  cutaneous  erysipelas  can  be  excited  in  the  lower  ani- 
mals, not  only  by  the  injection  into  the  veins  or  under  the  skin  of  matter 
containing  bacteria,  but  also  by  the  application  of  such  matter  to  a  raw 
surface.  If  tliis  should  be  confirmed  it  would  afford  an  easy  interpreta- 
tion of  the  spontaneous,  the  traumatic,  and  the  contagious  origin  of  ery- 
8i[)elas-,  but  a  perusal  of  the  recent  debate  at  the  Pathological  Society, 
above  referred  to,  will  show  how  very  far  we  are  at  present  from  any 
trustwortliy  knowledge  as  to  the  universaiit}'  and  the  significance  of  the 
presence  of  these  minute  organisms. 

'  But  erysipoliis  wiien  excited  by  a  wound  does  not  always  attai-k  the  wounded 
part.  I  may  mention  a  striking  case.  I  amputated  the  f(>ot  of  a  man  in  perfectly 
good  general  liealth  <m  account  of  chronic  disea.«e  of  the  tarsus,  in  the  new  liospital 
at  Wimbledon.  Ho  was  lodged  by  himself  in  an  airy  room  which  had  never  been 
occupied  previously,  but  was  quite  dry  and  in  every  respei-t  most  comfortable,  well 
ventilated,  and  overlooking  a  wide  expanse  of  country.  He  had  no  visceral  disease, 
and  had  never  in  his  life  suffered  from  erj^sipelas.  There  was  no  other  patient  in  the 
hospital  sulfering  from  erysipelas,  nor,  in  fact,  any  other  grave  case  whatever,  except 
one  of  amputation  of  the  leg,  performed  on  the  same  day.  I  had  no  patient  under 
my  care  suffering  from  erysipelas.  The  two  cases  of  an)putation  were  in  separate 
wards,  attended  by  tht;  same  nurse,  and  dressed  by  the  resident  medical  officer  of  the 
hospital.  Contagion,  therefore,  seemed  absolutely  impossible,  nor  can  1  conceive  a 
psiticnt  better  circumstanced  fur  recovery.  The  wound  went  on. perfectly  well,  but 
erysipelas  of  the  head,  face,  and  che>t  occurred  a  few  daj's  after  the  operation  and 
proved  rapidly  fatal.  The  other  case  of  amputation  (which  was  certainly  an  un- 
promising one)  proved  fatal  also,  from  pyaemia.  I  have  seen  many  other  cases  in 
which  a  wound  has  been  the  exciting  cause;  but  as  the  disease  has  appeared  in  a 
remote  part  we  must  seek  elsewhere  for  the  efBcvent  cause.  A  very  natural  expla- 
nation (though  hitherto  conjectural  only)  would  be  that  some  morbid  product  is 
generated  in  tlie  wound,  and  passes  along  the  channels  of  absorption  (veins  or  lym- 
phatics) to  the  heart,  and  thence  to  the  part  affected. 


72  COMPLICATIONS    OF    WOUNDS. 

Contagwusness  of  Erysipelas. — Direct  infection  from  putrefvin;?  dis- 
charges of  any  kind  ma^'  produce  erysipelas.  Hence  tiie  proliil)ition  of 
the  use  of  sponges  in  liospital  wards,  since  after  being  infected  by  the 
discharge  from  one  wound,  they  may  be  employed  to  cleanse  another  ;  and 
hence  also  tiie  necessity  for  very  great  care  in  washing  the  hands  after 
dressing  each  case  before  another  patient  is  handled.  It  seems  also  un- 
deniable that  erysipelas  has  been  propagated  by  contagion — that  is  to 
say,  that  some  material  may  be  given  off  from  the  body  of  a  patient  suf- 
fering from  erysipelas  which  will  excite  the  disease  in  a  person  in  health, 
and  still  more  in  a  wounded  or  sick  person — of  course,  supposing  in 
either  cass  a  previous  predisposition.  Too  numerous  instances  of  this 
have  been  recorded  by  writers  of  experience  and  credit  to  leave  any  rea- 
sonable doubt  that  erysipelas  is  occasionally  contagious.  Yet,  as  pa- 
tients are  constantly  received  into  our  ordinary  surgical  and  medical 
wards  without  any  spread  of  the  disease,  its  contagiousness  must  be  very 
trifling,  and  in  a  well-ventilated  and  well-managed  hospital  there  is  no 
practical  danger  in  so  placing  the  patients,  whilst  the  collecting  of  all  the 
patients  into  special  "erysipelas  wards''  seems  to  concentrate  the  poison 
and  increase  the  I'isk  of  contagion,  unless  such  wards  and  all  their  attend- 
ants are  absolutely  separated  from  the  rest  of  the  hospital,  M'hich  in  prac- 
tice it  is  A'ery  difficult  to  do. 

The  diagnosis  of  the  disease  is  usually  obvious.  In  some  few  cases 
there  may  be  a  little  difficulty  in  distinguishing  diffuse  inflammation  from 
phlebitis  or  from  inflamed  absorbents,  and  I  have  seen  a  more  fatal  error 
committed  in  treating. a  case  of  deepseated  abscess  below  the  fascia, 
accompanied  by  oedema  and  inflammation  of  the  cellular  tissue  above  it, 
as  one  of  diffuse  inflammation  merely.  The  patient  died,  with  numerous 
incisions  into  the  subcutaneous  tissue,  but  with  the  abscess  unopened 
below;  and  I  have  seen  the  same  error  committed  with  less  serious  re- 
sults, as  the  diagnosis  has  been  corrected  afterwards.  When  any  reason 
exists  for  believing  that  matter  is  situated  below  the  fascia,  an  explor- 
atory puncture  should  not  be  neglected. 

2'he  prognosis  of  the  disease  depends  on  a  great  number  of  different 
considerations.  Gseteris  paribus.,  the  different  forms  of  erysipelas  are 
dangerous  in  proportion  as  they  are  deepseated — the  cutaneous,  cellulo- 
cutaneous,  and  cellular,  in  that  order.  But  the  prognosis  varies  also 
with  the  condition  of  the  patient,  being  bad  in  the  intemperate  and 
bloated,  and  especially  in  those  with  diseased  kidneys  or  liver;  with  the 
patient's  age,  being  bad  in  the  aged  and  in  the  very  young,  though  good 
in  cliildhood;  with  the  exciting  cause,  being  worse  in  epidemics;  with 
the  form  of  the  disease,  l>eing  worse  in  erratic  erysipelas  and  in  recurrent 
attacks;  with  its  course,  being  worse  when  the  disease  does  not  subside 
at  the  usual  period,  and  particularly  if  the  fever  is  liglited  up  again  after 
partial  subsidence  about  the  first  week;  with  the  situation,  being  worse 
in  erysipelas  of  the  head  and  face,  and  peculiarly  so  in  diffuse  inflamma- 
tion of  tiic  neck,  and  especially  if  in  either  case  the  erysipelas  spreads 
inlernall}''  to  the  mouth  and  fauces.  These  are  tiie  main  prognostic  con- 
siderations, tliough  many  others  might  be  added  And  it  should  not  be 
omitted  that  erysipelas  is  sometimes  salutar}-,  ushering  in  a  better  state 
of  health,  and  preceding  the  definite  healing  of  wounds  and  ulcers  which 
iiad  lieen  long  open  and  sluggish. 

The  treatment  of  erysii)elas  resolves  itself  naturally  into  general  and 
local.  The  former  is  the  same  for  all  forms  of  the  disease,  and  is  regu- 
lated by  the  general  symptoms  present  in  each  i)articular  case,  i.  e.,  it 
consists  in  the  treatment  of  the  accompanying  fover.     In  the  present  day 


ERYSIPELAS.  73 

the  old  antiplilogistic  or  depletory  treatment  of  fever  has  been  practically 
abandoned  ;  yet  there  are  cases  of  eiysipelas  in  which,  if  I  can  trust  my 
own  observation,  the  indiscriminately  stimulant  treatment  (vvliich  has  so 
generally  superseded  that  of  indiscriminate  depletion),  is  very  ill  l)orne, 
and  has  a  direct  influence  in  prolonging  the  disease.  The  strength  of 
the  pulse,  the  general  appearance  of  the  ])atient,  and  his  apparent  vital 
power  must  be  the  surgeon's  guide.  In  the  plethoric  and  strong,  after 
the  bowels  have  been  freely  evacuated  with  a  mercurial  purge  (which 
should  be  done  in  every  case  of  erysipelas,  even  when  diarrhoea  is  present, 
for  the  diari'hoea  often  depends  on  loaded  bowels),  salines  with  small  doses 
of  antimony,  and  light  fluid  diet  without  stimulants  should  be  oi'dered. 
But  there  are  very  few  cases  (if  any)  which  will  not  be  benefited  by  the 
administration  of  wine  or  beer  carefully  at  some  period  of  the  attack; 
and  if  there  are  any  which  I'equire  bleeding  or  leeching  at  first,  I  have 
not  met  with  them,  although  I  am  piei)ared  to  admit  the  advisal>ility  of 
taking  blood  either  from  the  arm,  or  better  from  the  temples  by  leeches, 
in  cases  of  erysipelas  of  the  head  accompanied  by  sthenic  inflammation 
of  the  membranes  of  the  brain.  In  almost  all  the  cases  of  difluse  inflam- 
mation (cellulo-cutaneous)  which  we  see  after  injuries,  no  judicious  prac- 
titioner can  hesitate  as  to  the  desirability  of  at  any  rate  avoiding  depletion, 
and  a  resort  to  free  stimulation  is  generally  followed  by  amendment.  The 
diet  must  be  regulated  by  the  state  of  the  appetite  and  tongue.  It  can 
do  nothing  but  harm  to  load  a  man's  stomach  with  food  which  he  cannot 
digest,  but  when  meat  and  other  nourishing  diet  can  be  borne  it  should 
be  given  along  with  the  stimulants.  The  kind  and  quantity  of  the  latter 
must  depend  on  the  patient's  previous  habits  to  some  extent,  but  nothing 
seems  in  general  more  grateful  to  the  patient  and  more  supporting  than 
good  porter.  When  there  is  much  nervous  excitement  and  restlessness 
opium  should  be  carefully  administered  ;  but  as  a  rule  opiates  are  to  be 
avoided  in  erysipelas,  except  in  the  phlegmonous  form  after  injuries. 
Cam|)hor,  ammonia,  and  light  tonics  are  generally  well  borne  after  the 
bowels  have  been  regulated.  Iron,  particularly  in  the  form  of  the  Tinct. 
Ferri  Perchloridi,  is  undoubtedly  useful  in  many  cases,  and  it  is  believed 
by  some  surgeons  to  have  a  direct  influence  on  the  blood,  and  thus  to  act 
as  a  specific  on  the  disease.  This  idea  depends  on  an  assumed  condition 
of  the  blood  in  life  something  similar  if  not  identical  with  the  state  in 
which  the  blood  is  found  after  death.  There  is  no  doubt  that  in  many 
post-mortem  examinations  of  persons  dying  with  erysipelas  nothing  ab- 
normal has  been  found  except  a  thick,  tarry,  uncoagulated  condition  of 
the  blood,  staining  the  vessels,  soon  putrefying,  and  leading  to  a  diffluent 
condition  of  the  spleen  and  other  viscera  which  contain  much  blood.  On 
microscopic  examination  of  the  blood  the  corpuscles  are  found  irregular 
and  broken.  It  is  assumed  with  great  probabilit}'  that  this  testifies  to  a 
previous  disorganization  of  the  l)lood  during  life.  And  it  may  be  that 
iron,  if  it  can  be  assimilated,  will  cf)rrect  this;  and  certainly  the  free 
exhibition  of  iron  is  very  beneficial  in  many  cases.  But  then  it  must  be 
given  very  freely  (say  xv  to  xx  drops  every  three  hours)  in  order  to 
produce  any  such  specific  effect.  And  it  will  not  agree  with  the  j^atient 
if  given  when  the  tongue  is  foul  and  the  general  fever  is  rising.  When 
iron  has  been  prescribed  in  such  cases  I  have  often  seen  marked  benefit 
from  discontinuing  it,  and  prescribing  salines,  with  small  doses  of  anti- 
mony, if  the  strength  admits  of  the  latter  drug  being  borne;  or  if  there 
is  much  prostration,  combined  with  tincture  of  bark  and  ammonia. 

The  local  treatment  differs  according  to  the  form  of  the  disease.     In 
the  cutaneous  form  the  exclusion  of  the  air  is  often  very  soothing.    Thus 


74  COMPLICATIONS    OF    WOUNDS. 

in  erysipelas  of  the  face  a  mask  is  made  for  the  ])atient,  smeared  with 
some  ointment  (a  favorite  one  for  the  pur|)ose  at  St.  George's  Hospital 
is  an  equal  mixture  of  Uncr.  Phinibi  and  Ung.  Calaminaj),  or  the  part  is 
defended  witli  a  layer  of  <.'otton-\vool,  or  some  bland  warm  lotion  is  used, 
such  as  Lotio  Plumbi,  a  lotion  of  sulpliate  of  iron  5J  to  Oj,  or  of  the 
Tinct.  Ferri  Perchlor.  5'j  t<>  o^'i'j  <>f  water.  Diluted  tincture  of  iodine 
is  recommended  l>y  some.  Nitrate  of  silver  in  a  strong  solution  (about 
grs.  .XV  to'  the  oz.)  ai)pears  to  me  often  Aery  useful;  and  many  surgeons 
are  fond  of  drawing  a  ring  round  the  erysipelatous  rash  or  round  the 
limb  above  it  with  a  stick  of  caustic,  a  practice  to  which  there  is  certaiidy 
uo  objection,  though  I  cannot  speak  positivel}'  from  my  own  experience 
of  its  utility. 

In  diffuse  inflammation  and  in  cellulitis  more  decisive  measures  are 
necessary.  In  the  early  stage,  when  there  is  only  a  little  oedema  around 
the  wound,  the  discharge  of  inflammatory  products  is  to  be  insured  by 
laying  the  wound  freely  open  with  the  finger  or  director.  If,  notwith- 
standing this,  the  inflammation  spreads  and  tlie  tension  increases,  it 
becomes  a  question  wiietlier  or  no  incisions  should  be  made,  not  in  order 
to  evacuate  matter — for  as  yet  no  matter  will  have  been  formed  —  but  to 
relieve  the  tension  of  the  parts,  and  to  avert  the  gangrene  which  is  threat- 
ened, as  well  as  to  provide  free  exit  for  the  matter  when  it  does  form. 
For  there  can  be  no  doubt  that  the  pressure  caused  by  the  exudation  of 
serum  and  lymph  on  the  capillaries  which  pass  through  the  cellular  tissue, 
and  the  stretching  of  these  vessels  as  the  skin  is  pushed  away  from  the 
fascia,  are  potent  causes  of  gangrene.  When,  therefore,  the  local  symp- 
toms arc  marked  enough,  in  the  surgeon's  judgment,  to  require  such 
severe  measures,  incisions  ought  to  be  made  freely  and  boldly  into  the 
cellular  tissue.  Kach  incision  should  he  of  no  great  length  (say  two  or 
three  inclies),  but  they  should  together  embrace  the  whole  extent  of  the 
tense  parts;  and  if  the  tension  affects  fresh  parts  afterwards  they  should 
be  rej)eated.  A  good  proof  of  their  necessity,  and  a  good  augury  for  their 
beneficial  influence,  is  the  free  gaping  of  each  cut  as  it  is  made.  If  any 
cousidei'able  vessel  is  wounded  it  must  be  secured  either  by  torsion  or 
ligature,  but  a  certain  amount  of  bleeding  is  rather  to  be  encouiaged. 
If  the  luemorrhage  be  alarming,  but  its  source  cannot  l>e  detected,  in 
consequence  of  tl)e  cut  vessel  having  retracted  into  the  oedematous  tissue, 
the  bleeding  can  be  rei)ressed  by  stuffing  the  wound  with  lint  for  a  few 
hours  and  making  pressure  over  it.  After  four  or  six  hours  this  may  be 
witlidrawn  without  fear  of  renewed  bleeding. 

In  cases  not  severe  enough  to  demand  incision  the  parts  should  be 
relaxed  with  warm  lotions  or  poultices.  Many  surgeons  speak  favorably 
of  the  apparentl}'  less  severe  measure  of  multiple  punctures  with  a  lancet 
as  a  substitute  for  incisi(ms,  but  they  generall}'  give  a  good  deal  of  pain, 
and  are  insufficient  to  afford  relief. 

In  making  the  incisions  it  is  often  advisable  to  administer  an  anaes- 
tlietic,  more  especially  in  view  of  the  very  probable  necessity  of  the 
repetition  of  tiie  operation  ;  and  if  the  same  indications  call  for  it  no 
hesitation  should  be  felt  in  repeating  the  incisions  again  and  again.  I 
have  often  seen  a  case  terminate  happily  willi  a  dozen  or  more  incisions, 
emf)racing  every  pai't  of  the  liml),  and  have  often  seen  occasion  to  regret 
that  incisi(jns  had  not  been  made  freely  enough  where  tiie  patient  lias 
either  sunk  under  the  irritation  of  constantly  advancing  erysipelas,  or 
has  recovered,  but  with  much  loss  of  function  of  the  liml)  from  sloughing 
of  skin,  fascia,  or  tendons.  In  cases  where  this  has  unluckily  occurred, 
leading  to  stiffness  and  loss  of  motion  of  the  joints,  and  particularly  the 


GANGRENE.  75 

fingers,  careful  and  clilioent  passive  motion  after  the  wounds  are  healed 
wiil  often  l)e  rewarded  with  great  success.  Tlie  part  should  he  well 
steamed,  and  each  of  the  affected  joints  severally  attended  to,  hy  gentle, 
cautious,  and  gradually  increasing  passive  motion,  while  tiie  patient  is 
encouraged  to  use  tlie  part  as  much  as  he  can  without  great  pain  or  sub- 
sequent swelling. 

By  gangrene  is  understood  the  death  of  a  visible  portion  of  the  soft 
parts  and  its  removal  in  a  niasfj,  which  is  called  a  slough.  Tlie  terms 
Hphaccliis  and  mortification  are  also  sometimes  used  to  express  the  pro- 
cess of  gangrene.^ 

Gangrene  may  be  tlie  result  of  mere  spontaneous  inflammation,  but  as 
a  general  rule  this  is  not  so.  The  great  majority  of  the  cases  which  we 
see  in  i)raclice  own  some  definite  cause,  although  in  most  of  them  in- 
flammation has  played  an  important  part  in  completing  the  death  of  the 
tissues. 

Traumatic  and  Spontaneous  Gangrene. — Gangrene  is  divided  (a),  ac- 
cording to  its  exciting  causes,  into  traumatic  and  spontaneous,  and  (6), 
according  to  its  form,  into  moist  and  dry. 

The  usual  causes  which  produce  traumatic  gangrene  are  mechanical 
injuries,  chemical  injuries,  local  poisons,  heat  or  cold,  and  arrest  of  cir- 
culation. 

The  first  cause  is  too  familiar  to  need  any  illustration.  Of  chemical 
injuries  the  ordinary  caustic  issue  is  a  common  example,  where  the  skin 
is  destroyed  by  the  desiccating  action  of  the  potassa  fusa,  and  is  cast  off 
as  a  slough,  the  result  being  a  healthy  granulatiug  ulcer.  Closely  analo- 
gous to  such  cases  are  those  which  result  from  tlie  local  action  of  poisons, 
such  as  putrefying  urine.  Such  urine  escaping  through  a  rui)tured  ure- 
thra kills  the  cellular  tissue  into  which  it  is  extravasated.  producing 
secondai-ilv  the  death  of  the  skin  which  receives  its  nutrition  through  this 
cellular  tissue.  Gangrene  from  burns  is  unhappily  only  too  common,  and 
that  from  frostbite  is  toleraltly  familiar  to  most  surgeons.  Gangrene  from 
arrest  of  circulation  may  arise  from  obliteration  of  the  main  artery  atone 
spot,  as  when  the  femoral  is  tied,  or  from  general  pressure,  as  when  a 
liml)  is  destroyed  by  tight  bandaging.  Spontaneous  gangrene  occurs 
sometimes  as  tlie  direct  result  of  idiopathic  inflammation,  as  the  slough- 
ing which  follows  a  carbuncle;  or  it  may  be  caused  by  degeneration  of 
the  vessels  in  old  age  (senile  gaugrene),  by  impaction  of  a  plug  of  fibrin 
in  a  large  vessel  (gangrene  from  embolism),  by  inflammation  of  arteries 
leading  to  their  obliteration,  by  loss  of  nervous  power,  and  by  impaired 
nutrition.  The  sloughing  of  the  cornea  which  follows  on  injury  of  the  fifth 
nerve  is  usuall_y  quoted  as  an  illustration  of  gangrene  produced  by  loss  of 
nervous  power,  and  the  gangrene  which  used  to  be  produced  bj'  eating 
cock-spurred  rye,  of  gangrene  from  imi)aired  nutrition  ;  but  the  two  causes 
seem  identical,  for  loss  of  nervous  power  appears  to  produce  gangrene 
merely  b}'  impairing  the  nutrition  of  the  part. 

We  see,  then,  one  main  distinction  between  the  two  classes  of  cases, 
which  is  of  the  highest  importance  in  their  surgical  treatment,  viz. :  that 
the  causes  of  the  former  are  local,  and  therefore  often  susceptible  of  me- 

1  "  Gnngrene  proporly  sisjnifies  the  state  whicli  immediately  precedes  mortification, 
while  the  complete  mortification,  or  absolute  death  of  a  part,  is  called  sp/incetus." — 
Hooper's  Med.  Diet.  But  the  distinction  is  not  a  very  obvious  one,  and  the  term 
sphacelus  is  superfluous,  and  is  now  almost  disused.  When  mortification  is  spoken 
of  as  distinct  from  gangrene,  the  former  means  the  process,  the  latter  the  result. 


76  COMPLICATIONS    OF    WOUNDS. 

chanical  removal ;  while  those  of  the  latter  are  mostly  (general;  so  that 
even  if  the  atlected  part  of  the  Iiody  could  be  i-emoved  without  any  injury 
to  the  i)atient,  the  same  general  cause  would  in  all  prohahilitv  reproduce 
tiie  jrangrene  elsewiiere. 

Jlloist  and  !)/•)/  Gangrene. — The  division  of  gangrene  into  moist  and 
dry  is  a  classical,  and  in  the  extreme  cases  a  very  well-marked  one,  hut 
in  ordinary  instances  it  is  not  very  easy  to  refer  the  case  to  one  or  the 
other  foi'm.  The  best  examples  of  dry  gangrene  are  sometimes  seen  in 
the  lingers  or  toes  of  very  old  persons,  where  tlie  arteries  become  entirely 
impei'vious,  the  part  tui-ns  dry  and  white  (sometimes  yellow  or  brown  or 
black),  shrivels  up.  witii  little  pain  or  inflammation,  and  thus  separates 
from  the  body.^  The  purely  inflammatory  forms  of  gangrene,  on  the 
other  hand,  are  always  moist,  much  fluid  and  much  gas.  the  result  of  pu- 
trefaction, ai'e  efl'used  into  the  cellular  tissue,  and  the  affection  is  accom- 
panied usually  by  a  great  deal  of  pain.  So  that  it  is  clear  enough  tliat 
gangrene  dei)en(is  in  the  former  class  of  cases  on  deficient  supply,  and  in 
the  lalteron  ol>structed  return  of  blood.  But  in  most  cases  the  two  causes 
act  together.  Thus  in  senile  gangrene  the  main  cause  is  indisputalUy 
the  delicient  snpi)ly  of  Itlood.  and  it  is  therefore  usually  classed  as  a  form 
of  dry  gangrene,  yet  obstruction  of  the  cai)illary  and  venous  circulation 
also  plays  a  prominent  part,  and  in  many  cases  there  is  the  inflammatory 
pain  and  the  loading  of  the  part  with  the  products  of  inflammation  which 
are  characteristic  of  moist  gansrene. 

Phenomena  of  Gangrene. — Taking  an  ordinary  example  of  gangrene, 
in  which  the  part  has  been  previously  inflamed,  its  red  color  becomes  livid 
or  mottled,  blebs  or  liulkie  form,  i.e..,  the  cuticle  separates  from  the  cutis, 
and  fluid,  generally  blood-tinged,  is  efl^used  between  them ;  the  tempera- 
ture of  the  part  falls,  it  loses  its  sensibility,  then  the  part  turns  black  and 
decomposes,  so  that  it  crackles  with  emphysema.  If  cut  into  it  is  found 
sodden  with  foul  serum  ;  in  extreme  cases  all  the  tissues  of  the  limb  are 
softened  and  separated  fi'om  the  bone.  This  is  mortificalion.  Tlie  next 
step  is  sloughing — tiiat  is.  the  separation  of  the  dead  parts — a  purely 
inflammatoi-y  process,  exactly  analogous  to  that  by  which  a  foreign  body, 
such  as  a  dart,  if  fixed  in  the  living  parts,  is  loosened  and  thrust  out. 
The  living  (i)erhai)s  better  called  half-dead)  tissues  adjoining  the  gan- 
grenous part  liecome  inflamed,  and  thus  a  red  line  is  traced  around  the 
slough,  which  is  called  the  line  of  demarcation.^  and  the  formation  of 
which  proves  that  the  gangrene  has  stopped,  at  least  at  the  part  where  the 
line  is  found.  Next  the  inflamed  parts  suppurate,  and  thus  a  trench  is 
dug  around  the  dead  part;  granulations  spring  up  and  push  off  the  slough, 
which  is  novv  loose  and  can  l)e  picked  off.  Very  commonly  one  or  two 
strings  of  cellular  tissue  resist  longer  the  process  of  inflammation,  and 
the  slough  requires  to  be  cut  away  with  a  pair  of  scissors  ;  and  in  the  case 
of  a  limb  the  bone  takes  far  longer  to  separate  than  the  soft  parts,  and  it 
is  often  necessary  to  divide  it  in  order  to  rid  the  patient  of  the  offensive 
putrefying  mass.  When  the  process  of  casting  off  the  slough  is  completed 
the  result  is  an  ordinary  granulating  ulcer. 

The  genei'al  symptoms  caused  by  an  attack  of  gangrene  are  usually  of 
a  low  or  "typhoid"  character.     The  pulse  is  small,  weak,  and  frequent, 


'  This  is  f;omi'tim(!s  callod  "chronic"  gsintjrcne,  as  by  Travers,  who  saj's :  "The 
main  distinction  between  this  and  acute  gangrene  is,  that  from  the;  first  the  part  thus 
affected,  losing  its  temperature  and  color,  becomes  dry,  tougli,  and  slirunketi,  instead 
of  moist,  soft,  and  swollen,  and  takes  on  a  j'ellow  or  blackish-brown  color,  nearly 
resembling  that  of  a  mummy."  I  have  seen  the  color  in  the  fingers  perl'eclly  dead- 
white. 


GANGRENE.  77 

the  tongue  dry  and  brown,  the  appetite  bad,  and  tlie  strength  failing. 
Death  occurs  from  asthenia,  and  often  ver_y  rapidly  and  unexpectedly. 

Treatment. — In  the  treatment  of  gangrene  the  first  question  is,  whether 
or  not  the  part  can  be  removed.  Speaking  generally  this  is  only  advisa- 
ble in  cases  of  traumatic  gangrene,  although  in  some  of  the  more  favor- 
able examples  of  the  spontaneous  form  it  may  be  done  after  the  line  of 
demarcation  has  formed. 

In  the  case  of  a  purely  localized  cause,  such  as  ligature  of  the  main 
artery,  there  can  be  no  question  that  as  soon  as  gangrene  is  once  de- 
clared tile  surgeon  may  amputate  if  he  thinks  it  necessary,  for  in  such 
cases  there  is  not  usually  much  general  fever.  But  in  severe  and  exten- 
sive injuries,  such  as  the  passagi3  of  a  cart-wheel  over  a  limb,  the  prac- 
tice of  surgeons  diflers.  When  the  patient  is  first  seen,  directly  after 
the  accident,  if  the  injury  is  obviously  incompatible  with  the  mainte- 
nance of  the  life  of  the  member,  it  is  better  to  amputate  at  once,  before 
the  traumatic  fever  which  will  follow  has  had  time  to  set  in,  and  if  pos- 
sible to  amputate  through  healthy  unl)rnised  tissues.  Otherwise,  if  the 
surgeon  delays  the  amputation,  fever  will  ensue,  and  will  probably  pre- 
clude successful  amputation  (for  amputation  in  conditions  of  acute  fever 
is  usually  fatal),  and  diffuse  inflammation  often  accompanies  this  fever, 
and  spreads  the  gangrene  rapidl}'  beyond  the  range  of  the  original  injury,' 
so  that  the  patient  sinks  before  an}^  second  opportunity  of  removing  the 
limb  occurs.  Therefore  some  surgeons,  looking  to  these  unfavorable 
cases,  teach  that  it  is  better  to  wait  for  the  line  of  demarcation  in  cases 
of  traumatic  gangrene  before  performing  amputation,  while  others  say 
that  such  delay  is  unnecessary.  It  appears  to  me  that  the  surgeon's 
choice  must  be  regulated  by  the  amount  of  fever  ar.d  by  the  progress  of 
the  gangrene.  If  the  liml)  is  so  far  mortified  as  to  be  useless,  yet  a 
stump  can  be  formed  in  tolerably  healthy  parts,  and  the  general  condi- 
tion admits  of  it,  there  is  no  motive  for  waiting.  On  the  other  hand, 
when  the  fever  is  extreme  and  the  gangrene  is  spreading  very  rapidly, 
amputation  is  useless  and  often  immediately  fatal.  Such  cases,  in  fact, 
are  well  nigh  hopeless;  but  if  the  patient  has  any  chance  of  recovery  it 
is  in  waiting  till  the  gangrene  has  stopped.  But  the  not  infrequent 
occurrence  after  injuries  of  this  frightful  form  of  spreading  gangrene, 
accompanied  as  it  is  by  such  profound  fever,  shovvs  that  the  surgeon  has 
not  accurately  judged  the  nature  of  the  injury  at  the  time  of  its  occur- 
rence, or  he  would  have  amputated  at  once.  Yet  it  must  be  admitted 
that  the  error  is  one  which  it  is  difilcult  to  avoid.  'We  are  all  desirous 
rather  to  save  liml)s  than  to  amputate  them.  We  can  all  look  back  on 
cases  where  the  patient's  obstinacy  has  triumphed  over  the  surgeon's 
urgency,  and  has  been  justified  by  his  preserving  both  life  and  limb. 
And  it  can  hardly  be  doubted  that  formerly  amputation  was  somewhat 
too  frequently  performed.  We  have  lately  had  many  cases  published  of 
the  preservation  of  limbs  (whether  b}'  '' antiseptic  "  dressing  or  otl)er- 
wise)  which  would  some  years  ago  have  been  sacrificed ;  and  in  endeav- 

1  The  process  is  tlius  graphically  described  by  Mr.  Hotmts  C'uolc :  "Nature  en- 
deavors to  cast  ofl'  the  dead  from  the  living  tissues  by  an  inflamuialory  process  in  the 
latter,  whicii  speedily  lose  their  vitality  from  inability  to  support  this  action  towards 
repair.  According  to  Hunter,  a  diminution  of  power,  when  joined  to  an  increased 
action,  becomes  a  cause  of  nn)rtitication,  by  destroying  the  bahmce  whicli  ouglit  to 
subsist  between  the  power  and  action  of  every  part.  Thus  the  mortification  spreads 
towards  the  trunk,  preceded  by  a  blush  of  dusky  red,  marking  its  onward  course." 
I  may  add  that  in  many  cases  tiiere  will  be  found  a  diffused  or  phlegmonous  inflam- 
mation of  the  cellular  tissue,  spreading  along  the  course  of  the  lymphatics. 


78  COMPLICATIONS    OF    WOUNDS. 

oring  to  carry  o\it  such  truly  conservative  surgery  mistakes  are  inevitable. 
I  will  relate  two  cases.  A  man  was  brought  to  St.  George's  Hospital,  of 
large  frame,  healthy  appearance  and  history,  who  had  sustained  a  severe 
injury  to  the  el))ow-joint.  j\o  case  could  seem  more  decidedly  suitable 
for  excision  of  the  joint  and  preservation  of  the  limb.  I  performed  the 
operation  with  the  sanction  of  my  colleagues.  The  main  nerves  and 
vessels  were  perfectly  intact.  A  day  or  two  after  the  operation,  rapidly 
spreading  gangrene  attacked  the  forearm.  One  of  my  colleagues  in  iny 
absence  am[)utated  tiiearni  near  the  shoulder ;  gangrene  rapiclly  attacked 
the  stump,  and  death  followed  in  a  few  days.  The  i)ost-mortem  appear- 
ances threw  no  light  on  the  cause  of  this  fatal  tendency. 

Another  man,  also  of  robust  appearance.  ;iet.  80,  was  admitted  under 
my  care  from  the  country.  A  few  days  previously  a  charge  of  small  shot 
had  lodged  in  the  calf  of  each  leg  from  a  distance  of  about  twelve  paces. 
On  admission  there  were  found  numerous  shot-holes  in  both  calves,  with 
consideralile  bruising  and  swelling.  On  the  third  day  gangrene  of  one 
leg  had  set  in  and  spread  rapidity.  The  patient  when  seen  appeared  to 
be  sinking;  and  although  tiiere  seemed  little  prospect  of  recovery,  it  was 
judged  right  to  give  him  the  small  chance  that  amputation  might  afford 
him.  He  died,  however,  almost  immediately  after  the  operation.  On 
examination  of  the  limb  no  artery  of  consequence  was  found  wounded, 
nor  was  there  very  much  extravasation  of  ]>lood.  In  both  these  cases  it 
is  clear  enough  that  i)i"imary  amputation  as  soon  as  practicable  after  the 
accident  would  have  given  tlie  jjatient  the  best  chance  for  his  life  :  but  I 
do  not  know  how  tlie  cases  could  have  been  distinguished  IVom  a  multi- 
tude of  similar  injuries  in  which  the  limb  has  been  preserved. 

I  allude  to  sucli  cases  in  order  to  impress  on  the  mind  of  the  reader 
the  vital  im})ortance  of  early  interference  where  amputation  is  necessary, 
if  the  operation  is  to  have  a  fair  chance  of  preserving  lil'e.  But  if  the 
attempt  to  save  the  limb  has  been  made,  and  gangrene  sets  in  in  a  severe 
and  rapidly  spreading  form,  it  appears  to  be  of  little  use  to  amputate — 
at  least  1  have  not  seen  any  successful  cases.  And  if  the  gangrene  does 
not  spread  rapidly  and  is  not  accompanied  bv  the  severe  constitutional 
symptoms  which  always  accompany  the  acute  form,  it  is  questionable 
whether  under  ordinary  circumstances  amputation  is  necessary.  The 
exjiectant  treatment  may  succeed  in  [(reserving  part  or  the  whole  of  the 
limb. 

Thei-e  are  many  other  exceptions  to  the  rule  usually  laid  down,  that 
amputation  may  lie  'performed  in  traumatic  gangrene.  Thus  in  the  gan- 
grene which  is  caused  either  by  heat  or  cold  it  is  very  rarely  that  ampu- 
tation is  successfully  performed  ;  for  in  burns  the  limb  is  generally 
scorched  and  partially  disintegrated  far  beyond  the  part  at  which  it  is 
totally  destroyed;  and  in  frostbite,  though  the  disintegration  is  less  vis- 
ible, yet  it  is  so  real,  that  in  the  Crimean  cam[)aign,  where  this  injury 
was  fatally  prevalent,  the  surgeons  at  last  gave  up  every  form  of  opera- 
tive interference,  so  uniform  was  the  bad  success — due  no  doubt  in  part 
to  the  general  exhaustion  of  the  patients,  but  partly  also  to  the  local 
elfects  of  cold,  extending  beyond  the  frozen  toes  or  fingers,  and  indis- 
posing the  tissues  oi'  which  the  stump  is  formed  to  take  on  rei)arative 
action.  Gangrene  from  emlujlism  might  be  tliought  to  be  a  favoral)le 
case  for  amputation,  and  so  it  would  be  were  it  not  for  the  concomitant 
heart  disease.  In  gangrene  after  ligature  of  the  u)ain  artery  we  have 
perhaps  the  most  appropriate  example  of  the  use  of  amputation  in  trau- 
matic gangrene.  S'ow,  gangrene  from  embolism  resembles  this  in  many 
respects.     The  obstruction  to  the  circulation  is  limited  and  definite;  and 


GANGRENE. 


79 


the  condition  can  frequently  be  diagnosed,  as  it  was  in  the  instance  here 
figured  ;  hnt  as  it  is  ustially  only  a  feature  of  a  general  disease  whicli  is 
necessarily  fatal,  and  which  would  usually  preclude  recover}^  from  a  seri- 
ous operation,  we  luxi'dly  ever  see  amputation  practiced  in  such  cases. 

On  tlie  whole,  therefore,  ampu- 
tation on  account  of  gangi'ene  is 
more  often  practiced  before  gan- 
grene has  set  in,  Init  when  it  is 
judged  to  Ije  inevitable;  and  when 
amputation  is  performed  later  on, 
the  successful  cases  are  gener- 
ally those  in  which  the  surgeon 
has  waited  until  tlie  process  has 
stopped. 

If  the  surgeon  has  decided  to 
save  the  limb,  or  if  the  gangrene 
is  in  a  part  which  cannot  be  re- 
moved, tlie  first  indication  is  to 
wraj)  it  up  as  completely  as  possi- 
ble in  some  application  which  will 
deodorize  the  dead  parts  and  stim- 
ulate the  living  to  cast  them  oft'. 
For  the  latter  purpose  uniform 
gentle  heat  is  very  desirable,  and 
the  two  indications  may  be  com- 
bined by  a  charcoal  poultice ;  or 
some  tarry  preparation,  such  as 
carbolic  acid  or  creasote,  ma}'  be 
applied  to  the  sloughing  part,  and 
the  whole  wrapped  up  in  a  thick 
layer  of  cotton-wool.  Some  of  the 
balsams,  such  as  balsam  of  Peru  or 
Friar's  Balsam  (Tr.  Benzoin  Co.), 
poured  into  a  poultice,  or  resinous 
substances,  are  also  much  in  use. 
An  old  and  ver}' useful  application 
is  the  ''green  ointment"  of  the 
St.  George's  Hospital  Pharmaco- 
pojia.'  Many  other  local  applica- 
tions to  gangrenous  parts  might 
be  mentioned,  but  I  think  the 
principle  of  all  of  them  is  the 
same, — to  keep  up  the  heat  of  the 
parts  equal  to  or  a  little  above 
the  natural  heat  of  the  body;  to 
stimulate  the  living  parts  and  to 
deodorize  the  dead. 

The  general  treatment  of  gangrene  rests  also  on  simple  principles — 
difficult  as  it  may  be  to  apply  .them  in  practice — viz.,  to  clear  the  alimen- 


An  embolic  clot,  lodged  in  and  completely  ob- 
structing tbe  superficial  femoral  artery,  just  as  it 
springs  f'i-ouithe  bifurcation  of  theconnnon  femoral 
trunk.  The  Clot  was  irregularly  adlierent  to  the 
wall  of  the  vessel,  which  had  a  slightly  roughened 
appearance  at  the  point  of  contact.  Elsewhere  the 
lining  membrane  was  natural  and  the  vessel  quite 
empty.  At  the  upper  end,  corresponding  to  the 
deep  femoral  (which  was  unobstructed),  the  clot  was 
scooped  out  by  the  action  of  the  blood  p-issing  into 
that  artery.  The  patient  was  admitted  with  dis- 
eased heart  and  dropsy,  and  in  the  course  of  that 
disease  gangrene  of  the  foot  supervened.  The  na- 
ture and  seat  of  the  obstruction  could  be  quite  easily 
recognized  during  life.  Blocks  of  librin  were  found 
in  the  spleen  and  kidney. — St.  George's  Hospital 
Museum,  Ser.  vi,  No.  199. 


1  The  formula  for  this  is — R.  Ung.  Elcmi,  lb.  j,  Uiig.  Sambiici,  ^iij,  Bal.'^.  Copaib., 
^^iij.  The  oinlments  to  bo  melted  together  and  the  Cojiaibu  added  to  them  after 
they  have  been  removed  from  the  fire,  before  they  cool. 

Ung.  Sambuci  is  made  with  the  fresh  leaves  of  the  elder  (lb.  ij),  prepared  lard  (lb. 
ijss.j,  and  as  much  water  as  required. 


80  COMPLICATIONS    OF    WOUNDS. 

tary  canal  and  improve  the  digestion,  so  that  the  patient  may  be  able  to 
take  such  nntiinient  and  stimulants  as  will  keep  him  alive  through  the 
process;  and  to  calm  Hie  nervous  system  and  procuie  sleep  b}'  means  of 
opium  or  some  of  its  preparations;  or  if  these  are  not  tolerated,  b^'  some 
otlier  narcotic. 

Tiiere  are  few  cases  of  gangrene  in  which  opium  is  not  indicated,  and 
this  is  e.s|)ecially  the  case  tiie  older  the  patient  is;  and  tliere  are  perhaps 
none  (at  least  none  in  which  tlie  gangrene  is  extensive  enough  to  produce 
constitutional  symptoms)  where  alcoholic  stimulants  are  not  required. 
But  it  is  a  great  error  to  "^  i)our  in  "  stimulants  and  narcotics  without  any 
refei'ence  to  the  condition  ol"  the  tongue,  pulse,  and  temperature.  Nar- 
cotics are  used  cliietly  to  calm  the  patient  nnd  to  avoid  the  exhaustion 
which  excitement  and  pain  produce;  but  opium  when  ill-borne  will  often 
make  the  patient  semi-delirious,  and  will  cause  excitement  and  loathing 
for  food,  and  so  increase  the  exliaustion.  In  such  cases  the  narcotic  must 
be  used  cautiously  and  administei'ed  hypodermically  or  by  the  rectum, 
for  many  patients  can  tolerate  moi'phia  or  opium  in  tliis  manner  who  can- 
not take  it  by  the  stomaclu  But  in  some  persons  all  opiates  disagree,  in 
whatever  form  or  in  whatever  way  they  are  given.  Chloral,  in  full  doses, 
(say  9j),  should  be  tried  in  such  persons,  or  hyoscyamus,  or  the  Indian 
hemj)  (in  doses  of  gr.  i-ij  of  the  extract  or  n^x-xx  of  the  tincture,  cau- 
tiously' increased  if  it  seems  to  agree).  But  no  narcotic  is  nearly  so  cer- 
tain as  opium  or  morphia;  and  this  is  usually  not  merely  tolerated  in 
cases  of  gangrene,  but  the  patient's  general  condition  improves  under  its 
use,  visil)l\-  and  at  once.  Stimulants  are  used  to  procure  sleep,  to  assist 
appetite,  to  steady  the  pulse,  and  to  lower  the  temperature  ;  buttliey  will 
not  do  tliis  unless  tlie}^  are  digested.  Tlie  judicious  use  of  purgatives 
and  the  apportionment  of  the  needful  stimulant,  both  as  to  quantity  and 
quality,  to  tlie  patient's  powers  of  digestion,  will  tax  all  the  experience 
and  resources  of  the  surgeon,  especially  when  the  patient  is  somewhat 
advanced  in  life  and  has  already  ruined  his  digestion  and  health  by  the 
abuse  of  fermented  liquors. 

It  remains  to  speak  of  some  of  the  s[)ecial  forms  of  gangrene. 

Traumatic  Gangrene. — Enough  perhaps  has  ali'eady  been  said  about 
traumatic  gangrene  as  far  as  concerns  tlie  question  of  amputation.  It  may 
be  useful  just  to  remind  the  reader  that  the  limb  may  be  hopelessly  dis- 
organized, both  in  military  practice  by  spent  shot,  and  in  the  injuries  of 
civil  life  by  extensive  crushes,  without  the  skin  being  very  much  injured; 
the  soft  [jarts  are  separated  from  the  bone,  the  pulse  in  the  main  vessels 
is  stopped,  and  an  attentive  examination  will  leave  no  doubt  of  the  neces- 
sity for  amputation.  I  ought  also  to  add  that  the  indications  for  the 
removal  of  the  limb  are  quite  ditferent  in  early  and  in  late  life.  Injuries 
which  alter  middle  life  call  iuqjeratively  for  amputation  may  in  childhood 
or  about  the  age  of  |)ul)erty  be  most  reasonably  treated  on  the  expectant 
plan,  the  surgeon  feeling  conlident  that  if  gangrene  sets  in  and  anqjuta- 
tion  becomes  necessary  there  will  be  no  sucli  prolbuiid  traumatic  fever  as 
that  which,  in  later  life,  almost  precludes  the  hope  of  success. 

lU'xhoreti. — A  form  of  gangrene  which  niny  be  regarded  as  to  a  certain 
extent  traumatic  is  that  iV(;m  pressure — bedsores,  or  "gangrjtMia  ex  decu- 
V)itu."  They  are  usually  found  in  debilitated  and  emaciated  persons  who 
have  lain  long  in  bed,  and  whose  weakness  ])revents  them  from  shifting 
their  position  often  or  much.  They  form  usually  on  the  sacrum,  buttocks, 
hips,  and  heels.  The  skin  begins  to  look  red  and  thin,  and  then  a  circular 
black  slough  forms.  The  jjarts  may  slough  so  deeply  as  to  open  the  ver- 
tebral canal,  and  the  sl(Mighiiig  is  often  the  proximate  cause  of  death  in 


HOSPITAL    GANGRENE.  81 

cases  which  might  otherwise  get  well.  Hence  the  greatest  care  should  he 
exercised  in  all  chronic  cases  to  watch  the  state  of  the  parts  on  which 
bedsores  usually  form,  and  no  doubt  careful  and  dexterous  nursing  will 
prevent  their  foimation  in  nian}^  cases,  though  it  is  most  unjust  and 
untrue  to  say,  as  is  sometimes  said,  that  the  occurrence  of  bedsores 
proves  careless  nursing.  In  order  to  obviate  their  formation  the  first 
thing  is  to  contrive  frequent  slight  changes  in  the  patient's  position,  to 
pad  the  parts  where  the  bones  press  on  tlie  skin  with  air  or  water  pillows, 
elei)hant-plaster  cut  into  a  ring,  or  some  such  contrivance,  and  to  harden 
the  skin  by  painting  it  with  camphorated  spirit  or  weak  solution  of  nitrate 
of  silver.  If  the  redness  still  persists  a  soft  poultice  is,  I  think,  the  best 
application ;  and  when  gangrene  is  absolutely  declared  it  must  be  treated 
locally  like  any  other  form  of  sloughing. 

A  kind  of  bedsore  is  formed  in  fracture  of  the  spine  in  which  the  slough- 
ing is  partly  produced  ity  loss  of  nervous  influence.  This  will  be  spoken 
of  under  tiie  head  of  Injuries  of  the  Back. 

Tlie  sloughing  which  is  caused  by  tight  bandaging  is  an  illustration  of 
gangrene  from  pressure  with  which  we  are  happily  unfamiliar  in  these  days 
of  iin|)roved  medical  education.  Occasionally  the  formation  of  a  small 
limited  slough  can  hardly  be  avoided,  but  the  mortification  of  the  whole 
or  great  })art  of  the  skin  of  a  limb  is  justl}'  regarded  as  a  proof  of  crimi- 
nal negligence,  and  punished  accordingly.  In  the  unhappy  cases  where 
this  has  occurred  amputation  is  often  necessary. 

Ill  fro.Htbite  the  symptouis  seen  immediately  after  the  injury  are  usually 
rather  in  excess  of  the  real  amount  of  destruction.  Parts  are  cold,  white, 
destitute  of  sensation  and  of  circulation,  and  seem  condemned  to  inev- 
itable death,  which  really  will  recover  if  they  are  patiently  and  gradually 
restored  to  the  natural  warmth.  This  is  best  done  by  rubbing  the  part 
gently  with  snow,  and  bringing  the  patient  by  degrees  into  a  warmer 
atmosphere.  If  the  circulation  be  too  abruptly  stimulated  the  frozen 
parts  will  probably  slougli.  On  the  other  hand,  some  time  afterwards, 
the  apparent  is  less  than  the  real  injuiy,  since  the  parts  whicli  a{)pear  to 
be  perfectly  nourished  are  really  incapable  of  sustaining  the  reparative 
process,  and  if  operations  be  performed  through  them  renewed  sloughing 
or  tedious  ulceration  will  ensue.  In  the  cases  where  gangrene  sets  in 
immediately  it  is  of  the  dry  form  ;  the  parts  shrivel  up  at  once,  and  never 
regain  the  warmth  or  color  of  life.  In  other  cases  they  perisli  from  low 
infiamuiatiou,  being  unable  to  support  the  reaction  which  ensues  on  the 
return  of  the  circulation.  The  treatment  of  frostbite,  beyond  the  means 
required  to  restore  warmth  at  first,  involves  no  peculiarity  except  that 
the  atlected  parts  should  long  be  kept  warmly  wrapped  in  wool. 

UospHal  gangrene  is  an  extreme  form  of  sloughing  phagedsena.  The 
term  '•  |)haged!ena"  has  been  applied  to  a  combination  of  ulceration  and 
gangrene  in  which  as  the  ulcer  spreads  its  surface  sloughs  more  or  less 
deeply.  Tv^o  forms  of  this  atiection  are  recognized,  viz.,  spreading  pha,- 
ged;ena,  where  ulceration  is  the  prominent  symptom,  the  sloughing  being 
only  sui)erficial,  and  ploughing  phagedaena,  where  the  slough  which  forms 
on  the  surface  of  the  ulcer  is  thick,  black,  and  round  in  shape,  and  ap- 
pears to  involve  a  considerable  depth  of  tissue,  so  that  the  sloughing  is 
the  prominent  symptom;  but  underneath  tliis  slough  ulceration  is  going 
on,  and  these  ulcerating  tissues  will  themselves  rapidly  perish. 

The  disease  which  has  been  clescribed  to  us  by  military  surgeons'  as 

1  As  for  example,  in  Henncn's  Military  Surgery,  from  the  outbreaks  of  this  disease 
during  the  Peninsular  war;  or  Macleod's  Surgery  of  the  Crimean  War. 

6 


82  COMPLICATIONS    OF    WOUNDS. 

"  hospital  o;angrene,"  and  of  which  we  have  been  fortunate  enough  not  to 
have  seen  any  instances  in  the  hospitals  of  this  country,'  is  a  severe  form 
of  sloughing  piiagedfena,  accompanied  by  a  constitutional  affection  which 
is  usually',  in  fact  almost  always,  fatal.  Its  cause. api)ears  to  he  general, 
i.  e.,  to  be  contained  in  the  atmosphere  of  the  chamber  in  which  it  origi- 
nates, and  this  seems  to  be  usually  the  result  of  overcrowding,  deficient 
ventilation,  and  uncleanliness,  acting  on  men  depressed  by  wounds  and 
possibly  by  defeat.  The  condition  of  the  general  atmospliere  of  the  place 
may  favor  its  develo})ment,  but  cannot  induce  it,  for  it  is  almost  alvva3S 
observed  that  scattering  the  sick  into  the  neighborhood,  even  putting 
them  into  the  open  air  under  canvas,  stops  the  outbreak.  Direct  conta- 
gion, there  can  be  little  doubt,  acts  powerfully  as  an  exciting  cause,  and 
very  probably  the  flies  which  generally  abound  in  such  places  convey  the 
poison  from  one  wound  to  another.  From  this  contagious  property,  of 
which  many  striking  examples  are  given,  the  disease  is  sometimes  de- 
nominated "  Gangnena  contagiosa." 

The  disease  commences  with  pain  and  tightness  across  the  forehead, 
small,  quick  pulse,  anxious  countenance,  stinging  pain  in  the  wound, 
swelling  and  hardness  around  its  edges.  The  discharge  becomes  tliin, 
gleety,  and  blood-tinged,  with  masses  like  gruel  suspended  in  it.  In  a 
few  hours  the  limb  becomes  greatly  swollen,  with  blue  congested  veins; 
if  cut  into,  the  cut  edges  look  like  raw  pork,  from  the  oedematous  condi- 
tion of  all  the  parts.  The  wound  assumes  a  circular  form,  and  is  covered 
with  a  thick  black  slough,  or  its  surface  turns  white  or  ashy  gray.  The 
affection  is  attended  by  constitutional  or  traumatic  fever  in  its  sevei'est 
form,  from  which  the  patient  often  sinks  in  a  few  hours,  and  which  in  gen- 
eral goes  on  to  a  fatal  termination.  The  awful  mortality  attending  on  this 
disease  is  attested  by  many  sad  histories  of  overcrowded  militai-y  hospi- 
tals and  transport  ships,  as  in  an  instance  recorded  by  Mi".  Holmes  Coote 
of  a  French  Crimean  transport,  from  which  sixty  dead  bodies  were  thrown 
overl)oard  in  a  passage  of  thirty-eight  hours. 

Wlien  this  formidable  disease  has  invaded  a  hospital  there  seems  no 
question  that  the  first  thing  which  should  be  done  is  to  empty  the  build- 
ing of  all  the  sick  and  wounded  which  it  contains,  isolating  them  if  pos- 
sible ;  and  if  that  is  not  possible  putting  them  under  canvas  in  the  open 
air.  The  most  minute  attention  must  also  be  paid  to  the  cleanliness  of 
the  dressings,  ever}'  material  with  which  the  wounds  are  touched  being 
burnt  at  once  ;'^  the  gangrenous  surfaces  should  also  be  covered  over  with 
thick  layers  of  charcoal,  creasote,  carbolic  acid,  or  some  other  disinfect- 
ant, so  that  there  can  be  no  possibility  of  the  convej'ance  of  matter  from 
one  sore  to  another.  The  sloughing  surfaces  should  be  destroyed  by 
means  of  an  active  caustic,  of  which,  perhaps,  fuming  nitric  acid  is  the 
best;  opium  should  be  freely  given,  and  the  patient's  strength  sui)p()rted 
by  lilieral  quantities  of  nutriment  and  stimulants.  The  cauterization 
should  be  repeated  as  often  as  ma^'  be  judged  necessary,  the  patient  being 
under  ana^stliesia. 

Phagedsena. — The  disease  to  which  the  name  of  hospital  gangrene  has 

1  In  Soutli's  Ch«lius,  i,  08,  may  bo  seen  an  account  by  Li-ton  of  a  severe  outbreak 
of  i-loughini;  pluiL^edicrui  in  University  Collei^c  Hospital  in  the  year  1841,  wbicli  at- 
taciic'd  a  hirge  nuniluM-  of  patients  sinuiltaneou!-!}',  and  wliicii  lie  classed  as  •'  liD.-pital 
gani^ronc,"  but  no  case  proved  fatal.  » 

^  It  is  not  cnoui^h  merely  to  scald  or  boil  sp()nc;cs.  Mr.  Coote  relates  tbat  in  an 
outbreak  of  pliagcdscna  in  St.  Bartholomew's  Hospital  the  extension  of  the  disease 
in  two  instances  was  clearly  traced  to  the  use  of  a  sponu;e  which  had  first  beitn  ap- 
plied to  a  gangrenous  sore,  then  boiled,  and  afterwards  ap|)lied  to  a  healthy  wound. 


PHAGED.ENA.  83 

been  given,  I  think  erroneously,  and  which  has  been  seen  of  late  years 
occasionally  in  our  London  hospitals,  differs  from  the  formidal)le  affection 
above  described  in  tiie  essential  particulars  that  little  or  no  constitu- 
tional fever  accompanies  it,  and  that  it  involves  very  little  danger  to  life. 
I  make  bold  also  to  say  that  it  differs  in  another  respect,  viz.,  that  it  has 
not  been  proved  to  originate  from  any  hospital  influence.  We  have  had 
several  outbreaks  of  this  disease  at  St.  George's  Hospital,  and  have  always 
found  that  it  has  been  prevailing  at  the  same  time  in  the  neighborhood 
of  the  hospital,  and  has  attacked  persons  who  have  had  no  connection 
whatever  with  the  latter,  so  that  the  influences,  whatever  they  were, 
which  generated  the  disease  could  not  have  been  confined  to  the  iiospital. 
It  is,  of  course,  theoretically  possible  that  dirt  and  overcrowding  might 
have  generated  the  gangrenous  affection  both  in  private  houses  and  in 
the  hospital  simultaneousl>'.  All  that  I  can  say  is  that  the  efforts  of  nu- 
merous skilled  inquirers,  most  ardently  interested  in  discovering  any 
such  cause  acting  in  the  hospital,  have  hitherto  failed  entirely  to  detect 
it,  and  it  seems  to  me  both  incorrect  as  a  matter  of  science  and  unfair  (I 
had  almost  used  a  stronger  word)  to  call  it  by  a  name  which  implies  that 
there  is  some  proved  and  admitted  unhealthiness  in  our  hospital  wards, 
when  no  such  thing  has  ever  been  shown  to  be  true.  I  prefer,  therefore, 
to  denominate  this  affection  simply  Phaged^ena,  and  to  confess  that 
though  tliere  is  a  good  deal  of  reason  to  suspect  that  it  owes  its  origin, 
at  least  very  frequently,  to  carelessness  in  hospital  management,  and 
particularly  in  the  matters  used  for  dressing  wounds,  yet  that  in  very 
many  cases  it  has  been  found  hitherto  impossible  to  verify  this  suspicion, 
and  therefore  impossible  to  explain  the  causation  of  the  disease. 

It  occurs  in  two  forms:  the  ploughing  phagedaena,  the  severer  forms  of 
which  approach  the  local  character  of  hospital  gangrene,  and  whicii  are 
characterized  by  the  round  black  slough  and  its  thickened  border  ;  and 
the  iipreading  pJiogedasna,  in  which  the  wound  spreads  with  an  ii'regular 
edge  and  a  foul,  sloughy  surface.  The  depth  of  this  sloughing  from  the 
surface  of  the  ulcer  is  hardly  ever  considerable,  though  sometimes  from 
the  swelling  in  and  around  the  sore  it  appears  so.  In  the  limbs  it  seldom 
extends  below  the  deep  fascia,  though  I  have  known  it  to  do  so,  and  for 
the  same  reason  haemorrhage  is  very  rare.' 

Mr.  Pick'"'  has  noticed  an  interesting  fact,  which  is  sometimes  to  be  ob- 
served in  phagedsena,  viz.,  that  the  pain  of  the  wound  ceases  about  twenty- 
four  hours  before  the  commencement  of  the  sloughing,  and  that,  coin,ci- 
dent  with  this  cessation  of  pain,  tliere  is  a  well-marked  and  vei-y  striking 
fall  of  the  thermometer.  The  traumatic  fever  is  usually  high  in  cases 
which  are  attacked  by  phagedaiua,  so  that  the  temperature  will  prol)ably 
have  ranged  up  to  105^  or  106*^  F.  From  this  there  will  be  a  sudden  fall 
down  to,  or  even  below,  DS*^,  and  twenty-four  hours  afterwards  the  phage- 
dfena  will  show  itself  Frotn  these  phenomena  Mr.  Pick  has  been  able  to 
prognosticate  the  occurrence  of  phagedsena  in  a  case  of  amputation,  where 
the  surgeon  in  attendance  was  perfectly  satisfied  that  the  wound  was 
going  on  quite  well.  But  this  phenomenon  is  not  a  constant  one,  nor  is 
its  cause  obvious. 

The  pain  in  phagedaena  varies  much.     Sometimes  wounds  may  spread 

'  It  is  as  well,  perhaps,  to  point  out  that  this  remark  does  not  apply  to  cases  in 
which  (iis  in  sloughing  after  hubo  affecting  the  deepseated  ghindsj  the  fascia  may 
have  been  perforated  before  the  |)hagedifcna  set  in.  In  such  cases  the  vessels  are  often 
exposed  and  occasionally  give  way. 

^  St.  George's  Hospital  lieports,  vol.  iii,  p.  81. 


84  COMPLICATIONS    OF    WOUNDS. 

to  a  very  considerable  extent  with  bnt  little  suffering,  at  others  very  large 
doses  of  opium  are  required  to  quell  the  pain. 

The  treatment  of  phageda?na  should,  I  think,  be  mainly  local;  the  sur- 
geon should  endeavor  to  procure  a  more  healthy  surface  to  the  wound,  by 
applications  of  which  energetic  caustics  appear  to  me  the  best.  If  the 
sultject  be  young  and  healthy,  steeping  the  attected  surface  in  nitric  acid, 
the  patient  being  under  chloroform,  almost  always  stops  the  phageditna. 
If  this  should  fail,  or  if  the  surgeon  be  unwilling  to  employ  so  strong  a 
measure,  the  sore  must  be  dressed  with  some  detergent  and  stimulating 
application,  such  as  those  used  in  other  forms  of  gangrene  (see  page  79). 

With  regard  to  internal  treatment,  some  persons  believe  tiiat  opium 
exerts  a  specific  influence  on  the  spread  of  phagedaena.  Having  had  a 
large  experience  of  opium  so  given,  I  am  convinced  that  it  has  no  such 
influence.  Opium  is  very  useful,  indeed  necessary,  in  such  doses  as  are 
required  to  procure  sleep  and  allay  pain,  and  its  good  effects  are  indis- 
putable in  elderly  persons  of  broken  health  and  dissipated  habits,  but  if 
given,  as  I  have  seen  it,  in  enormous  quantities  frequently  repeated,  it 
seems  to  me  to  do  harm,  and  I  have  seen  phagedsena  go  on  while  the 
patient  was  being  poisoned  by  opium — indeed,  in  one  case  up  to  the  pa- 
tient's death  from  the  latter  cause  merely.  If  this  man  had  not  been 
treated  at  all  I  have  no  doubt  that  he  would  have  got  well.  Such  gross 
instances  of  malpraxis  are,  no  doubt,  rare,  but  I  have  equally  little  doubt 
that  the  error  of  giving  opium  beyond  what  is  necessary,  under  the  idea 
that  it  is  specific  in  sloughing,  is  common.  There  ai'e  many  cases  wliich 
do  well  witli  no  opium  at  all.  It  is  always  well,  I  tliink,  to  evacuate  the 
bowels,  and  stimulants  with  nourishing  food  are  usually  indicated.  Bark, 
quinine,  and  ammonia  also  seem  to  accelerate  convalescence. 

Senile  gangrene  is  the  indirect  result  of  the  ossification  or  atheroma- 
tous condition  of  the  arteries  common  in  old  age.  It  occurs  in  two  forms, 
the  dry  and  the  moist.  In  the  former  the  disease  is  purely  one  of  ob- 
structed blood  supply,  and  the  arteries  will  sometimes  be  found  filled  with 
clot  for  a  very  considerable  distance.  Billrotli  points  out  that  in  senile 
gangrene  it  is  not  merely  the  anatomical  condition  of  tlie  arterial  wall 
that  is  at  fault,  but  that  tiiere  is  IVequently  also  disease  of  the  heart,  and 
a  tendency  to  embolism  or  arterial  tliroml)Us,  so  that  the  gradual  spi'ead 
of  obstruction  up  the  tube  of  the  main  arteiy  can  be  verified  l»y  exami- 
nation during  life.  Cases  of  si)OutMneous  gangrene  are  on  record  at  all 
periods  of  life,  even  in  childhood,  though  but  rarely,  and  usually  after 
acute  blood  diseases,  as  fever,  iiut  it  will  be  sufficient  to  describe  here 
the  two  forms  of  senile  gangrene,  leaving  the  lare  cases  of  spontaneous 
gangrene  at  other  ages  to  be  dealt  with  on  the  same  i)rinciplcs.  The 
purely  dry  form,  which  in  my  own  experience  has  been  decidedly  the  ex- 
ception, is  the  result  of  mere  obstruction  ;  the  toes  (in  some  very  rare 
cases  the  fingers)  turn  black  and  shrivel,  usually  without  much  pain  or 
constitutional  disturbance;  then  a  line  of  demarcation  forms,  and  the  pa- 
tient may  recover.  In  rai'er  cases  a  finger  may  sim[jly  shrivel  up,  without 
any  discoloration.  In  the  other  form  there  is  consideralile  pain  and 
mu(;h  redness  around  the  black  parts,  together  with  (edematous  swelling 
of  the  j)art,  and  all  the  evidences  of  inflammation  ;  and  it  is  clear  that  the 
gangrene  is  i)artly  inflammatory,  i)eing  caused  probably  by  some  irrita- 
tion making  a  call  on  the  powei's  of  tlie  part  which  the  deficiency  of  its 
circulation  renders  it  unal)le  to  snppl}'.  In  many  instances  the  outbreak 
of  the  disease  is  referred  with  great  probability  to  some  trifiing  injury, 
often  a  cut  received  in  cutting  the  toenails.  This  form  tends  far  less  to 
limitation  and  therefore  to  recovery  than  the  dry  form.     The  disease  is 


XOMA.  85 

far  more  common  in  the  male  than  in  the  female  sex,  and  appears  often 
to  depend  partly  on  visceral  degeneration,  the  resnlt  of  overfeeding,  and 
which  is  freqnently  marked  also  by  a  gouty  tendency. 

In  the  treatment  of  senile  gangrene  the  fii'st  point  is  to  support  the  pa- 
tient's strength,  and  the  second  to  support  the  warmth  of  the  part,  in  hopes 
that  the  gangrene  may  stop.  Opium  must  be  given  to  allay  pain,  and  it 
seems  always  to  be  well  borne  ;  tlie  part  must  l)e  wrapped  in  cotton-wool 
and  well  deodorized.  Amputation  as  a  lule  is  to  be  deprecated,  and  the 
few  cases  in  which  it  has  been  successfully  practiced  afford  to  my  mind  no 
argument  against  this  rule,  since  we  know  that  recoveries  also  occur  with- 
out amputation.  Possil)ly  there  may  be  exceptions  in  cases  where  the 
surgeon  can  clearly  detect  the  limit  of  the  arterial  affection,  but  such 
cases  must  be  very  rare,  and  the  few  amputations  which  I  have  seen 
practiced  for  senile  gangrene  have  not  predisposed  me  in  favor  of  the 
idea. 

There  are  two  forms  of  gangrene  which,  singularly''  enough,  are  peculiar 
to  childhood,  viz.,  cancrum  oris  and  noma  vulvtie.  The  two  names  have 
been  confused,  since  some  surgeons  call  cancrum  oris  also  by  the  name  of 
noma,  but  it  seems  to  me  better  to  keej)  the  terms  separate. 

Cancrum  Oris. — The  former,  cancrum  oris,  is  a  very  formidable  disease 
in  its  worst  forms.  It  is  due  to  some  profound  exhaustion  of  the  whole 
system,  and  usually  follows  on  one  of  the  eruptive  fevers  (measles  most 
commonly)  in  children  wiio  have  previously  been  ill-fed,  ill-nourished, 
and  brought  np  in  bad  air — at  least,  I  am  not  aware  that  it  occurs  in 
others— and  in  these  it  does  sometimes,  though  not  often,  occur  without 
any  feverish  attack  acting  as  a  predisposing  cause.  The  cheek  swells, 
turns  red  and  hard,  and  then  a  black  spot  shows  itself  either  on  the  cheek 
or  on  the  gums;  ulceration  takes  place,  the  gangrene  extends  itself  to  a 
variable  distance  in  the  soft  parts,  the  breath  becomes  horribly  foul,  the 
gums  are  exposed,  the  bone  crumbles  away,  and  the  teeth  drop  out.  The 
child  is  usually  very  feverish  and  depressed.  Death  is  very  common, 
though  not  universal,  even  in  severe  cases. 

Noma  vulvae  is  a  similar  affection  of  the  external  organs  of  generation 
in  little  girls  ;  sometimes  it  seems  to  be  merely  the  result  of  dirt  and 
neglect,  and  then  usuall}^  moie  curable;  at  other  times  owing  to  the  same 
general  causes  as  cancrum  oris,  and  in  such  cases  much  more  dangerous. 
It  begins  either  on  the  mucous  or  cutaneous  surface  of  the  vulva,  some- 
times, indeed,  at  a  distance  from  it  in  the  skin  of  the  groin.  The  ulcera- 
tion speedily  assumes  the  sloughing  form  of  phagedaena,  and  occasionally 
extends  to  a  considerable  distance,  so  as  to  cause  great  loss  of  tissue,  and 
in  some  cases  greatly  to  narrow  the  opening  of  the  vagina  after  recovery. 
This,  however,  seldom  takes  place.;  more  commonly  after  recovery  the 
destruction  is  found  to  have  been  much  more  superficial  than  it  seemed 
at  first.  Both  in  cancrum  oris  and  in  noma  vulvae  death  often  takes  place 
very  unexpectedly,  and  without  any  post-mortem  appearances  to  account 
for  it.  This  has  sometimes  been  explained  in  the  case  of  the  mouth  aflec- 
tion  as  being  the  result  of  poisoning  from  the  imbibition  of  tiie  foul  gas 
generated  by  the  gangrene,  and  it  may  sometimes  be  so,  but  such  ex- 
planation is  not  applicable  to  the  case  of  noma. 

The  treatment  of  these  diseases  is  similar  to  that  of  other  forms  of  gan- 
grene, but  here  it  is  still  more  essential  to  destroy  the  sloughing  parts 
completely,  which  is  best  done,  I  think,  by  soaking  them  with  strong 
nitric  acid.  The  French  surgeons,  however,  prefer  the  actual  cautery. 
Chloroform  must  be  administered,  the  cheek  thoroughly  exposed,  and 
the  acid  applied  slowly  and  carel'ully  to  every  part  of  the  sloughing  sur- 


86  COMPLICATIONS    OF     WOUNDS. 

face.     When  the  disease  does  not  commence  in  the  mouth  it  is  most  im- 
portant to  stop  its  spread  before  it  has  extended  into  that  cavity. 

Free  stimulation  with  wine  is  almost  always  necessary,  and  the  exhibi- 
tion of  tonics  with  diffusible  stimulants.  Chlorate  of  potash  enjo3's  a 
great  reputation,  and  may  be  given  in  any  dose  up  to  a  scruple,  but  I 
cannot  say  that  I  am  convinced  of  its  efficacy,  and  should  be  sorry  to 
trust  to  it  without  the  other  and  more  powerful  means  of  treatment. 

TetanuH  is  defined  as  "a  tonic  spasm  of  the  voluntary  muscles,  with 
exacerbations;"  that  is  to  say,  the  muscles  affected  are  in  a  constant 
condition  of  spasmodic  tension,  and  this  is  exaggerated  from  time  to  time 
into  violent  convulsive  action. 

Tetanus  is  divided  into  traumatic  and  spontaneous.  In  this  country  it 
is  almost  always  caused  by  an  injury,  and  the  most  various,  and  some- 
times the  most  trivial  injuries  have  been  known  to  cause  it ;  but  even  in 
this  country,  though  rarely,  and  more  commonly  in  the  tropics,  it  occurs 
spontaneousl3^^  Tetanus  is  also  divided,  according  to  its  course,  into 
acute,  subacute,  and  chronic,  and  varieties  of  the  disease  are  named  from 
the  muscles  implicated,  viz.,  trismus  or  lockjaw,  when  the  muscles  around 
the  jaw  are  alone  or  chiefly  affected  ;  oi)isthotonos,  when  (as  not  uncom- 
monly occurs  in  the  spasms  of  acute  tetanus)  the  muscles  of  the  back 
draw  the  patient's  body  into  the  form  of  a  bow,  the  body  resting  on  the 
head  and  heels ;  emprosthotonos,  when  the  abdominal  muscles  bend  the 
body  in  the  opposite  direction;  and  pleurosthotonos,  when  it  is  bent  to 
one  side.  The  two  latter  are  very  rare;  at  least,  in  this  country.  I  have 
never  spoken  to  any  one  who  has  seen  an  example  of  either.  Trismus 
exists  more  or  less  at  the  commencement  of  all  attacks  of  acute  traumatic 
tetanus.- 

The  symptoms  of  tetanus  are  usually  as  follows  :  At  any  period  after 
the  receipt  of  an  injury  or  after  a  surgical  operation,  with  no  especial  pre- 
monition, the  patient  begins  to  complain  of  an  uneasy  feeling  of  stiffness 
about  the  neck  and  lower  jaw — "  stiff  neck,"  as  he  probably  terms  it. 
After  this  there  is  difficulty  in  swallowing  and  chewing,  and  then  com- 
plete fixedness  of  the  jaws,  the  masseters  and  muscles  about  the  upper 
part  of  the  neck  being  felt  firmly  co'ntracted.  There  is  also  commonly  at 
an  earl}'  period  pain  in  the  epigastrium,  referred  to  affection  of  the  dia- 
phragm. Convulsive  cramps  now  occur  at  any  attempt  to  open  the  jaws 
or  to  swallow.  There  are  sudden  and  violent  cramps  in  the  region  of  tiie 
diaphragm.  The  muscles  of  the  abdomen  and  then  those  of^  nearly  all 
the  body  are  rigidly  contracted,  so  that  the  abdomen  feels  like  a  lioard, 
and  on  handling  the  limbs  they  may  be  as  stiff  as  in  death,  but  the  mus- 
cles of  the  wrists  and  fingers  are  usually  exempt  from  spasm.  Tlie  con- 
traction of  the  facial  muscles  gives  asardonic  grin  to  the  features,  "  the 
tetanic  grin."  The  tetanic  state  is  now  fully  estal)lished.  The  pulse  is 
usually  unaffected,  except  during  the  spasms,  when  it  is  quickened.  In 
the  acutest  cases,  however,  there  is  often  great  general  fever,  as  the 
thermograph  from  a  rapidly  fatal  case,  on  page  90,  will  show.  Tlie  bowels 
are  generally  constipated  and  the  motions  scybalous.  The  spasms  vary 
much  in  severity.  They  are  sometimes  so  severe  as  to  jerk  the  patient 
out  of  bed,  and  even  to  rupture  the  muscles.^     Occasionally  the  tongue 

'  Tho  fipontiinfous  origin  of  tlie  disease  should  not  be  admitted  in  any  civen  case 
without  inquiry.  I  have  known  a  case  rei^arded  as  spontaneous  in  wiiich  after  death 
a  wound  was  found  whioii  tlie  patient  liad  forirotten. 

■^  See  Sir  B.  Brf)die's  evidence  on  Palmer's  trial  in  the  newspapers  of  the  time,  or 
Dr.  A.  S.  Taylor's  paper  in  the  Guy's  Hospital  Reports  for  1850,  pp.  29(5,  297. 

3  Most  museums  contain  specimens  of  one  of  the  long  muscles  ruptured  in  tetanus. 


TETANUS.  87 

is  protruded  from  the  month,  and  being  canght  by  tlie  ch)sing  jaws,  is 
severely  lacerated. .  The  spasms  are  liable  to  be  brought  on  by  any  sud- 
den impression — a  noise,  the  slamming  of  a  door,  a  draught  of  air.  Sleep 
is  rare  and  short  in  acute  cases.  The  contraction  of  the  muscles  either 
ceases  altogether  or  is  greatly  relaxed  in  sleep.  The  intellect  is  not 
atfected.  Death  seems  to  be  caused  sometimes  by  spasm  of  the  glottis  ; 
but  usually  occurs  from  suffocation  during  a  spasm  produced  by  the  stiff- 
ness of  the  muscles  of  respiration,  or  from  exhaustion. 

All  this  applies  to  the  acute  form  of  the  disease;  the  subacute  and 
chronic  differ  from  the  acute  only  in  the  course  and  severity,  not  in  the 
character  or  order  of  succession  of  the  sym|)toms.  Speaking  generally, 
the  later  after  the  injury  the  symptoms  come  on,  the  more  chronic  is  the 
course  of  the  disease,  and  therefore  the  greater  chance  is  there  of  the  pa- 
tient's recovery. 

There  is  a  form  of  tetanus,  called  trismus  nascentium,  which  affects  in- 
fants in  the  first  or  second  week  of  life,  and  which  has  been  connected  by 
some  authors  with  the  section  of  the  umbilical  cord.  It  is  very  fatal, 
though  instances  of  recovery  are  not  unknown.  Generally,  however,  this 
infantile  tetanus  ends  in  death  much  more  speedily  than  the  adult  dis- 
ease.    Tetanus  has  also  been  kuovvn  to  be  caused  by  parturition. 

Nothing,  or  next  to  nothing,  is  known  as  to  the  predisposing  causes  of 
tetanus.  It  is  much  more  common  in  hot  countries  than  in  cold,  and  it 
attacks  personsof  the  negro  race  much  more  commonly  tiian  whiles.  Bad 
hygienic  conditions  seem  to  favor  its  development,  as  malaria,  and  pos- 
sibly bad  ventilation. 

The  idiopathic  form  of  the  disease  seems  far  more  common  in  the 
tropics  than  in  this  country.  It  has  been  referred  to  various  causes,  of 
which  the  best  authenticated  seems  to  be  the  sndden  suppression  of  per- 
spiration by  exposure  to  cold  and  damp;  and  it  appears  that  a  loaded  state 
of  the  bowels  is  at  any  rate  a  predisposing,  and.  it  has  been  looked  upon 
as  an  exciting,  cause  of  idiopathic  tetanus. 

Diagnosis. — Tetanus  requires  to  be  diagnosed  from  hysterical  affec- 
tions, from  the  convulsions  produced  by  strychnia  poisoning,  from  epi- 
lepsy, and  from  hydrophobia.  As  above  stated,  the  symptoms,  in  the 
early  stage,  are  those  of  f)rdinary  stiff  neck  (rheumatic  affection  of  the 
muscles  of  the  jaw  and  neck),  l)ut  the  progress  of  the  case  prevents  any 
permanent  confusion. 

The  diagnosis  from  hysteria  is  not  always  perfectly  easy,  and  this  will 
be  evident  from  the  simple  consideration  that  tetanus  may  attack  an  h3's- 
terical  person,  and  may  be  complicated  with  hysterical  fits.  But,  ordi- 
narily, hysterical  lockjaw  or  any  other  tetanic  symptom  simulated  by 
hysteria  may  be  distinguished  from  the  real  disease  by  the  patient's  gen- 
eral condition  and  appearance,  by  the  complete  relaxation  of  the  spasms 
from  time  to  time,  and  by  the  fact  that  sooner  or  later  the  patient  is  sure 
to  be  able  to  eat. 

From  strychnia  poisoning  the  diagnosis  may  also  for'  a  time  be  very 
difficult,  as  the  celebrated  trial  of  the  surgeon  Palmer  for  the  murder  of 
a  man  named  Cook  by  strychnia  shows,  in  which  many  medical  men 
swore  that  in  their  opinion  the  man  died  of  tetanus,  or  of  epilepsy  with 
tetanic  complications.  But  the  same  trial  brought  out  very  clearly  the 
differences,  viz.,  that  the  spasm  from  strychnia  poisoning  commences  and 
culminates  with  great  rapidity,  and  without  any  previous  stiffness  about 


Thus,  in  St.  George's  Museum,  Sec.  iv,  No.  1,  is  the  rectus  abdominis  muscle  torn 
across  in  a  tetanic  spasm. 


SS  COMPLICATIONS    OF    WOUNDS. 

the  jaws  and  neck;  and  that  if  the  dose  is  insufficient  to  cause  death  the 
symptcMns  subside  with  equal  rapidity,  leaving  the  patient  in  perfect 
liealth,  but  for  the  exlianstion  following  the  spasms  ;  tiiat  there  is  notliing 
of  the  tonic  spasm  with  convulsive  exacerl^ations  which  characterizes  true 
tetanus.  The  spasms  nlso  of  strychnia  ditler  from  those  usually  seen  in 
tetanus  in  that  they  affect  tiic  muscles  of  tlie  trunk  and  limbs  only,  and 
not  the  jaw,  and  that  they  affect  tiie  muscles  of  the  wrists  and  fingers, 
which,  as  above  noted,  are  usually  unaffected  in  tetanus.  These  minor 
differences,  however,  could  hardly  be  alone  relied  on. 

From  hydrophobia  the  differences  are  these:  in  hydrophobia  the 
spasms  are  clonic — that  is,  the  jaw  may  be  spasmodically  closed,  but  it 
will  drop  into  complete  lelaxation — which  is  not  the  case  in  tetanus.  In 
tetnnus  there  is  no  dread  of  water,  no  aversion  to  it,  thougli  the  attempt 
to  drink  may  cause  spasm,  as  any  other  excitement  may  ;  the  countenance 
in  tetanus  thongh  distorted  is  calm,  unlike  the  glowing  eyes  and  excited 
face  of  hydrophobia;  and  the  state  of  the  mind  corresponds,  being  calm 
and  collected  in  tetanus,  wild  and  often  sulyect  to  delusions  in  hydro- 
phobia. 

From  epilepsy  there  are  numerous  distinctions.  An}'  case  of  epilepsy 
likely  to  be  mistaken  for  tetanus  will  in  all  prol)ability  be  accompanied 
by  insensibility,  which  is  never  the  case  in  tetanus,  and  by  blueness  of 
the  surface.  And  then  there  is  the  great  distinction  that  epileptic  seizures 
have  complete  remissions,  ?'.  e.,  the  spasms  are  clonic,  while  tetanic  con- 
vulsions are  connected  together  by  the  tonic  spasm. 

Palhologij. — Nothing  is  really  known  of  the  pathology  of  tetanus. 
Tlieie  have  been  cases  in  which  a  morbid  condition  of  nerves  has  been 
found  at  the  seat  of  the  injury,  and  where  the  removal  of  the  nerve  so 
injured  has  been  followed  by  immediate  recovery.  There  have  also  been 
cases  in  which  after  death  distinct  evidence  of  inflammation  of  the  trunk 
of  the  nerve  has  been  found,  extending  to  some  distance,  and  others  in 
which  the  spinal  cord  has  been  found  inflamed.  From  which  the  inference 
has  been  drawn  that  the  pathology  of  the  disease  consists  essentially  in 
inflammation  propagated  through  the  nerve  or  nerves  injured  to  the  spinal 
cord,  thus  exciting  the  general  spasmodic  condition.  This  explanation, 
though  the  most  logical  which  has  as  3'et  been  offered,  is  a|)parently  con- 
tradicted by  the  anatomy  of  many  cases  in  which  the  nerves  have  been 
found  to  all  appearance  healthy,  and  by  the  course  of  others,  in  which 
tlie  injui-ed  part  has  been  removed,  with  no  benefit.  Though,  dou])tless, 
in  the  latter  cases  the  ill  success  might  be  explained  b}'  supposing  that 
the  morbid  condition  of  the  medulla  was  already  generated  ;  and  in  the 
former  it  may  l)e  said  with  much  plausibility  that  morbid  conditions  really 
existing  may  have  been  overlooked  in  consequence  of  the  method  of  re- 
search not  having  been  sufficiently  delicate.  Dr.  Lockhart  Clarke'  has 
described  altei'ations  in  the  minute  structure  of  tlie  spinal  cord  in  tetanus, 
which  may  very  probably  have  existed  in  many  cases  where  the  cord  was 
put  down  as  "  healthy,"  since  such  changes  would  not  bo  detected  by  an 
ordinary  nakcil-e^'e  examination  of  the  cord,  such  as  is  usually  made. 
To  the  same  effect  are  Dr.  Dickinson's  observations,'^  and  other  i)atholo- 
gists  have  published  similar  cases.  It  is  unnecessary  to  describe  these 
changes  minutely.  Accurate  plates  frfun  Dr.  Dickinson's  prei)arations 
are  to  be  found  in  the  Si/st.  of  Hurg.,  vol.  i,  p.  330.  Suffice  it  to  say  that 
they  show  inflammatory  exudation  and  extravasation  of  blood  in  the 
white  columns  and  softening  of  the  central  gray  matter  of  the  cord.    IJut 


I  Med.-Chir.  Trans.,  vol.  xlviii.  *  lb.,  vol.  li. 


TETANUS.  89 

Other  investigators,  of  undoubted  skill, liave  failed  to  find  those  changes;' 
and  even  allowing  them  to  be  constant,  it  would  still  remain  a  question 
whether  they  are  the  cause  of  the  disease  or  its  consequence.  However, 
if  we  do  not  regard  the  tetanic  condition  as  being  due  to  irritation  of  the 
spinal  cord  propagated  to  it  tiirough  the  injured  nerves,  we  must  take 
refuge  in  the  vague  theory  "  that  it  results  from  poisoning  with  some 
peculiar  substanc^es  which  possibly  are  very  rarely  formed  in  wounds, 
and  thence  absorbed"  (Billroth).  Suc^h  a  theory  leaves  onr  knowledge 
of  the  i)athology  and  treatment  of  the  disease  just  where  it  found  it.  But 
if  we  admit  that  the  disease  starts  from  irritation  of  the  injured  nerve, 
one  practical  conclusion  of  great  importance  would  follow,  viz.,  that  the 
nerve  or  the  part  should  be  removed  at  the  first  definite  symptom  of 
tetanus,  and  I  must  say  that  such  a  rule  seems  to  me  a  good  one.  Mr. 
Bryant'-  mentions  a  case  in  which  *•'  Mr.  Key  amputated  a  leg  on  account 
of  tetanus,  which  had  appeared  six  days  after  an  unreduced  dislocation 
of  the  astragalus.  The  symptoms  disappeared  at  once  after  the  operation. 
On  dissecting  the  foot  the  posterior  til)ial  nerve  was  found  to  have  been 
put  violently  on  the  stretch  by  the  projecting  astragalus."  I  have  seen 
at  least  one  similar  case.  That  amputation  usually  fails,  however,  is 
quite  true  ;  and  this  we  might  expect,  since  the  S3^mptoms  show  that  the 
irritation  has  already  reached  the  central  organ.  Yet  the  chance  that  it 
may  not  have  gone  so  far  as  not  to  be  capable  of  recovery,  if  only  the 
peripheral  excitement  is  removed,  justifies  amputation,  in  my  opinion,  in 
appropriate  cases.  To  be  of  any  service  it  must  be  done  early.  The 
same  end  ma}'  possibly  in  some  instances  be  effected  by  excision  of  a 
portion  of  the  nerve,  luit  it  is  rarely  that  the  precise  nerve  can  be  isolated. 
Irrespective  of  these  surgical  measures  the  treatment  of  tetanus  is 
entirely  empirical,  and  completely  unsuccessful.  Possibly  we  ought  to 
except  from  this  sweeping  condemnation  the  application  of  ice  to  the 
spine,  which  has,  indeed,  some  logical  basis,  inasmuch  as  it  seeks  to  re- 
duce the  temperature,  and  tlius  to  combat  the  inflammation  of  the  part 
whose  irritation  is  believed  to  generate  the  disease,  and  in  that  sense 
may  be  said  not  to  be  empirical,  but  it  seems  entirely  unsuccessful. 
Nearly  every  drug  in  the  Pliarmacopoeia  has  been  tried  with  occasional 
successes ;  but  these  successes  have  been  obtained  mainly  in  the  sub- 
acute form  of  the  disease.  Acute  tetanus,  though  not  uniformly  fatal,  is 
very  generally  so,  and  the  few  patients  who  have  survived  appear  to  have 
recovered  under  quite  different  kinds  of  treatment.  If  life  can  be  pro- 
longed beyond  the  third  week  recovery  becomes  probable,  though  in- 
stances of  death  up  to  the  thirty-ninth  day  are  recorded  by  Mr.  Poland.^ 
Therefore,  in  our  present  ignorance  of  the  real  pathology  of  the  disease, 
and  consequently  of  the  effect  of  medicines  on  it,  our  great  object  is  to 
keep  the  patient  alive  till  the  time  when,  as  experience  teaches,  the  irrita- 
tion may  have  worn  out,  and  his  powers  ma}'  suffice  to  carry  him  through. 


'  Billroth  says:  "  Koki  tan  sky  claims  to  have  seen  a  developnnent  of  young  con- 
nective tissue  in  tlie  spinal  medulla,  which  would  make  it  appear  that  there  was  an 
inflammatory  affection  of  this  nerve  centre.  My  examination  of  the  spine  and  nerves 
in  tetanus  have  thus  far  given  only  negative  results." — Surg.  Path.,  translated  by 
Hackley,  p.  3()5. 

^  Practice  of  Surgery,  p.  36. 

3  Out  of  327  fatal  cases,  79  died  within  2  days. 

104     "     in  from  2  to    5  days. 
90     "  "5  to  10  days. 

43     "  "     10  to  22  days. 

11     "     beyond  the  22d  day. 

Syst.  of  Surg.,  vol   i,  p.  328. 


90 


COMPLICATIONS    OF    WOUNDS. 


Fig.  12. 


mkW" 


Chloroform  may  be  cautiously  tried,  and  if  it  can  be  borne  it  will  relax 
the  spasms  and  permit  the  introduction  of  food  into  the  stomach;  but  its 
exhibition  often  sets  up  an  amount  of  spasm  which  threatens  to  prove 
fatal.  Most  patients  can  get  enouoh  fluid  nourislunent  through  the  closed 
teeth  to  keep  tliemselves  alive,  or  they  can  be  fed  by  a  tulie  passed  through 
the  nostrils.  If  this  is  not  the  case  life  cannot  be  long  supported  by 
enemata.  and  under  tliese  circumstances  I  entertain  no  doubt  that  it  is 
justifiable  to  induce  anoesthesia  at  any  risk  in  order  to  feed  the  patient. 
And  in  such  circumstances  the  larynx  may  be  opened,  in  order  to  obviate 
death  from  spasm  while  the  patient  is  being  narcotized.  Also  if  death 
is  threatened  from  spasm  of  the  glottis,  tracheotomy  may  be  performed. 
In  one  such  case  I  saw  much  difficulty,  from  the  neck  being  twisted,  in 
keeping  the  incision  near  the  middle  line.  Sleep 
is  alwaj's  to  be  procured  by  chloral  or  by  morphia, 
which  may  be  injected  subcutaneously.  The 
bowels  ought,  no  doubt,  to  be  unloaded  at  the 
commencement  of  the  disease,  and  the  purgation 
should  be  frequently  repeated;  the  patient  ought 
always  to  be  kept  in  a  cool,  quiet,  darkened  room, 
and  carefully  defended  from  draughts  and  noises. 
As  to  the  internal  treatment,  it  is  undoubtedly 
justifiable  to  use  some  of  tlie  medicines  which 
have  proved  successful  in  other  hands,  or  to  try 
any  new  plan  of  treatment  which  affords  a  rational 
prospect  of  success.  Of  the  former  class,  the  ad- 
ministration of  the  tincture  of  aconite  is,  I  think, 
on  the  whole  tlie  most  promising.  Five  minims 
of  the  Pliarmacopoeia  tincture  may  be  admin- 
istered in  a  small  quantity  of  any  convenient 
vehicle  every  two  hours  until  some  definite  im- 
pression is  produced  on  the  pulse  and  tempera- 
ture. In  acute  tetanus  the  temperature  sometimes 
rises  abruptly  and  continuously  till  the  time  of  death,  as  in  the  case  from 
which  the  annexed  thermograph  was  taken  ;  and  it  is  in  these  cases  that 
large  doses  of  alcohol  may  be  expected  to  prove  advantageous;  but  the 
use  of  alcohol  as  a  specific,  the  patient  being  kept  in  a  state  of  constant 
intoxication  or  semi-intoxication,  seems  to  me  not  only  useless  but  in- 
jurious. It  would  be  vain  to  enumerate  all  the  specifics  which  have  at 
various  times  l)een  recommended.  They  have  all  obtained  their  reputa- 
tion from  their  success  in  a  few  cases,  which  were  in  all  probability  of 
the  subacute  form — a  form  in  which  recovery  is  common  under  any  treat- 
ment, or  under  no  definite  treatment,  if  the  bowels  be  kept  free  and  the 
patient's  strength  supported  by  such  food  as  he  can  easily  take  and 
assimilate.  Opium,  chloral,  Calabar  bean,  nicotin,  turpentine,  camphor, 
quinine,  strychnia,  curara,  are  the  chief  among  the  many  remedies  which 
have  obtained  some  reputation,  and  some  of  these  substances  have  been 
injected  into  the  veins,  as  chloral.  I  will  onl}'  say  that  tliosc  medicines 
which  tend  to  constipation  (as  opium)  seem  to  be  mischievous  ;  those 
which  are  highly  poisonous,  as  nicotin,  curara,  strychnia,  appear  to  add 
a  new  danger  to  tlie  disease,  without  any  reasonable  hope  of  benefit ;  and 
the  same  appears  to  be  true  of  intravenous  injection.  Quinine  is,  I  have 
no  doubt,  cotnpletely  inert;  chloral,  camphor,  and  turpentine  are  doubt- 
less useful  in  subacute  tetanus,  and  the  first  may  aff'ord  some  relief  in  the 
spasms  of  the  acute  disease  ;  but  none  of  tliese,  nor,  as  far  as  1  know, 
any  other  medicine  seems  to  have  any  curative  virtue  in  acute  tetanus. 


Thermograph  of  tetanus. 
From  a  case  under  my  own 
care,  which  proved  fatal  ISJ/^ 
hours  after  the  first  decided 
symptoms  of  the  disease.  The 
case  is  recorded  in  Dr.  Dick- 
inson's paper  in  Med.-Chir. 
Trans.,  li,  where  the  post- 
mortem appearances  are  de- 
scribed and  figured. 


DELIRIUM     TREMENS,  9] 

Delirium  tremens,  the  delirious  excitement  whicli  depends  on  chronic 
intoxication,  is  a  disease  which  we  have  only  too  frequent  opportunity  of 
seeing  in  our  hospital  patients,  lioth  as  a  spontaneous  affection  (in  which 
respect  it  falls  within  the  care  of  the  physician)  and  as  a  complication  of 
surgical  injury,  in  which  latter  respect  alone  I  shall  here  speak  of  it. 

The  delirium  which  is  excited  in  a  patient  laboring  under  chronic  intoxi- 
cation— that  is  to  say,  in  one  whose  blood  and  tissues,  especially  those 
of  the  brain,  are  deteriorated  by  the  too  free  use  of  alcohol — is  marked 
by  several  peculiarities  which  distinguish  it  from  the  delirium  of  ordinary 
fever,  as  well  as  from  any  other  form  of  aberration  of  mind.  The  main 
peculiarity  of  the  delirium  is  its  buny  character,  and  the  prevalence  of  one 
dominant  idea  which  is  generally  distressing  or  alarming  to  the  patient.' 
The  delirium  is  not  usually  violent,  and  any  person  who  is  not  afraid  of 
the  patient,  and  who  can  speak  to  him  with  authority,  can  generally  con- 
trol him.  The  next,  and  perhaps  the  most  characteristic,  feature  of  the 
disease  is  the  tremor  from  which  it  takes  its  name,  and  which  is  generally 
seen  in  all  the  muscles,  those  of  ihe  tongue  and  face  as  well  as  the  extremi- 
ties, though  it  is  most  marked  in  the  hands.  Another  and  most  painful 
symptom  is  the  want  of  sleep,  and  indeed  of  any  rest  either  of  body  or 
mind;  and  this  sleeplessness  will  usually  l)e  found  to  precede  the  delirium. 
A  restless,  tremulous,  feverish,  half  rational  condition  commonly  ushers 
in  the  defined  attack  of  delirium.  The  general  condition  is  also  most 
unlike  that  of  the  delirium  of  either  traumatic  or  any  other  fever.  Trau- 
matic fever  may  of  course  accomi)any  the  attack  of  delirium  tremens  in 
surgical  cases,  but  apart  from  this  there  is  little  evidence  of  general  fever. 
The  temperature  is  not  high,  the  skin  is  usually  bathed  in  a  profuse  sweat, 
the  tongue  instead  of  being  dry  and  brown  is  moist,  white,  and  oedema- 
tous,  the  pulse  is  small  and  quick,  but  not  hard.  There  is  almost  always 
a  loathing  for  food,  and  the  patient  often  vomits.  Evidences  of  visceral 
disease  will  often  be  discovered,  especially  in  the  kidneys  and  liver. 

The  treatment  of  delirium  tremens  used  to  be  conducted  on  the  anti- 
phlogistic plan,  the  disease  being  confounded  with  inflammation  of  the 
inain,  and  this  treatment  was  very  fatal.  In  the  reaction  from  this  error 
it  became  usual  to  treat  the  disease  with  enormous  quantities  of  stimulants 
and  of  opium  ;  and  I  cannot  but  think  that  this  treatment,  if  pursued  on 
a  merely  routine  plan,  is  also  unsuccessful,  i.  e.,  that  it  aggravates  instead 
of  diminishing  the  danger  of  the  disease,  though  not  to  so  great  a  degree 
as  tie  depleting  plan.  In  fact,  every  case  of  delirium  tremens  should  be 
treated  on  its  own  indications.  In  the  premonitory  stage,  when  the  occur- 
rence of  tremor,  with  some  restlessness,  in  a  patient  known  or  reasonably 
suspected  to  be  of  drunken  habits,  gives  fair  cause  for  believing  that  an 
attack  of  delirium  tremens  is  imminent,  it  is  only  too  common  to  ply  the 
patient  with  more  stimulants,  probalily  on  the  principle  contained  in  the 
old  proverb,  "  A  hair  of  the  dog  that  l)it  you."  No  treatment  can  have 
less  support  from  logic,  nor  do  I  think  that  experience  lends  it  any  sup- 
port either.  In  patients  of  drunken  habits  adn)itted  into  the  hospital  I 
make  it  a  rule  to  give  them  no  more  stimulant  than  to  a  healthy  and  sober 
person,  to  purge  them  freely,  supplying  them  with  a  good  supporting 
diet,  and  procure  sleep  by  the  subcutaneous  injection  of  morphia  if  nec- 
essary ;  and  under  this  regimen  the  threatening  symptoms  almost  uni- 
formly disappear.  When  the  delirium  is  fully  developed  the  same  line 
of  treatment  should  be  pursued.  The  chief  indications  are  to  soothe  the 
patient  as  much  as  possible,  to  procure  sleep,  and  to  enable  him  to  take 

^  See  Barclay,  Syst.  of  Surg.,  vol   i,  342. 


92  COMPLICATIONS    OF    WOUNDS. 

food.  For  the  first  purpose  it  is  most  essential  to  use  no  mechanical  re- 
straint if  it  can  be  avoided.  In  public  institutions,  where  separate  rooms 
can  be  obtained  for  the  treatment  of  the  case,  and  the  services  of  a  num- 
ber of  men  can  be  procured  if  required,  it  ought  to  be  very  rarely  neces- 
sary to  tie  down  a  patient  sutfering  from  delirium  tremens  ;  and  if  unnec- 
essary it  cannot  but  be  prejudicial  to  the  case.  In  order  to  procure  sleep 
opium  or  morphia  must  generally  be  given.  The  slighter  cases  may 
recover  the  power  of  sleep  under  free  purging,  as  they  regain  that  of 
taking  food  ;  but  in  almost  all  traumatic  cases  it  is  advisable  to  procure 
sleep  at  once,  as  the  restlessness  of  the  patient  renders  him  liable  to  dis- 
turb the  injured  parts.  Chloral  may  procure  sleep  in  the  slighter  cases; 
but  speaking  generally  tlie  best  agent  for  this  purpose  is  morphia,  which 
ought  to  be  injected  under  the  skin  in  a  tolerably  large  dose  (gr.  ^),  and 
repeated  in  about  half  an  hour,  if  sleep  is  not  ol)tained,  and  so  on  until 
the  patient  does  go  to  sleep.  At  the  same  time  the  bowels  should  be  kept 
very  freely  open,  and  it  may  be  necessary  to  give  some  tonic,  quinine, 
ammonia,  or  bark  with  mineral  acid. 

The  use  of  stimulants  in  delirium  tremens  will  need  all  the  care  and 
all  the  experience  of  the  surgeon.  In  most  cases  I  believe  some  amount 
of  stimulant  must  be  given,  since  the  patient  is  weakened  both  by  the 
shock  of  the  injury  and  by  the  restlessness  and  agitation  of  the  delirium, 
and  cannot  bear  the  deprivation  of  his  accustomed  drink.  But  I  am  in 
the  habit  of  limiting  that  quantity  as  much  as  the  state  of  the  pulse  per- 
mits while  the  patient  remains  unable  to  take  food,  and  diminishing  it 
rapidly  as  soon  as  nutrition  can  be  procured  otherwise.  And  when  the 
patient  is  once  out  of  serious  danger  I  am  quite  sure  that  the  enforce- 
ment of  total  abstinence  is  as  good  for  his  physical  as  for  his  moral  health. 

In  other  cases,  as  it  seems  to  me,  in  which  the  symptoms  are  not  urgent 
and  the  pulse  is  strong,  there  is  no  need  for  the  administration  of  any 
stimulant  or  tonic  ;  but  on  the  contrary,  along  with  the  free  administration 
of  purgatives  the  cautious  use  of  antimony  seems  to  assist  in  getting  rid 
of  the  poison  and  restoring  the  appetite.  As  to  the  alleged  benefits  to 
be  derived  from  the  administration  of  very  large  doses  of  digitalis,  I 
have  no  experience.  Generally  when  the  patient  can  once  be  got  to 
take  food,  and  particulaily  solid  food,  with  a  relish,  sleep  will  return, 
and  he  will  soon  be  well ;  and,  conversely,  if  sound  sleep  can  be  procured, 
generally  tiie  appetite  will  return  and  the  case  will  do  well.  But  this  is 
only  generally  true.  In  some  cases  the  patient  will  sink,  although  the 
insomnia  has  been  conquered.  A  man  was  very  lately  under  my  care 
with  compound  fracture  of  the  leg  in  whom  a  severe  attack  of  delirium 
tremens  came  on  shortly  after  the  injury.  After  two  days  of  restlessness 
a  sound  and  natural  sleep  of  several  hours  was  procured  by  the  subcuta- 
neous use  of  moiphia.  He  awoke  refreshed  and  free  from  any  signs  of 
the  constitutional  effect  of  opium,  l)ut  soon  began  to  sink,  and  died  rapidly. 
Extensive  disease  of  the  liver  and  other  viscera  was  the  cause  of  death 
in  this  instance.  And  our  prognosis  in  cases  of  delirium  tremens  must 
always  be  a  cautious  one,  since  latent  visceral  disease,  such  as  fatt}'  heart, 
may  very  possibly  l)e  present. 

I  would,  however,  again  urge  on  the  reader  the  great  importance  of 
avoiding  over-narcotism  or  over-stimulation  in  tliis  disease.  Great  as  the 
virtue  of  opium  and  morphia  is  when  judiciously  employed,  we  must  not 
forget  that  when  not  well  borne  they  constantly  produce  delirium,  and 
that  a  form  of  delirium  tiemens  has  sometimes  been  known  to  be  pro- 
duced by  opium-eating.  Nor  can  I  see  on  what  ground  of  reason  or  of 
therapeutical  experience  we  can  expect  a  cessation  of  the  effect  from  a 


DISSECTION-WOUJS'DS.  93 

continu.ince  of  the  very  irritation  wliich  produced  it.  Yet  tins  is  exactly 
what  is  implied  in  the  routine  treatment  of  delirium  tremens  with  stimu- 
lants. We  find  a  patient  who  has  soddened  his  brains  witli  gin  and  beer, 
and  probably  has  already  suffered  from  previous  attacks  of  delirium,  and 
we  think  we  shall  cure  him  with  more  ^in  and  beer. 


CHAPTER   III. 

POISONED  WOUNDS  AND  ANIMAL  POISONS. 

The  inflammatory  complications  which  we  have  been  studying  hitherto 
attack  wounds  of  all  kinds,  irrespective,  as  far  as  we  know,  of  anything 
special  in  the  nature  of  the  injury  ;  but  there  is  a  large  class  of  wounds 
in  which  the  inoculation  of  some  detinite  poison  produces  symptoms 
more  or  less  peculiar. 

It  would  be  endless  to  enumerate  all  the  varieties  of  poison  which  may 
be  conveyed  into  wounds,  or  all  the  various  ways  in  whicii  such  convey- 
ance may  be  effected.  It  will  be  enough  for  our  present  purpose  to  divide 
poisoned  wounds  into  the  three  following  kinds  :  (1)  wounds  inoculated 
with  matters  which  produce  only  ordinary  traumatic  fever  and  its  compli- 
cations ;  (2)  wounds  inoculated  with  matters  which  produce  symptoms  of 
specific  general  poisoning;  (o)  wounds  inoculated  with  matters  which 
produce  definite  diseases.  The  first  class  of  cases  is  only  separated  from 
those  which  have  been  described  in  the  previous  chapters  by  the  fact  that 
in  these  a  maferies  morbi  is  known  to  have  been  inoculated,  whilst  in 
those  nothing  of  the  kind  is  known  to  have  taken  place,  though  there  can 
belittle  doubt  that  in  many  instances  the  wound  has  really  been  poisoned 
at  the  time  of  its  infliction  ;  and  in  many  of  the  cases  of  secondary  com- 
plications (erysipelas,  pysemia,  etc.)  the  symptoms  are  so  exactly  similar 
to  those  of  poisoned  wounds  as  to  leave  no  reasonable  doubt  that  they 
depend  on  the  imbibition  into  the  blood  of  morbid  poisons  developed 
spontaneously  in  the  wound,  exactly  similar  to,  if  not  identical  with, 
those  which  are  inoculated  in  cases  of  poisoned  wound  (see  p.  46).  The 
first  class  of  poisoned  wounds  is  best  illustrated  by  dissection-wounds — 
injuries  which  display  the  phenomena  of  such  wounds  in  their  most  ciiar- 
acteristic  form,  with  the  exact  circumstances  of  which  we  are  acquainted 
from  the  moment  of  their  infliction,  and  with  which  few  of  us  are  not 
familiar  from  painful  experience.  The  very  same  injuries  are  suffered,  in 
the  course  of  their  business,  \\y  cooks,  butchers,  fishmongers,  etc.;  and 
similar  symptoms  ma}'  be  elicited  l»y  inoculation  with  various  other  sub- 
stances, both  vegetable  and  mineral,  though  these,  especially  mineral 
matters,  do  not  often  occasion  more  than  mere  local  inflammation. 

The  phenomena  ot  dissection-wounds  occur  in  an  acute  or  chronic 
form.  The  former  is  perhnps  the  most  formidable  and  the  most  rapidly 
fatal  of  all  the  forms  of  septicaemia.    I  have  spoken  of  them  as  ''  wounds," 


94  ANIMAL     POISONS. 

but  the  inoculation  may  pass  through  the  unbroken  skin,  and  has  done 
so  in  many  recorded  instances — notably  that  of  Sir  J.  Paget. ^  It  seems 
universally  admitted  that  '*  the  most  dangerous  postmortem  examina- 
tions are  those  of  women  who  have  died  with  puerperal  peritonitis;  and 
that  the  intlammatory  products  of  pycemial  disease  are  especially  virulent 
after  death."  Tliey  are  also  especially  virulent  before  death.  Thus,  Sir 
J.  Paget  tells  us.tliat  both  his  own  nurse  and  the  nurse  of  a  friend  of 
his  who  was  suffering  at  the  same  time  from  dissection-wound  ha(i  their 
fingers  poisoned  by  the  matter.  The  danger  seems  only  present  during 
life  or  for  a  short  time  after  death;  when  advanced  putrefaction  comes  on 
no  such  special  poisonous  property  is  observed.  Wounds  poisoned  in 
the  dissecting-room  hardly  ever  develop  more  than  the  milder  or  chronic 
symptoms.  The  nature  of  the  virus  is  not  known,  nor  is  it  known  what 
makes  a  man  liable  to  it;  but  it  seems  as  if  an  immunity  could  be  ac- 
quired by  constant  exposure,  exactly  as  one  can  be  acclimatized  to  an}' 
other  form  of  morbid  influence.  "  They  who  are  day  after  day  engaged 
in  dissections  or  in  post-mortem  examinations,"  sa^'s  Sir  J.  Paget,  "  usu- 
ally acquire  a  complete  immunity  from  the  worse  influences  of  the  virus. 
They  ma}-  sutier  local  troubles  from  it,  or  they  may  lose  health  through 
the  influence  of  bad  air  or  overwork,  but  they  do  not  suffer  with  any  infec- 
tion of  tl)e  lymph  or  blood."  Though  spoken  of  for  convenience  as  dis- 
section-wounds or  dissection-poisons,  the  affection  is  one  which  ma}' 
result  also  from  the  inoculation  of  matters  from  living  bodies,  as  many 
cases  show — notably  that  which  deprived  the  profession  some  years  ago 
of  the  rising  talent  of  Mr.  Maurice  Collis,  who  died  from  inoculation 
received  in  an  operation  for  the  removal  of  a  tumor  of  the  jaw.  Sir  J. 
Paget  has  noticed  a  fact  which,  if  it  be  confirmed  by  subsequent  expe- 
rience, will  be  of  the  highest  importance,  viz.,  that  one  attack  serves  to 
give  an  imuuinity  for  a  considerable  time  from  renewed  infection,  though 
this  immunity  is  not  permanent. 

The  most  acute  cases  are  well  described  in  the  words  of  Mr.  Callender, 
quoted  on  i)age  59,  as  a  description  of  septicaemia  in  its  severest  and 
most  rapidly  fatal  form;  and,  as  far  as  I  know,  the  occurrence  of  such 
symptoms  precludes  all  hope  of  recovery,  though  we  must,  of  course,  try 
to  support  the  patient  and  relieve  tension  in  any  parts  which  may  be 
inflamed  by  tiinel}' incisions.  But  fi'equently  the  fatal  issue  occurs  before 
any  local  inflammation  shows  itself. 

Happily,  however,  such  cases  are  very  rare.  The  only  one  which  has 
lately  occurred  in  this  city  was  that  which  led  to  the  lamented  death  of 
Dr.  Anstie.  The  subacute  form,  such  as  that  which  is  illustrated  by  Sir 
J.  Paget's  illness,  of  which  he  has  given  so  graphic  and  practical  an  ac- 
count in  his  recently  published  volume,  is  much  more  common.  The 
channel  of  infection  seems  in  tliese  and  the  chronic  cases  usually  to  be 
the  lymphatic  vessels,  whilst  there  is  reason  to  believe  that  in  some  at 
least  of  tlie  acute  cases  the  poison  passes  directly  into  the  mass  of  the 
blood  thiough  the  veins.  The  first  symptom,  therefore,  in  most  of  the 
subacute  cases  is  inflammation  of  the  glands,  with  or  without  inflamed 
absorbents;  and  as  the  seat  of  inoculation  is  almost  always  the  hand  or 
forearm,  the  glands  affected  are  the  axillary.  Frequently  the  inflamma- 
tion and  resulting  suppuration  is  confined  to  these  glantls  or  the  tissues 
which  envelop  them.  At  other  times  diffuse  inflammation  attacks  the 
whole  of  the  cellular  tissue  of  the  chest  or  back,  leading  to  extensive 
suppuration.     But  the  measure  of  the  acuteness  of  the  process  and  of  the 

'  Cliniial  Lectures  and  Essays,  p.  322. 


DISSECTION-WOUNDS.  95 

danger  is  given  by  that  of  the  fever  w^hich  accompanies  these  local  lesions. 
However  severe  the  latter  may  be,  we  expect  the  patient  to  recover  so 
long  as  tlie  pulse  is  fairly  good,  the  temperature  not  excessive,  the  appe- 
tite tolerable,  and  the  internal  organs  unaffected.  But  a  patient  in  this 
state  is  always  hanging  on  the  verge  of  erysipelas  or  pyjemia;  and  when 
a  recurrence  of  rigors,  or  any  symptom  of  mischief  in  the  chest  or  joints, 
shows  that  the  local  poison  has  or  may  have  passed  into  the  mass  of  the 
blood,  the  prognosis  becomes  much  more  anxious.^  Yet  in  many  cases 
during  the  course  of  the  hjcal  inflammation  we  see  a  low  form  of  bron- 
chopneumonia come  on  and  pass  off  harmlessly.  It  is  difficult  to  account 
for  this  otherwise  than  as  the  result  of  pya^mic  poisoning,  except  in  cases 
where  (as  in  Sir  J.  Paget's)  there  may  have  been  some  previous  illness 
which  has  left  a  predisposition  to  pneumonic  inflammation.  But  I  have 
seen  the  same  event  where  no  such  predisposition  existed  ;  and  it  has 
seemed  to  me  that  the  prognosis  depends  mainly  on  the  time  of  occur- 
rence of  the  chest  symptoms,  being  more  favorable  the  longer  after  the 
injury  they  occur.  There  are  other  cases  in  which  the  disease  begins, 
not  in  the  glands,  but  as  phlegmonous  erysipelas  of  the  limb,  not  neces- 
sarily starting  from  the  wound,  and  other  rarer  cases  of  common  cuta- 
neous erysipelas  occur ;  but  these  cases  do  not  offer  any  other  noticeable 
peculiarity.  The  danger  is  the  same,  the  course  of  the  constitutional 
infection  is  the  same,  and  the  treatment  must  be  the  same  in  whatever 
part  the  erysipelatous  inflammation  commences — whether  in  the  skin,  the 
cellular  tissue,  or  the  glands.  For  it  must  be  remembered  ti)at  (as  stated 
above)  the  relation  between  erysipelas  and  absorbent  inflammation  is  a 
very  close  one  indeed,  and  it  seems  a  matter  of  perfect  indifference 
whether  the  disease  commences  by  one  form  of  inflammation  or  the  other, 
and  whether  it  starts  from  the  axilla  or  the  forearm. 

The  chronic  cases  are  those  which  are  also  happily  b}'  far  the  most 
common,  being  limited  merely  to  inflammation  with  or  without  abscess 
of  the  glands,  or  slight  absorbent  inflammation  with  slight  and  transient 
disturbance  of  the  general  health. 

Treatment. — In  this,  as  in  all  other  cases,  prevention  is  better  than 
cure.  All  students  know  the  importance  of  having  the  hands  well  greased 
or  oiled  wlien  performing  a  post-mortem  examination  in  a  case  of  acute 
internal  inflammation  ;  and  if  they  are  unlucky  enough  to  prick  or  cut 
tliemselves,  the  first  thing  is  to  tie  a  ligature  tightly  around  above,  and 
then  the  wound  should  be  at  once  squeezed,  so  as  to  encouiage  a  copious 
flow  of  blood  from  it,  and  it  should  then  be  sucked  for  a  long  time,  so 
that  all  morbid  matter  may  be  sucked  out  of  it.  It  may  then  be  right 
to  cauterize  it  tlioroughly,  and  undoubtedly  this  plan  gives  more  security 
against  absorption  of  virus,  but  of  course  at  the  expense  of  some  inevi- 
table local  inflammation.  On  the  first  ai)pearance  of  any  unpleasant 
symptom,  rest,  country  air,  purgation,  and  generous  living  are  essential. 
Most  surgeons  agree  in  thinking  that  the  reason  why  dissection-wounds 
are  so  much  less  fatal  now  ihan  heretofore  is  because  the  so-called  "  an- 
tiphlogistic "  has  been  superseded  by  the  stimulant  plan  of  treatment. 
When  the  characteristic  symptoms  are  developed  the  treatment  must  be 
conducted  on  the  same  principles  as  in  other  cases  of  blood  poisoning. 

^  Sir  J.  Paget  says  :  "  This  seem*  tc  be  a  point  of  distinction  between  these  dissec- 
tion-poisons and  pyjemia:  their  etfects  are  at  first,  however  severe,  comparatively 
Hniited  to  the  part  poisoned,  and  to  tiie  lymiihatic  vessels  and  glands,  or  to  the  cellu- 
lar tissue  nearly  in  relation  with  it.  They  may  lead  to  pyaemiii,  but  they  do  this 
only  by  secondary  changes  or  as  it  were  by  some  accident  "—Op.  cit.,  p.  331. 


96  ANIMAL    POISONS. 

Eost  of  body  and  quiet  of  mind  (if  possible)  are  of  great  importance, 
but  the  latter  is  not  eas_y  to  obtain.  1  have  usually  found  that  surgeons, 
when  overtaken  themselves  by  any  grave  surgical  malady,  are  peculiarly 
nervous  and  ap|)rehensive,  as,  indeed,  is  natural.  Yet  such  apprehensions 
are  more  common  in  the  subacute  than  in  the  acuter  and  more  deadly 
form  of  the  complaint,  in  which  the  mind  is  too  much  oppressed  to  have 
much  room  for  fear,  and  therefore  the  inevitable  anxiety  may  generally 
be  relieved  by  the  assurance  that  such  cases  almost  always  iend  well.  The 
patient's  strength  must  be  su[)ported  by  such  food  and  drink  as  he  can 
easily  and  comtbrtably  digest ;  and  Sir  J.  Paget  testifies  to  the  relief 
aiforded  by  free  and  early  incisions  into  the  abscesses,  and  I  would  add, 
into  an}'  iuHamed  part  where  tension  is  manifest,  though  no  pus  may  be 
formed.  And,  as  the  same  great  authority  intimates,  it  is  probable  that 
diligent  and  judicious  nursing  has  quite  as  much  to  do  with  the  patient's 
recover^'  as  medical  or  even  surgical  treatment. 

II.  Wound.-i  of  Venomous  Animals. — Wounds  inoculated  with  matters 
which  act  as  general  poisons  are  chicHy  those  inflicted  by  the  bites  of 
venomous  seri)ents  or  the  stings  of  venomous  insects,  though,  as  to  the 
latter,  it  seems  that  practically  it  is  only  the  scorpion,  and  that  only  in 
very  hot  climates,  whose  sting  produces  any  serious  general  symptoms. 
The  insects  of  this  climate,  hornets,  wasps,  bees,  etc.,  produce  only  local 
inflammation  by  their  stings,  and  this  so  trivial  as  seldom  to  require  any 
skilled  assistance.  Some  form  of  ammonia  (sal  volatile  or  eau  de  luce), 
indigo,  in  the  form  of  the  domestic  *■'  blueball,"  whitening,  flour,  ink,  are 
some  of  the  common  remedies  enumerated  in  the  order  of  their  apparent 
efliciency.  It  is  said  that  bees'  and  wasps'  stings  inside  the  throat  some- 
times produce  a  degree  of  swelling  which  requires  scarificaLion. 

So  also,  in  this  climate,  the  bite  of  a  snake  usually  produces  local  con- 
sequences only.  The  common  snakes  are,  of  course,  perfectly  harmless 
— in  fact,  are  common  and  favorite  playthings  of  schoolboy's — but  the 
adder,  or  viper,  is  undoubtedly  venomous.  I  never  saw  a  case  in  which 
the  venom  produced  any  worse  consequences  than  a  sharp  attack  of 
phlegmonous  erysipelas,  thougli  this  may,  of  course,  prove  fatal.  But 
the  tropical  snakes  infuse  into  their  bites  a  venom  which  acts  as  a  spe- 
cific poison,  and  in  the  most  venomous  species  this  poison  is  as  rapidly 
and  as  surely  fatal  as  any  substance  known  to  pharmacologists.  In  the 
severest  cases  the  effects  are  developed  so  rapidly  as,  according  to  Mr. 
Busk,  to  resemble  those  of  prussic  acid  more  tlian  anything  else,  l)ut 
usually  an  interval  elapses.  The  sym|)toms  may  be  divided  into  general 
and  local.  'IMie  first  symptom,  in  nearly  all  cases,  appears  to  be  a  general 
shock  to  the  nervous  system,  attended  with  faintness,  tremor,  and  great 
depression,  sometimes  with  stupor,  loss  of  siglil,  vcMuiting,  trismus,  and 
general  insensibility.  At  the  same  time  great  and  sometimes  intense 
local  pain  is  set  up.  The  limb,  if  the  wound  is  in  one  of  the  exti'cmities, 
rapidly  swells;  at  first  pale,  the  surface  of  the  swelling  soon  becomes 
red,  and  afterwards  livid,  and  covered  with  phlyctennht  filled  with  sani- 
ons  fluid.  In  some  cases  the  swelling  continues  to  spread  through  the 
whole  limb  up  to  the  trurdc  or  even  through  the  entire  body,  whose  sur- 
face assumes  a  jaundiced  hue.  The  [local]  symptoms,  in  fact,  very 
closely  resemble  those  of  ordinary  phlegmonous  erysipelas.  The  consti- 
tutional sym[)toms,  independently  of  the  first  siiock,  are  what  might  be 
expected  to  accompany  such  a  local  affection,  and  in  intensity  are  in 
proportion   to  its  violence.'     Mr.  Husk  points  out  the  analogy  between 


'  Busk,  in  Sy>t(!m  (if  Suii^^cry,  vol.  v,  p.  941  ;  2d  ed. 


SNAKE- BITE.  97 

this  dreadful  poison  and  the  ferments  which  act  in  the  blood  to  develop 
the  most  formidable  kinds  of  fever,  as  small-pox,  and  to  the  dissection- 
poisons  of  which  we  have  just  spoken.  Bnt  he  also  dwells  on  the  fact 
that,  unlike  those  poisons,  which  produce  (as  far  as  is  known)  the  same 
intensity  of  symptoms,  whether  they  are  introduced  in  small  quantity  or 
large,  the  serpent-poison  depends  for  its  intensity  directly  on  its  quantity 
in  relation  to  tlie  mass  of  the  blood  into  which  it  is  introduced  ;  so  that 
two  l)ites  will  kill  the  same  animal  more  quickly  and  surel}'  than  one, 
and  a  similar  bite  from  the  same  serpent  will  act  more  intensely  on  a 
small  animal  than  a  large  one.  The  situation  of  the  bite  also  influences 
the  rapidity  and  certainty  of  the  action,  a  bite  on  the  face  or  trunk  being 
far  more  dangerous  than  one  on  the  extremities.  The  knowledge  of 
these  deadly  animals  is  essential  to  those  who  have  to  practice  in  tropical 
climates,  but  the  present  work  is  hardly  the  place  for  any  description  of 
them.  I  must  refer  the  reader,  for  a  condensed  account,  to  the  essay  of 
Mr.  Busk  above  quoted,  and  for  more  complete  anatomical  and  zoological 
details  to  the  special  works  on  the  subject,  and  particularly,  on  the  sub- 
ject of  the  Indian  snakes,  to  Professor  Fayrer's  great  work,  The  Thana- 
tophidia  of  India. 

The  treatment  of  these  injuries  must  be  divided  into  the  prophylactic 
and  the  curative.  As  in  all  other  poisoned  wounds,  the  most  effectual 
treatment  is  at  once  to  tie  a  ligature  tightly  round  the  limb  above  the 
wound,  to  excise  the  part  freely  with  a  sharp  knife,  and  then  to  suck  the 
blood  out  repeatedly,'  and  cauterize  the  surface  deeply  before  removing 
the  ligature  ;  or  if  the  finger  is  the  seat  of  tlie  bite,  to  cut  it  off  at  once. 

But  it  is  obvious  that  op[)ortuuities  for  adopting  such  precautions  can 
very  rarely  be  afforded.  Then  arises  the  question,  is  any  other  treatment 
of  any  avail  ?  Now,  it  must  be  premised  that  the  venomous  sei'pents 
differ  greatly  in  the  activity  of  their  venom  ;  that  the  probability  of  in- 
oculation and  the  intensity  of  the  poisoning  will  differ  according  as  the 
poison-gland  is  full  or  empty;  and  that  a  person  may  be  bitten  without 
any  penetration  of  the  skin  having  been  effected,  or  any  of  the  virus 
being  brought  into  contact  with  the  absorbent  vessels. 

Thus  it  is  never  quite  certain,  when  a  person  recovers  after  the  bite  of 
a  deadly  serpent  under  a  certain  mode  of  treatment,  whether  he  has 
recovered  in  consequence  of  the  specific  effects  of  the  treatment,  or  in 
consequence  of  the  insutticiency  of  the  dose  of  the  poison  ;  and  this  ob- 
jection has  been  made  to  tlie  only  method  of  specific  treatment  which  it 
is  in  the  least  worth  while  to  discuss,  viz.,  the  intravenous  injection  of 
ammonia,  and  made  on  the  great  authority  of  Professor  Fayrer.  He 
attempts  to  show  that  in  wounds  produced  by  the  deadly  serpents  of 
India,  when  those  wounds  fairly  penetrate  the  skin,  the  injection  of  am- 
monia into  the  veins  rather  hastens  death  than  otherwise,  and  he  regards 
the  plan  as  positively  hurtful.  The  recoveries  which  have  ensued  in 
Australia  he  explains  as  due  to  the  less  poisonous  nature  of  the  serpents 
of  that  country',  or  to  the  insufficient  injection  of  the  poison.  Yet  it 
must  be  admitted  that  in  mau}'^  cases  of  serpent-bite  in  Australia  the 
poison  seems  to  have  been  potent  enough  to  produce  death  when  no 
treatment  has  been  adopted  ;  that  the  symptoms  described  in  many  of 
the  Australian  cases  have  been  very  alarming,  and  that  the  treatment 
seems  to  have  approved  itself  to  persons  of  experience,  so  as  to  have 
come  widely  into  use  in  the  country  in  which  it  was  devised.     And  as  to 

'  There  is  no  danger  in  sucking  the  poison  out  of  any  wound,  except  the  danger 
of  there  being  a  crack  or  wound  in  the  mouth  by  which  the  poison  may  be  absorbed. 

7 


98  ANIMAL    POISONS. 

the  increased  danger  wliicli  the  injection  itself  may  cause,  it  is  surely  a 
matter  of  very  slight  importance.  In  a  case  which  is  certain  otherwise 
to  prove  fatal  in  a  very  short  time  it  matters  little  whetlier  the  treatment 
employed  exposes  tlie  patient  to  the  danger  of  dying  a  few  minutes  sooner, 
provided  only  that  it  otters  an}-  reasonable  cliance  of  safety.  And  I  must 
say  that  to  my  mind  it  is  quite  clear  that  Professor  Halford's  treatment, 
whetlier  it  is  sufiiciently  energetic  or  not  to  combat  the  effects  of  the  virus 
of  the  most  deadly  serpents,  has  acted  beneficially^  and,  as  far  as  we  can 
judge  from  published  accounts,  has  saved  life  in  many  of  the  bites  from 
the  Australian  serpents,  and  deserves  to  be  fully  tested  in  those  of  other 
countries.  Professor  Halford  directs  that  the  liquor  ammoniae  fortior  is 
to  be  diluted  with  two  or  three  times  its  bulk  of  water,  and  of  this  mix- 
ture from  twenty  to  thirty  drops  are  to  be  injected  into  one  of  the  large 
veins  as  near  the  bite  as  possible.  If  the  symptoms  are  relieved,  but  the 
patient  seems  still  in  danger,  the  injection  may  be  repeated  as  soon  as 
the  operator  thinks  it  prudent. 

If  this  treatment  is  delusive,  no  other  is  at  present  known  ;  the  various 
specifics  so-called, such  as  theTanjore  pill,thedecoction  of  snakeroot.etc, 
are,  I  believe,  admitted  to  be  inert,  and  the  only  thing  that  can  Jie  done 
is  to  keep  the  patient  alive  by  copious  stimulation  or  artificial  respiration.^ 

III.  The  next  class  of  poisoned  wounds  is  that  in  which  specific  dis- 
eases are  excited.  These  are  wounds  poisoned  by  tlie  secretions  from 
diseased  animals,  viz.,  Glanders  and  Hydrophobia.^ 

Glanders  in  the  horse,  and  in  man  also,  appears  in  two  forms,  one  of 
which  is  acute,,  and  ver}'  deadly' — acute  glanders,  ov  glanders  proper ;  the 
other  is  chronic,  and  often  followed  by  recovery — farcy,  or  chronic 
glanders.  Glanders  consists  essentially  in  the  eruption  under  the  mucous 
membrane  of  the  respiratory  passages  in  the  face  of  a  number  of  inflam- 
matory deposits,  or  buds,  somewhat  resembling  the  gummata  found  in 
sj'philis,  only  much  more  rapidly  formed.  Accompan^'ing  this  eruption 
is  a  general  inflammation  of  the  whole  submucous  tissue,  and  usually  also 
(though  not  always)  a  vesicular  or  pusttilar  eruption  on  the  free  surface 
of  the  mucous  membrane.  Pi'evious  to  the  eruptive  stage  there  is  a  pre- 
monitory feverish  stage,  characterized  b_y  general  in(lisi)Osition,  with 
peculiar  wandering  pains,  loUowed  by  feverish  excitement  and  shivering, 
and  succeeded  by  pains  which  simulate  rheumatism,  and  which  appear  to 
be  often  due  to  an  eruption  nnder  the  skin  similar  to  the  glanders  erup- 
tion under  the  mucous  membrane.  The  longer  the  premonitory  stage  is 
dela3'ed  after  inoculation,  and  the  longer  the  eruption  is  delayed  after  the 
premonitor}'  stage,  the  more  ho[)eful  is  the  case. 

The  glanders  eruption  attacks  the  internal  organs,  especially  the  lungs 
and  pleural,  and  less  commonlj'  the  testicle,  kidney,  pancreas,  and  the 
synovial  membranes.  JJesides  the  eruption  in  or  under  the  skin  and 
mucous  membrane  there  is  a  peculiar  alfection  of  the  lymphatic  vessels 
and  glands,  to  which  the  name  "  farcy  "  is  more  particularly  ai)pr()priated, 
and  vvjiich  consists  in  the  development  in  the  course  of  the  lymphatic 
vessels  of  tubercles — "  f;ircy-buds"  as  they  are  called — which  appear  to 
be  exactly  similar  to  tlie  tubercles  constituting  the  glanders  eruption. 
And  coincident  with  this  are  the  usual  symptoms  of  diffused  intlamma- 

'  All  intercf-tinu  summary  of. some  experiments  on  intravenous  injeetion  and  artifi- 
cial respiration  in  snake-bile  will   be  found  in   Brit.  Med.  Journ.,  June  19,  1875. 

2  Possibly  the  maligiumt  pustule  or  "  charbon  "  might  bo  added  to  tlicse,  l.ut  I 
have  thought  it  better  tt>  place  this  in  the  same  chapter  with  Carbuncle,  under  the 
affections  of  tlie  Skin. 


GLANDERS.  99 

tion  and  obstruction  of  the  lymphatics,  pain,  cedema,  suppuration,  and 
ultimately  permanent  laming  of  the  affected  limb. 

It  seems  almost  a  pity  to  describe  the  disease  under  two  different 
names,  since  glanders  and  farcy,  as  above  described,  do  not  differ  from 
each  other  in  an}'  essential  particulars,  and  the  inoculation  from  a  farcy- 
bud  will  produce  glanders  and  vice  versa.  Sometimes  the  term  glanders 
is  restricted  to  cases  in  which  the  nose  is  affected,  and  farcy  to  those  in 
which  it  is  not:  a  more  intelligilile  though  an  equall}'  arbitrary  division. 

Virchovv  describes  the  tubercles  of  glanders  (or  farcy)  under  the  skin 
thus:  ''At  (irst  there  appear  some  red  spots,  which  are  very  small  and 
I'esemble  fleabites,  and  soon  acquire  a  papular  elevation,  subsequently 
rising  above  the  level  of  the  surface  like  small  shot,  assuming  a  yellow 
color.  These  shotlike  knots  are  either  flat  or  round,  and  do  not  lie  in  a 
bladder-like  elevation  of  the  epidermis,  but  in  a  kind  of  hole  in  the  corium, 
as  if  the  latter  had  been  punched  out.  They  are  not  always  solitary,  but 
often  disposed  in  groups.  There  is  some  surrounding  injection,  and 
under  the  epidermis  there  is  found  a  puriform  and  ^yellow  fluid,  seemingly 
consistent,  and  which  is  chiefly  formed  from  softening  of  the  knot.  They 
are  composed  of  a  homogeneous  yellowish  substance,  which  is  pretty  firm 
and  somewhat  brittle,  and  has  a  great  resemblance  to  tubercle.  Micro- 
scopically examined,  they  present  an  amorphous  granular  appearance, 
mixed  with  cell-elements  and  cell-growths,  and  numerous  fat-globules."  ' 
The  eruption  is  formed  by  vesication  over  these  tubercles,  tlie  vesicles 
soon  becoming  filled  with  pus,  in  which  stage  the  eruption  is  likened  to 
varicella.  The  action  on  the  mucous  meml>rane  of  the  nose  must  be 
similar,  but  it  is  less  eas}'  to  verify  it.  It  is  accompanied  with  discharge 
from  the  nose,  which  soon  becomes  purulent,  oedema,  and  inflammation 
of  the  face,  sometimes  passing  on  to  gangrene,  swelling  and  abscess  of 
the  salivary  glands  and  of  the  tonsils. 

In  its  acute  form  the  disease  is  very  fatal,  and  sometimes  very  rapidly 
so.  It  proves  fatal  either  by  mere  exhaustion  or  by  a  form  of  pya^njiain 
which  the  secondary  deposits  are  found  chiefly  in  the  muscles  and  subcu- 
taneous tissue,"  or  from  the  effects  of  the  glanders  eruption  in  the  viscera, 
and  particularly  the  lungs. 

But  glanders  or  farcy  in  the  chronic  form  may  not  prove  fatal,  though 
it  is  a  very  formidable  disease,  and  usuall}-  leaves  the  limb  crippled  by 
long-continued  suppuration  and  sloughing.  In  some  cases  acute  glanders 
follows  on  chronic  farcy,  doubtless  from  auto-inoculation. 

In  some  cases,  dcnonnuatei]  flying  farcy^  the  farcy-buds  subside  with- 
out suppurating  in  one  part  while  the  disease  shows  itself  in  another. 

The  disease  can  only  be  communicated  to  man  by  inoculation  from  an 
animal  similarly  diseased — and  the  disease  is  only  known  in  horses  and 
asses  ;  but  there  is  no  doubt  that  when  generated  it  is  highly  contagious 
from  man  to  man,  so  that  all  possible  precautions  should  be  adopted; 
and  it  has  been  proved  by  experiment  to  be  inoculable  from  man  to  the 
horse  or  ass. 

Mr.  Poland,  who  has  seen  several  cases  (which  I  fortunately  have  not, 
only  one  case  having,  as  far  as  I  know,  been  admitted  into  St.  George's 
Hospital  during  maiiy  years,  and  that  in  my  absence''),  says  that  "in  the 
premonitory  stage  it  can  hardly  be  diagnosed  from  other  forms  of  blood- 
poisoning,  and  that  in  the  early  eruptive  stage  it  is  very  much  like  the 


1  Poland,  from  Handb.  der  Path,  u  Ther.     Bd.  ii,  Abth.  1. 
^  See  the  second  illusti'ation  on  p.  70S  of  Mr.  Poland'.*  e>.s;iy, 
3  It  is  described  by  Dr.  Dickinson,  Lancet,  Marcli,  18G9. 


100  ANIMAL     POISONS. 

small-pox,  and  ma}' have  its  sliottv  feel;  but  when  once  the  eruptive  stage 
is  developed  all  doubt  is  at  an  end  ;  the  presence  of  a  peculiar  exanthem, 
the  local  nasal  discharge,  if  present ;  the  erj'sipelatous  blush  in  the  face 
and  c\ves ;  the  tumors  and  knots  in  the  cellular  tissue  and  muscles  ;  and  the 
local  suppuration  sufRcientl}'  attest  its  character." 

The  disease,  both  in  horses  and  men,  is  now,  we  may  hope,  becoming 
rarer  in  consequence  of  its  being  better  known,  and  in  consequence  of 
the  greater  attention  which  is  paid  to  the  cleanliness  and  ventilation  of 
stables.  It  ought  never  to  be  generated  in  the  horse,  and  if  it  is  the  ani- 
mal should  be  killed  at  once.  If  a  groom  or  any  one  handling  a  horse 
supposed  to  be  glandered  is  so  unfortunate  as  to  get  any  of  the  matter 
into  a  crack  on  his  hand,  or  on  to  the  naked  hand  (whence  it  is  probably 
transferred  to  the  nose  in  most  instances),  or  if  any  is  l)lown  directly'  into 
the  nose  the  same  prompt  and  decisive  measures  sliould  be  adopted  as  are 
recommended  in  serpent-bites  or  the  l)ites  of  rabid  animals:  that  is  to 
say,  the  poison  should  be  destroj-ed  as  promptly  and  as  speedily  as  pos- 
sible by  caustic,  and  if  possible  a  ligature  should  meanwhile  be  tied  above 
the  part  inoculated. 

The  treatment  of  glanders  and  farcy  offers  nothing  that  is  peculiar.  Its 
principles  are,  first,  to  disinfect  and  deodorize  the  discliarge  ;  and,  sec- 
ondly, to  support  the  jDatient  through  tlie  fever.  For  the  former  purpose 
the  nose  should  be  freely  washed  out  either  with  creasote  lotion,  as  recom- 
mended by  Dr.  Elliotson  in  his  original  paper  (Med.-Ghir.  Trans.,  vol. 
xvi),  in  which  the  disease  was  for  the  first  time  accurately  described,  or 
with  Condy's  fluid  or  carbolic  acid.  Mr.  Poland  speaks  with  approbation 
of  turpentine  embrocations  and  fumigation  with  volatile  stimulating  anti- 
septics, couve3'ed  through  the  medium  of  warm  vapor.  The  second  indi- 
cation is  to  be  carried  out  (as  in  dissection-poisons)  by  free  and  early 
incisions  and  the  judicious  use  of  stimulants  and  tonics. 

Equinia  Mitis. — Glanders,  when  fully  developed,  is  hardh^  to  be  con- 
founded with  any  other  disease.  Those  who  handle  horses'  feet  when 
affected  with  a  disease  known  to  farriers  as  "  the  grease,"  are  liable  to  a 
slight  pustular  eruption  in  the  hands  and  wrists,  to  which  the  name  of 
"equinia  mitis  "  is  given,  in  order  to  mark  its  origin  and  to  distinguish 
it  from  tlie  virulent  constitutional  poison  of  glanders.  It  is  a  merely  local 
and  a  perfectly  harmless  affection.  The  eruption  consists  only  of  the 
common  phlyzacious  pustules,  instead  of  the  hard  shottj-  tubercles  of 
glanders — there  is  no  general  disease — and  tlie  whole  thing  subsides  in  a 
few  days  with  cleanliness  and  soothing  applications.  Such,  at  least,  has 
been  tlie  course  of  those  cases  which  I  have  seen,  in  all  of  which  the  hand 
has  alone  been  affected  ;  but  one  is  recorded  by  Mr.  Cock^  in  which  the 
accidental  inoculation  on  the  nostril  of  the  matter  from  a  '•  greasy  "  horse 
produced  symptoms  much  resembling  those  of  glanders. 

Ili/drojjJiobia. — Perhaps  the  most  awful  of  all  diseases  is  that  which  is 
derived  from  the  bite  of  an  animal  suffering  under  dog  madness,  or  rallies, 
and  unluckily  the  ajipreliension  often  produces  mental  torture  hardly  less 
terrible  tlian  the  disease  itself  It  is  consolatory,  therefore,  to  be  assured 
that  the  disease  in  animals  is  very  far  rarer  than  might  be  inferred  from 
the  constant  cry  of  "mad  dog"  which  is  raised  whenever  a  poor  cur, 
being  worried  into  a  bad  temper,  bites  and  foams  at  the  mouth.  Dog- 
bites  are  extremel}'^  common — hydrophobia  one  of  the  rarest  of  maladies. 

Tlie  disease  derives  its  name  from  tlie  dread  of  water  which  its  develop- 
ment causes  in  the  human  subject,  but  rabies  in  the  dog  causes  no  such 


'  Lancet,  1851,  vol.  ii,  p.  129. 


HYDROPHOBIA,  101 

dread;  in  fact,  the  dog  generally  seeks  the  water  greedily,  though  possibly 
spasm  may  prevent  him  from  swallowing  it.  The  disease  in  the  dog  ought 
to  be  known,  in  order  that  proper  precautions  may  be  taken  ;^  but  this  is 

1  The  subject  is  so  important  in  respect  of  precaution  tliat  I  tliink  it  necessary  to 
give  the  symptoms  of  doij  madness  as  described  by  Trousseau  (Clin.  Medicine,  vol.  i, 
p.  693,  New  Syd  Soc.'s  Trans.),  on  the  authority  of  Monsieur  Bouley,  clinical  pro- 
fessor to  the  school  at  Alfort,  "based  on  what  he  had  seen  himself,  and  on  quotations 
from  Youatt's  work  :"  "There  are  three  well-marked  stages  of  the  complaint  in  the 
dog.  The  first  is  characterized  by  melancholy,  depression,  sullenness,  iind  fidgeti- 
ness ;  the  second  by  excitement,  by  rabid  fury  ;  and  the  third  and  hist  by  general 
muscular  debility  and  actua-  juiralysis. 

"  Whether  the  f^lisease  originated  de  novo  or  was  communicated,  the  dog  looks  ill 
and  sullen  after  a  period  of  incubation  of  very  variable  length  ;  he  is  constantly  agi- 
tated, turning  round  and  round  inside  his  kennel,  or  roaming  about  if  he  is  at  large. 
His  eyes,  when  turned  on  his  master  or  friends  of  the  house,  liave  a  strange  look  in 
them,  expressive  of  sadness  as  well  as  of  distrust.  His  attitude  is  suspicious,  and  indi- 
cates that  he  is  not  well.  By  wandering  about  the  house  and  yard  he  seems  lo  be 
seeking  for  a  remedy  to  his  compb\int.  He  is  not  to  be  trusted  even  then,  because, 
though  he  may  still  obey  you,  yet  he  does  it  somewhat  slowly  ;  and  if  j'ou  chastise 
him  he  may,  in  sjiite  of  himself,  inflict  a  fatal  bite.  In  most  cases,  however,  a  mad 
dog  respects  and  spares  the  person  to  whom  he  is  attached.  But  his  agitation  in- 
creases;  if  he  is  in  a  room  at  the  time  he  runs  about,  looking  under  the  furniture, 
tearing  the  curtains  and  carpets,  sometimes  flying  at  the  walls,  as  if  he  wished  to 
seize  a  prey.  At  other  times  he  jum])s  up  with  open  jaws,  as  if  trying  to  catch  flies 
on  the  winsT ;  the  next  moment  he  stops,  stretches  his  neck,  and  seems  to  listen  to  a 
distant  noise.  He  probably  has  then  hallucinations  of  sight  and  hearing,  seeing  ob- 
jects that  do  not  exist,  and  hearing  sounds  that  are  not  emitted.  This  delirium  may 
still  be  suddenly  dispelled  by  his  mastei''s  voice,  and  according  to  Youatt,  '  dispersed 
by  the  magical  influence  of  his  master's  voice,  all  these  dreadful  objects  vanish,  and 
the  creature  creeps  to  his  master  with  the  expression  of  attachment  peculiar  to  him. 
There  follows  then  an  interval  of  calm  ;  he  shortly  closes  his  eyes,  hangs  down  his 
head,  his  forelegs  seem  to  give  way  beneath  him,  and  he  looks  on  the  point  of  drop- 
ping. Suddenly,  however,  he  gets  up  again,  fresh  phantoms  rise  before  him  ;  ho 
looks  around  him  with  a  saviige  expression,  and  rushes  as  far  as  his  chain  allows  him 
against  an  enemy  who  exists  only  in  his  imagination.'  By  this  time  already  the 
animal's  bark  is  hoarse  and  mufHed.  Loud  at  first,  it  gradually  fails  in  force  and  in- 
tensity, and  becomes  weaker  and  weaker,  apparently  indicating  incomplete  paralysis 
of  the  muscles  of  the  jaws,  just  as  the  dropping  down  pointed  to  paralysis  of  the  mus- 
cles of  the  forelegs.  In  some  cases  the  power  of  barking  is  completely  lost,  the  dog 
is  dumb,  and  his  tongue  bangs  out  through  his  half-opened  jaws,  from  which  dribbles 
a  frothy  saliva.  Sometimes  his  mouth  is  perfectly  dry,  and  lie  cannot  swallow,  al- 
though in  the  majority  of  cases  he  can  still  eat  and  drink.  When  he  has  vainly  at- 
tempted toswallow  lie  pi'obablj'  believes  it  is  because  some  foreign  body  sticks  in  his 
throat,  for  he  puts  his  muzzle  between  his  paws  and  works  with  them  as  if  he  wanted 
to  get  rid  of  this.  Although  he  can  no  longer  drink  people  are  misled  into  the  be- 
lief that  he  does  so  from  his  lapping  fluids  with  great  rapidity.  On  close  examination, 
however,  the  fluid  is  found  to  keep  the  same  level  in  the  vase  which  contains  it,  and 
one  can  see  that  the  dog  does  not  in  reality  swallow,  that  he  does  not  drink,  but 
merely  bites  the  water.  Although  he  cannot  swallow  fluids  he  can  still  in  some  cases 
swallow  solids,  and  he  may  thus  swallow  anything  within  his  reach,  bits  of  wood, 
pieces  of  earth,  the  straw  in  his  kennel,  etc  This  circumstance  is  one  of  very  great 
importance  to  bear  in  mind,  because  when  the  body  of  a  mad  dog  is  dissected  a  good 
many  substances  which  have  not  been  digested  may  be  found  in  its  stomach,  and  do 
thus  furnish  a  ])roof  of  his  complaint. 

"  One  period  of  the  disease  does  not  pass  suddenly  into  another,  but  by  an  easy 
transition.  Even  in  the  first  stage,  that  of  depression  and  melancholy,  the  animal  is 
from  time  to  time  very  agitated,  and  shifts  his  posture.  This  agitation  increases  to  a 
considerable  degree,  and  in  the  second  stage  constitutes  the  rabid  fury  which  charac- 
terizes this  period,  together  with  hallucinations  of  sight  and  hearing.  During  this 
second  period  the  animal  drops  down  in  a  state  of  exhaustion  after  paroxysms  of 
rage  ;  he  seems  completely  prostrate,  his  head  hangs  down,  his  limbs  give  way  under 
him,  and  he  can  no  longer  swallow.     These  are  signs  of  incipient  paralysis. 

"  Towards  tiie  close  of  the  second  stage  the  dog  often  breaks  his  chain,  and  runs 
far  away  from  his  master's  house  ;  he  wanders  about  in  the  fields,  seized  from  time  to 


102  ANIMAL    POISONS. 

not  more  the  province  of  the  surgeon  than  of  any  other  person.  A  sur- 
geon has  usually  to  form  his  own  opinion  as  to  the  presence  of  hydro- 
phobia in  the  animal  which  inflicted  the  bite  from  the  account  given  him 
b^'  tlie  patient  or  his  friends  when  applying  for  advice  on  account  of  the 
injury,  and  I  think  I  may  say  that  the  safest  course — the  one  which  is 
best  for  the  patient,  and  that  which  is  most  likely  to  be  correct  in  cir- 
cumstances where  anything  like  certainty  is  impossible  (for  it  is  difficult 
for  any  one  not  very  familiar  with  dogs  to  distinguish  the  early  stage  of 
rabies  when  he  sees  it,  and  still  more  so  to  judge  on  the  subject  from 
another  person's  description) — is  to  be  very  chary  in  admitting  that  the 
suspicion  of  the  animal's  madness  had  any  foundation,  and  to  give  the 
most  favorable  prognosis,  yet  at  the  same  time  not  to  neglect  any  of  the 
precautions  against  the  imbibition  of  poison  which  are  used  in  other  cases 
of  poisoned  wounds,  and  which  are  descrilied  on  p.  95.  When  these  pre- 
cautions have  been  taken,  or  if,  unfortunatel_v,  they  have  been  overlooked, 
and  an}' time  over  half  an  hour  has  elapsed,  nothing  further  can  be  done  ; 
though  even  at  alater  period  it  is  quite  justifiable  to  cauterize  the  wound, 
in  order  to  relieve  the  patient's  own  ni)prehensions,  even  if  it  cannot 
really  affect  the  progress  of  the  case.  What  distinguishes  hydrophobia 
from  every  other  form  of  poisoned  wound  is  the  great  uncertainty  of  its 
jDeriod  of  incubation,  and  the  incredible  length  of  time  during  which  the 
poison  may  remain  latent,  and  yet  ultimately  break  out  in  all  the  viru- 
lence of  the  disease.  Many  cases  are  recorded  in  which  more  than  a  year 
has  elapsed  lietween  the  receipt  of  the  injury  and  the  outbreak  of  the 
disease — one  in  which  as  much  as  five  j^ears  and  a  half  intervened — and 
though  we  might  believe  that  in  some  of  these  cases  a  mistake  had  been 
made,  and  the  disease  had  been  due  in  reality  to  another  injur^^  which  had 
passed  unnoticed,  or  that  in  others  hysterical  hydrophobia  has  been  mis- 
taken for  the  real  disease,  3'et  we  can  hardl}^  resist  the  conclusion  that 
(in  some  mysterious  and  hitherto  perfectly' inexplicable  manner)  the  poi- 
son contained  in  the  saliva  of  the  rabid  animal  may  remain  inactive  in 
some  part  of  the  body  for  weeks  or  months,  and  then  at  length  pass  into 
the  mass  of  the  blood.  Yet  the  neighborhood  of  the  wound  displays  no 
visible  peculiarity,  nor  the  absorbent  glands  nor  any  other  part.  The 
wound  has  usually  quite  healed,  and  the  patient  has  often  altogether  for- 
gotten the  accident;  so  that  the  explanation  which  some  have  hazarded 
is  quite  insulTicient — that  the  disease  is  really  no  affection  of  the  body  at 
all,  but  a  mental  disorder  due  to  constant  apprehension — a  form  of  in- 
sanity. The  disease  undoubtedly  originates  spontaneously  in  the  dog, 
but  in  the  human  sul)ject  it  is  only  known  as  a  consequence  of  inocula- 
tion. 

Like  other  poisons,  except  perhaps  those  which  are  most  virulent,  the 
poison  of  hydrophobia  is  very  uncertain  in  its  action.  Thus,  if  several 
persons  he  lutten,  only  one  may  suffer,  as  was  the  case  in  the  instance 
wbieh  Dr.  Marcct  recorded  in  the  first  volume  of  the  Medico- Chii'urgical 

tirno  witli  paroxysms  (^f  fury,  and  then  lie  stops  from  fiitij^ue,  fis  it  wore,  luid  remains 
several  hours  in  a  somnolent  stale.  Ho  has  no  Ioniser  the  strength  to  run  after  other 
creatures,  although,  if  he  be  worried,  he  can  still  gather  strength  to  tly  at  and  bite  an 
individual.  If  he  bo  not  destroyed  as  \w.  wanders  about  he  generally  dies  in  a  ditch 
(jr  in  some  retired  corner.  lie  apparently  perishes  from  hunger  and  thirst  and  in- 
tense fatigue;  but  veterinary  surgeonsdo  not  say  that  bodies  from  asphy.\ia,  brought 
on  by  spa.sm  of  the  pectoral  muscles  or  by  convulsions  " 

The  dis(;ase  is  known  in  other  animals — cats,  wolves,  horses,  etc.,  and  has  been 
propagated  by  thcni  to  men — but  its  symptoms  Imvo  only  been  fully  described  in  the 
dog. 


HYDROPHOBIA.  103 

TranaacHoyis.  Trousseau  estimates  that  about  half  the  persons  bitten 
take  the  disease.  Tlie  disease  begins  not  uncommonly  with  renewed  irri- 
tation in  the  scar  of  tlie  wound,  or  with  irritation  in  the  nerves  leading 
from  it,  testifying  to  the  fact  that  some  morbid  action  is  going  on  there. 
And  there  is  often  a  period  of  sullen  depression,  a  passion  for  solitude, 
and  a  change  of  temper  and  disposition  exactly  analogous  to  the  first 
stage  of  rabies  in  the  dog.  There  is  also  a  general  feeling  of  bodily 
malaise,  differently  described  in  different  cases,  but  often  referred  to  the 
nape  of  tiie  neck,  and  sometimes  mistaken  for  rheumatism  or  stiff'-neck, 
Feverishness  tiien  succeeds,  more  or  less  marked  in  different  cases,  and 
then,  at  a  varialije  period,  the  peculiar  and  cliai-acteristic  feature  of  the 
disease  manifests  itself,  viz.,  that  any  attempt  to  swallow  fluids  will  pro- 
duce severe  paroxysms  of  dyspnoea ;  and  in  the  worst  cases  these  par- 
oxysms are  produced  not  only  by  attempts  at  di'inking,  but  by  swallow- 
ing anything,  and  even  by  the  sight  or  the  very  idea  of  fluid,  and  in  some 
cases  tliey  occur  spontaneously.  As  the  case  proceeds,  the  mind,  which 
was  at  first  quite  calm  and  reasonable,  sinks  under  the  agony  produced 
by  thirst  and  by  constant  restlessness,  and  the  {)atient  becomes  more  or 
less  insane  ;  yet  is  usually  quite  under  control,  and  easily  made  conscious 
of  liis  own  delusions.  The  excitement  increases,  the  eyes  become  wild 
and  staring,  the  whole  countenance  expressive  of  rage  mixed  with  terror; 
the  patient  is  in  a  constant  state  of  excitement,  and  gets  hai-dly  any  sleep, 
and  that  little  is  nnrefreshing  and  im]ierfect.  As  is  also  noticed  in  the 
lower  animals,  the  sexual  feelings  are  often  inordinately  excited,  producing 
satyriasis  and  involuntary  emissions,  or  in  the  female,  nymi)homania. 
After  this  stage  of  excitement  and  mania  often  follows  one  of  exhaustion, 
in  which  the  patient  recovers  his  reason  and  his  power  of  swallowing, 
but  dies  of  asthenia;  at  other  times  he  dies  in  the  furious  stage,  either 
exhausted  or  suffocated.^  No  instance  of  recovery  has  hitherto  been  re- 
corded. 

It  must  be  added,  also,  that  though  i\\e  disease  is  named  from  the 
dread  of  water,  and  though  that  symptom  is  a  dreadful  one,  and  the  con- 
vulsions which  drinking  occasions  may  be  terrible,  yet  patients  who  have 
sufficient  resolution  may  overcome  it,  and  may  even  take  considerable 
quantities  of  fluid,  and  endure  the  contact  of  water  in  washing,  as  may  be 
seen  in  the  account  of  Dr.  Marcet's  patient  above  referred  to. 

One  other  symptom  deserves  notice,  since  it  has  been  regarded  as  the 
essence  of  the  disease.  I  mean  the  development  under  the  tongue  of 
certain  vesicles  or  pustules,  which  have  been  regarded  as  being  the  path 
through  which  the  poison  finds  its  way  into  the  system,  so  that  it  is  said 
that  if  these  pustules  be  destroyed  by  caustic  the  development  of  the 
disease  will  be  prevented.  I  fear  the  statement  is  delusive,  though  it 
should,  of  course,  be  kept  in  mind,  and  in  so  uniformly  fatal  a  disease 
any  slight  hope  of  safety  is  not  to  be  neglected.  These  vesicles  (or 
Zi/.ss?',  as  the,y  are  called)  are  said  to  be  always  found  in  persons  inocu- 
lated with  the  bite  of  a  rabid  animal,  between  the  third  and  twentieth 
day  after  the  bite.  The}^  would  not  make  their  appearance,  of  course,  if 
the  virus  had  been  thoroughly  destroyed  or  eradicated  at  the  time  of  its 
introduction.  As  they  are  very  fugitive,  soon  bursting  and  disappearing, 
it  is  said  that  it  is  necessary  to  examine  the  patient  twice  a  day  in  order 
to  be  sure  of  not  overlooking  them,  and  when  detected  they  are  to  be  at 
once  laid  open  and  cauterized  ;  and  where  this  is  done  thoroughly  it  is 

'  Trousseau  seems  to  regard  asphyxia  as  the  usual  if  not  almost  the  universal  way 
of  death  in  these  cases. 


104  ANIMAL    POISONS. 

said  that  hydrophobia  has  never  appeared,  Tliese  statements  rest  chiefl}' 
on  the  authoritj^  of  two  physicians,  Dr.  Marochetti,  of  Rnssia,  and  Dr. 
Xanthos,  of  Siphnos.  They  embody  the  popular  belief  in  those  countries, 
and  so  far  as  the  accounts  which  I  have  seen  of  them  extend,  I  should 
not  have  thought  them  worthy  of  much  credit,  but  they  have  been  to 
some  extent  confirmed  by  a  French  physician.  Dr.  Magistel,  who  pro- 
fesses to  have  met  with  the  eruption  :  and  they  are  supported  by  the 
great  authority  of  Trousseau,  so  far  at  least  as  that  he  believes  the 
statements  to  be  pi'obable,  and  the  fact  worthy  of  the  attention  of 
practitioners.^  It  must  be  recollected  that  the  whole  subject  refers  to 
the  prophylaxis  of  hydrophobia,  not  to  its  treatment  when  developed. 
Accepting  the  statement,  the  ditt'iculty  would  be  to  keep  so  constant  a 
watch  on  the  parts  as  would  be  necessary  not  to  miss  this  verj^  fugacious 
S3Mnptom,  without  unnecessarily  alarming  the  patient,  for  we  know  not 
what  effect  constant  apprehension  may  have  in  a  disease  so  manifestly 
connected  with  mental  disturbance  as  hj'drophobia. 

The  disease  has  never,  as  far  as  I  know,  been  propagated  from  man 
either  to  other  men  or  to  the  lower  animals,  though  the  saliva  of  hydro- 
phobic men  has  been  inoculated  for  experiment  into  the  dog. 

As  to  the  real  pathology  of  the  disease  nothing  is  known.  That  it 
consists  in  some  disturbance  propagated  from  the  medulla  down  the 
eighth  pair  of  nerves  is  clear  enough,  for  though  the  leading  phenomena 
of  the  disease  have  fixed  attention  chiefly  on  the  mental  disturbance 
produced  bj^  the  sight  or  touch  or  thought  of  water,  and  the  spasms 
which  follow  on  attempts  at  drinking,  we  must  remember  that  the 
disturbance  is  corporeal  as  well  as  mental,  and  the  eflfects  are  true 
reflex  action  proceeding  from  irritation  of  the  hypersensitive  afferent 
filaments.  This  is  strikingly  illustrated  by  a  case  which  Trousseau 
relates  (op.  cit.,  p.  684)  where  an  oesophagus  tube  was  passed  through 
the  nares  and  seven  ounces  of  broth  poured  into  it.  Half  of  the  broth 
had  been  conveyed  into  the  stomach,  when  the  pharynx  and  oesophagus 
were  thrown  into  such  violent  spasm  as  to  compress  the  tube  and  prevent 
the  further  i)assage  of  the  broth,  and  the  spasm  spread  to  the  respiratory 
muscles  with  such  force  tliat  the  patient  very  nearly  died. 

Tlie  post-mortem  appearances  do  not,  however,  throw  any  more  light 
on  the  nature  of  this  irritation  of  the  medulla  or  eighth  pair  of  nerves 
in  hydrophobia  than  they  do  on  that  of  the  spinal  cord  in  tetanus.  Tlie 
fauces,  pliar3'nx,  and  stomach  are  found  congested,  and  congestion  of 
the  brain  and  other  internal  organs  has  been  noted,  but  the  minute 
examination  of  the  nerves  of  the  part  and  of  the  nervous  centres  has 
hitherto  only  led  to  disappointment. 

The  diagnosis  of  this  affection  seems  eas}'^  enough.  It  appears  that  it 
may  be  mixed  with  tetanus,'-  but  otherwise  it  can  hardly  be  confounded 
with  it,  nor  is  there  much  difficulty  in  distinguishing  the  real  from  the 
hysterical  (or,  as  Sir  J.  Paget  would  call  it,  the  "neuromimetic")  form 
of  hydrophobia.  The  course  of  the  two  diseases  is  quite  ditferent;  the 
implication  of  the  larynx  in  tiie  spasms,  so  constant  in  hydrophobia,  is 
absent  in  tlie  simulated  affection,  and  in  the  latter  the  patient  is  sure  in 
the  course  of  time  to  be  able  to  swallow  naturally. 

The  treatment  is  unfortunately  quite  unsuccessful.  Surgeons  have 
thought  that  if  the  patient's  strength  could  be  keiJt  up  for  a  certain 


'  For  a  full  acconnt  of  this  pnrt  of  the  subject  sco  the;  interesting  lectuie  on  hydro- 
phobia in  Trousx'iiu's  Clin    Med.,  vol.  i,  p.  700. 
«  See  Ogle,  in  Brit,  and  For.  Med.-Chir.  Rev.,  1868. 


HEMORRHAGE.  105 

length  of  time  the  irritation  would  disappear,  and  perhaps  it  might,  but 
the  attempt  has  hitherto  proved  futile.  Forcible  feeding,  as  in  Trous- 
seau's ease  above  referred  to,  has  produced  such  tremendous  s})asms  as 
almost  to  kill  the  patient  at  once.  Probably  the  administration  of  chloro- 
form or  the  attempt  to  perform  tracheotomy  would  do  the  same  ;  yet  it 
is  a  perfectly  fair  experiment  to  tr^-  until  the  experience  of  a  few  cases 
shall  have  demonstrated,  as  I  fear  it  would,  its  inefficiency.  It  is  sug- 
gested by  Trousseau's  translator.  Dr.  Victor  Bazire,  on  the  theory  that 
the  essence  of  the  disease  is  asphyxia,  and  that  if  death  by  asphyxia 
could  be  prevented  the  patient  might  be  saved.  A  great  deal  might  be 
said  against  this  view,  but  I  need  not  detain  the  reader  with  the  discus- 
sion in  this  place.  Some  have  suggested  excision  of  the  nerve  supposed 
to  be  affected,  or  amputation  of  the  limb.  Either  operation  may  be 
justifiable  under  given  circumstances,  but  neither  holds  out  much  rational 
prospect  of  success. 


CHAPTER  IV. 

HEMORRHAGE  AND  COLLAPSE. 

H/EMORRHAGE,  its  causes,  sources,  and  treatment,  forms  a  most  impor- 
tant part  of  practical  surgery,  and  in  the  judgment  of  many  eminent  sur- 
geons it  is  in  the  treatment  of  unexpected  and  profuse  hiemorrhage  that 
the  resources  and  qualities  of  a  great  surgeon  are  displayed  more  than 
in  any  other  emergency.  The  topic  follows  naturall}'  after  the  consider- 
ation of  wounds  and  their  treatment,  since  haemorrhage  is  a  symptom  in 
every  wound,  and  is  the  chief  and  most  important  symptom  in  many. 
Still  a  great  number,  perhaps  the  majority  of  the  cases  of  haemorrhage 
which  surgeons  are  called  on  to  treat,  are  not  traumatic ;  and  the  reader 
will  see  in  the  sequel  that  thei'e  are  few  surgical  diseases  in  which  the  ques- 
tion of  liiemorrhage  does  not  at  some  time  occur.  It  will  hardly  be  pos- 
sible, therefore,  to  exhibit  in  this  place  an  adequate  view  of  all  the  causes 
of  haemorrhage  in  surgical  practice,  nor,  indeed,  would  it  be  desirable 
to  repeat  here  matter  which  must  form  a  great  part  of  the  sequel  of  the 
book. 

Hseraorrhage  may  be  looked  at  from  several  different  points  of  view. 
Of  these,  the  most  important,  and  those  to  which  I  shall  here  confine 
myself,  are  two — viz.:  (1)  as  to  whether  the  haemorrhage  is  spontaneous 
or  traumatic,  and  (2)  as  to  whether  the  bleeding  is  from  one  or  more 
large  vessels  (arteries  or  veins),  or  from  a  great  number  of  small  ones. 

Spontaneous  hsemorrhage  is  best  illustrated  hy  that  curious  affection 
which  is  seen  occasionally  in  this  country,  and  more  frequently,  it  is 
believed,  in  Germany,  called  the  hsemorrhagic  diathesis.  In  this  diathesis 
there  is  a  constitutional  predisposition  to  bleed,  sometimes  with  no  pre- 
vious injur}-,  but  commonly  after  some  slight  wound,  very  frequently 
that  of  the  removal  of  a  tooth,  or  some  other  trifling  laceration ;   and 


106  HAEMORRHAGE, 

the  hoemorrliage  will  proceed,  sometimes,  unchecked  by  ireatinent,  until 
the  patient  is  exhaiisted,  when  it  commonl3^  stops,  though  in  rare  cases 
it  proves  directly  fatal.  It  is  more  common  for  death  to  follow  some 
other  disease,  which  the  patient  would  if  stronger  have  thrown  off. 

The  constitutional  tendency  is  hereditary,  and  usually  in  the  males  of 
the  family.  Females  suffer  also  from  the  disease,  but  more  rarely — an 
exemption  which  has  been  attributed  to  the  natural  outlet  provided  by 
menstruation.  And  it  is  asserted  that  men  who  have  hemorrhoidal  dis- 
charges sometimes  procure  thereby  the  cessation  of  the  luTemorrhagic 
diathesis.  It  seems,  however,  that  though  females  suffer  less  frequently 
than  males,  the  diathesis  is  commonly  received  through  the  mother.  It 
is  not,  however,  always  inherited  nor  always  congenital;  and  it  is  said 
that  the  diathesis  may  be  excited  b}'  privation  of  exercise  and  confinement 
in  a  damp  unhealthy  place. 

In  some  cases  the  haemorrhage  is  periodic :  and  it  is  sometimes  pre- 
ceded by  a  distinct  warning — a  period  of  excitement,  in  which  the  pulse 
beats  excessively  ;  the  patient  is  restless,  and  perceives  an  odor  of  blood 
in  his  nostrils.  Some  da^'s  after  this  the  bleeding  will  begin,  or  if  an 
injury  is  received  the  wound  will  bleed  forthwith.  In  the  intervals  be- 
tween the  attacks  of  haemorrhage  a  peculiar  affection  of  the  joints  may 
be  noticed,  varying  from  severe  pain  to  synovial  effusion,  or  the  general 
inflammatory  thickening  of  all  parts  of  the  joint,  called  "  white  swelling." 
So  long  as  the  joint  disease  is  present  the  tendency  to  bleed  seems  to  be 
suspended.  The  nature  and  situation  of  the  haemorrhage  vary:  subcuta- 
neous haemorrhage  (petechife),  bleeding  from  the  nose  and  mouth,  hema- 
turia, and  melena  are  the  most  common. 

The  treatment  is  generally  successful.  If  the  patient  is  strong  enough 
to  bear  it.  free  watery  purging  (as  b}^  Glauber's  salt,  sodffi  sulph.,  in  ,^ss. 
doses)  seems  very  beneficial,  and  the  exhibition  of  some  salt  of  iron  (the 
carbonate  is  the  favorate  preparation)  in  the  intervals  between  the  haemor- 
rhages is  often  a  great  adjuvant.  When  internal  hemorrhage  occurs  the 
ergot  of  rye  is  highly  recommended,  and  may  be  given  in  5-grain  doses 
every  half  hour.  External  hemorrhage  is  best  controlled  by  well-regulated 
pressure,  aided  by  some  astringent,  of  which  the  perchloride  of  iron  is 
the  best,  or  in  some  cases  by  the  actual  cautery.  In  some  instances  it 
has  been  noticed  that  the  bleeding  has  ceased  on  converting  a  lacerated 
wound  into  a  clean  incised  cut,  and  venesection  has  ever  been  practiced 
with  advantage;  but  it  seems  unnecessarily  dangerous  to  make  fresh 
wounds  in  a  case  where  any  cut  may  bleed  lfncontrollabl3^ 

The  (jeneral  symptoms  of  hsemovvhage  are  as  follows:  When  profuse 
and  rapid  (as,  for  instance,  when  a  large  artery  is  laid  open)  the  patient 
rapidly  faints;  or,  if  the  hemorrhage  is  less  excessive,  the  pulse  and 
temperature  fall,  and  he  feels  weak  and  faint;  languor,  yawning,  noises 
in  the  head,  throbbing  of  the  temples,  and  flashes  of  light  in  the  eyes 
l)recede  the  access  of  syncope.  When  syncope  occurs,  the  bleeding  as  a 
rule  stops;  but  if  this  is  not  the  case,  in  consequence  either  of  the  size 
of  the  vessel  or  from  some  mechanical  impediment  to  its  closure,'  the 
patient  must  die  unless  the  bleeding  is  arrested  by  surgical  treatment, 
(jlenerally,  however,  it  does  stop,  but  sometimes  recurs  with  the  same 


'  The  main  mechanical  obstacles  to  the  closure  of  the  vessels  are  their  dilatation 
by  hfnt,  as  in  the  case  of  vessels  wounded  in  the  interior  of  the  bod}',  their  being 
kept  open  V)y  the  walls  of  a  bony  or  fibrous  canal  in  which  they  lie,  ilieir  partial  di- 
vi.-ion,  and  the  presence  of  foreign  bodies  in  their  interior. 


INJURIES    OF    ARTERIES.  107 

train  of  s^-mptoms,  onl.y  more  rnpidly  ending  in  syncope.  On  recovery 
from  syncope  vomiting  often  takes  place,  the  pulse  rises  rapidly  in  rate,  but 
not  in  volume,  being  wealc,  small,  and  easily  affected  by  any  external  agency. 

The  recurrence  of  hiiemorrhage  after  syncope  is  prevented  by  the  blood 
forming  a  clot  in  the  bleeding  vessel  and  in  the  tissues  around  it,  which 
the  returning  circulation  is  too  weak  to  displace ;  and  this  process  is  greatly 
favored  by  the  contraction  and  retraction  of  the  arteries  when  completely 
divided,  as  will  be  explained  further  on. 

Repeated  or  hahilual  hftmrji-rhnfie  produces  a  general  pallor,  or  rather 
a  waxy  appearance,  of  the  whole  body,  fainting  on  slight  exertion,  rest- 
lessness, emaciation,  sometimes  partial  or  complete  amaurosis,  and  fre- 
quently constant  and  extreme  drowsiness.  As  it  goes  on  the  patient 
becomes  more  and  more  weak  and  exhausted,  sometimes  entirely  uncon- 
scious, pulseless,  and  livid.  Death  takes  place  usually  in  a  very  sudden 
manner,  or  is  caused  by  some  slight  exertion. 

It  is  hardly  possible  to  estimate  correctly  the  quantity  of  blood-loss 
which  is  necessary  to  occasion  death.  It  varies  much  with  age;  infants 
succumbing  rapidly — much  with  the  patient's  state  of  mind :  a  ha?morrhage 
which  vvould  not  prove  fatal  if  the  j^atient  were  unconscious  may  easil}' 
cause  death  when  his  mind  is  agitated  and  his  heart  under  the  influence 
of  terror — much  with  the  temperature  in  which  he  is  placed  :  bleeding 
which  would  not  prove  fatal  if  the  patient  were  in  a  warm  I'lace  may  prove 
fatal  when  the  heart  is  embarrassed  by  the  resistance  offered  by  tissues 
congealed  by  cold — with  the  organ  affected,  and  with  the  condition  of 
health  or  disease  in  which  he  may  ha|ipen  to  find  himself. 

It  has  often  been  noticed  that  after  repeated  bleedings  (either  acci- 
dental or  therapeutic)  the  blood  becomes  watery,  more  prone  to  escape 
from  the  vessels,  even  without  injury,  and  less  apt  to  coagulate. 

Injuries  of  Arteries. — The  bleeding  which  occurs  in  most  wounds  pro- 
ceeds chiefly  from  the  capillaries  and  from  small  vessels  which  cease  to 
bleed  spontaneously.  But  bleeding  from  the  larger  arteries  must  be  at 
once  stopped,  or  else  it  will  prove  fatal,  or  at  any  rate  cause  a  most  in- 
jurious loss  of  blood. 

The  injuries  of  arteries  may  be  thus  classified :  1.  Contusion.  2.  Partial 
laceration.  3.  Complete  laceration.  4.  Partial  division.  5.  Complete 
division. 

1.  About  contusion  of  arteries  little  is  really  known.  It  seems  unde- 
niable that  contraction  and  even  total  closure  of  the  artery  may  follow 
on  mere  contusion,  and  that  this  ma}'  be  a  cause  of  gangrene.  So  Guthrie 
relates  a  case  in  which  a  bullet  passed  between  the  popliteal  arter^^  and 
vein  without  opening  either.  Gangrene  ensued,  and  the  man  died.  "  The 
coats  of  the  arter^'^  were  not  destroyed  in  substance  though  bruised  ;  it 
was  at  this  spot  much  contracted  in  size,  and  tilled  above  and  below  with 
coagula."^  But  such  injuries  can  hardly  occur  uncomplicated,  nor  can  the 
exact  condition  of  the  artery  be  diagnosed.  They  must  be  treated  b}' 
the  ordinary  rules  for  traumatic  gangrene. 

2.  Partial  laceration  of  the  artery  consists  in  the  tearing  of  the  in- 
ternal and  middle  coats  while  the  external  coat  remains  entire.  I  once 
had  an  opportunity  of  seeing  the  symptoms  of  this  injury  so  clearly 
marked  that  it  was  easy  to  diagnose  both  the  nature  and  the  precise  seat 
of  the  lesion.     A  man  was  brought  into  St.  George's  Hospital  with  a  very 

*  Guthrie,  On  Wounds  and  Injuries  of  the  Arteries,  p.  22,  case  24.  See  also  simi- 
lar cases  in  Moore's  essay  in  Syst.  of  Surg.,  2d  ed.,  vol.  i,  p.  734. 


108 


HJEMORRHAGE. 


Fig.  13. 


severe  injury  to  tbe  head,  caused  by  a  fall  from  his  horse,  of  which  he 
died  in  3^  hours.  On  examinino-  one  wrist  there  was  no  pulse;  on  the 
other  side  it  was  perfectly  natural.  The  brachial 
vessels  could  be  plainly  felt  in  their  usual  situa- 
tion, but  there  was  no  pulse  there.  In  the  axilla 
the  pulsation  could  be  felt  down  to  a  certain 
point,  and  there  it  stopped  at  once.  There  was 
no  bruise,  nor  any  other  injury  in  the  armpit. 
It  was  eas3'  to  see  that  the  axillary  artery  had 
been  partly  torn  at  this  spot,  and  that  the  torn 
coats  had  been  pushed  into  the  tube  of  the  vessel 
by  the  blood  so  as  to  close  the  tube ;  and  the 
condition  of  the  artery  was  exactly  verified  by 
post-mortem  examination,  as  is  rei:)resented  in  the 
adjoining  figure. 

The  injury  here  is  precisely  the  same  as  that 
which  is  inflicted  bj^  the  surgeon  in  the  opera- 
tion of  tying  the  artery,  but  without  the  abid- 
ing irritation  of  the  ligature.  The  artery,  there- 
fore, will  not  probably  give  way  above  the  seat 
of  the  injury.  It  may  expand  into  an  aneurism 
of  the  kind  sometimes  caWed  false — i.  e.,  the  sac 
formed  only  by  the  external  coat  (see  the  section 
on  Aneurism) — but  more  probably  this  part  will 
become  lined  and  filled  with  coagulum,  and  be- 
3'ond  the  obliteration  of  the  artery  nothing  further 
will  ensue.  Gangrene  is  less  likely  to  follow  than 
after  the  ligature  of  the  artery. 

3.   Complete  subcutaneous  laceration  of  an  ar-. 
The  axillary  artery,  showing  tcry  Is  more  commouly  sccu  in  the  popliteal  than 

laceration  of  its  two  internal  j^„y  ^^1^^^.  ^.ggg^j^  j,^  j^^^gt^  ^^  ^j^g  j.gg^,n  ^^  ^.^^^ 
costs   wliicn  hnvG  l)GGn  ciissGCtcd  "^ 

by  the  force  of  the  blood  stream  violcncc,  and  is  therefore  usually  accompanied 
from  the  external  coat  for  about  b}'  Other  Icsions,  such  as  laceratiou  of  the  pos- 
haif  an  inch,  and  turned  down   terior  ligament  of  the  joint  or  rupture  of  the 

into  the  cavity  of  the  vessel,  so  •  ^  n      i     ii  mi  •         i    <-• 

as  to  block  it  up.  a  shows  ihe  ^^^lu,  and  usually  both.     The  circulation  ceases, 

coagulum  lodged  above  the  re-  the  pulsc  disappears  Irom  the  lower  arteries,  the 

versed  portion  of  the  inner  coats;  temperature  of  the  limb  rapidly  falls,  enormous 

6,  the  sheath  of  the  vessel,  which  extravasation  of  blood  below  the  fascia  distends 

■was  perfectlv  natural. — From  St.    ^,       ,.      ,        .  ,        .  ,        ,  , 

George's  Hospital  Museum,  Ser.  the  limb ;  in  somc  cascs  a  bruit  cau  be  heard, 
vi,  No.  95.  I  have  never  seen  an^^  case  where  pulsation  was 

present  in  the  extra vasated  blood.  Gangrene 
rapidly  ensues  if  the  limb  is  not  amputated.  Such  cases  are  easy  of 
diagnosis  from  the  rapid  fall  of  temperature,  the  great  swelling,  and  the 
loss  of  pulsation  in  the  arteries  below  the  seat  of  injury. 

But  I  have  seen  cases  where  some  amount  of  circulation  went  on,  and 
where  pulsation  was  at  first  perceptible,  though  feeble,  in  the  tibial  ar- 
teries, yet  where  gangrene  set  in,  though  not  so  rapidly;'  and  after  am- 
putation the  arteiy  was  found  completely  separated  into  two  parts. 
Either  the  blood  at  first  found  its  way  from  one  end  of  the  arteiy  into  the 
other,  the  rupture  being  complete,  or,  as  is  more  probable,  the  laceration 


'  A  case  is  relatfid  by  Mr.  Pick,  in  Path.  Trans.,  vol.  .xvii,  p.  74,  in  which  the 
laceration  wa.s  at  fir.^t  incomplcto,  and  liifi  j)atii'iit  was  al)l«  to  walk  several  miles  after 
the  accident.  Gangrene  came  on  very  gradiuilly,  and  amputation  was  not  performed 
till  thirty-five  days  after  the  injury.  Tiie  two  parts  of  the  popliteal  artery  were  still 
united  by  a  fragment  of  the  anterior  wall  of  the  ves.sel. 


WOUNDS    OF    ARTERIES. 


109 


Fio.  14. 


was  at  first  incomplete,  but  the  nntoni  part  of  the  vessel  afterwards  gave 
way. 

If  the  diagnosis  can  be  made  with  certainty  primary  amputation  is  the 
safest  course  in  the  lower  limb.  In  the  arm  the  surgeon  would  tie  the 
vessel  if  the  swelling  were  increasing,  or  if  not  would  trust  to  pressure  on 
the  artery  above,  vvith  careful  bandaging  of  the  whole  limb,  and  a  com- 
press at  the  seat  of  injury.  But  in  the  upper  extremity,  as  in  the  lower, 
when  gangrene  has  commenced  amputation  should  be  no  longer  delayed. 

The  total  laceration  of  an  artery  in  a  wound,  as  when  a  limb  is  torn  off 
by  machinery,  does  not  usually  give  rise  to  haemorrhage ;  the  artery  is 
twisted  by  the  force  exactly  in  the  same 
way  as  it  is  by  the  surgeon  in  an  ampu- 
tation, and  it  can  be  seen  pulsating  down 
to  the  lacerated  part.  The  process  by 
which  it  is  closed  will  be  described  under 
the  head  of  Torsion,  further  on. 

4.  The  incomplete  is  often  a  more  seri- 
ous injury  than  the  complete  division  of 
an  artery,  since  the  wounded  artery  is  pre- 
vented from  retracting.  Thus,  when  arte- 
riotomy  was  a  recognized  operation,  the 
anterior  temporal  artery  was  punctured, 
and  would  continue  to  bleed  as  long  as 
the  puncture  in  the  vessel  corresponded 
to  that  in  the  skin.  When  the  surgeon 
wished  to  stanch  the  hremorrhage  he  cut 
the  vessel  across. 

The  direction  of  the  wound" is  of  some 
importance  in  reference  to  the  proba- 
bility of  future  mischief.  Tlius,  if  a 
longitudinal  wound  be  inflicted  on  an 
artery  in  a  living  animal,  and  the  wound 
be  afterwards  examined,  it  will  be  found 
to  be  a  mere  slit,  while  a  transverse  wound 
gapes  open  and  becomes  oval,  or  rather 
lozenge-shaped,  in  consequence  of  the 
state  of  longitudinal  tension  in  which  the 
vessel  normally  is  placed,  rather  than  from 
any  retraction  of  the  muscular  fibres. 
Mr.  Savory  shows  that  a  similar  shape  is 
assumed  by  transverse  wounds  made  after 
death,  and  that  on  dissecting  the  artery 
away  and  removing  it  from  the  body  the 
wound  closes  again.' 

An  artery  partially  divided  will  go  on 
bleeding  until  some  efficient  external  ob- 
stacle   is    opposed    to    the    exit    of  blood,    a*  ''»'■  »«  ^^e  nearest  branch  on  eitherside, 
and  this  is  often  eflfected  by  the  displace-    tapering  as  it  extends  up  the  vessel,  and 
„    ,  .  ,  n    •  clot  IS   also  poured   out  external  to  the 

ment  Ot  the  various  layers  of  tissue  over-    sheath.    The  cut  in  the  sheath  (?<  6)  is  here 
lying  the  vessel  (so  that  the  wound  in  the     represented  as  a  linear  fissure.    In  practice 

artery  no  longer  corresponds  to  that  in  the   ^^^  ^'^''*'''  ^""^"^  sape  more  widely  as  it  is 

skin),  and  by  the  accumulation  of  blood-  **"  *  ''^  "'''^'' 

clot  in  the  interspaces.     When  the  bleeding  stops,  the  wound  may  close 


Diagrammatic  representation  of  complete 
division  of  an  artery.  The  ends  of  tlie 
vessel  (a  a)  are  seen  to  be  retnicied,  i.  e., 
drawn  up  into  the  sheath  ;  and  contracted, 
i.  e.,  compressed  into  a  conical  shape  by  the 
contraction  of  the  circular  muscular  fibres. 
The  part  of  the  sheath  thus  left  vacant, 
and  the  ends  of  the  vessel,  are  represented 
as  tilled  with  clot.    The  clot  often  extends 


Savory,  On  the  Shape  of  Transverse  Wounds  of  the  Blood  ves.<els. 


110  HiEMORRHAGE. 

like  any  other  wound,  or  it  may  give  way  to  tlie  distending  force  of  the 
circulation  till  a  traumatic  aneurism  has  formed,  as  will  be  shown  in 
speaking  of  Aneurism. 

There  is  another  form  of  incomplete  division,  very  rarely  met  with,  in 
wiiich  the  weapon  has  divided  the  external  coats  of  the  vessel,  but  with- 
out penetiating  its  tube.  As  it  seems  certain,  however,  that  the  internal 
(or  internal  and  part  of  the  middle)  coat  which  has  been  left  uncut  will 
yield  to  the  force  of  the  circulation  afterwards,  this  inj\uy  is  to  be  re-' 
garded  and  treated  exactly  as  a  wound  penetrating  the  vessel.^ 

5.  Complete  Division. — When  an  artery  is  completely  divided  it  re- 
tracts  and  contractu.  It  retracts,  since  it  is  always  on  the  stretch,  and 
therefore  when  divided  its  ends  separate,  exactly  as  those  of  any  other 
elastic  tube  would  do,  and  it  contracts  from  the  irritation  of  the  injury 
acting  on  its  circular  muscular  fibres  and  causing  them  so  to  narrow  the 
calibre  of  the  vessel  that  it  tapers  out  into  a  conical  end  within  the  sheath.' 
This  contraction  of  the  muscular  fibres  offei's  an  obstacle  to  the  circulation 
of  blood  through  the  vessel,  and  therefore  to  the  occurrence  of  luvmorrhage, 
which  is  in  proportion  to  the  strength  of  the  muscular  coat,  and  is  there- 
fore much  more  elHcient  in  the  smaller  arteries,  where  the  muscular  coat  is 
very  much  stronger,  relatively-  to  their  size  (and  therefore  to  the  pressure 
of  the  blood-stream  on  them ),  than  it  is  in  the  great  arteries,  where  it  is 
entirely  unable  to  resist  the  pressure  of  the  circulation.  Hence  the  total 
division  of  a  large  artery  b}'  a  clean  cut  proves  fatal  at  once  unless  the 
vessel  is  promptly  secured,  whilst  arteries  of  smaller  calibre  will  cease  to 
bleed  with  or  without  the  assistance  of  syncope.  John  Hunter  says  that 
he  believes  if  a  leg  were  amputated  with  no  precaution  for  stopping  haem- 
orrhages that  the  patient  would  not  usually  bleed  to  death,  i.  e.,  that  ar- 
teries the  size  of  the  tibials  would  generally  close  spontaneously.' 

Injiirie.^  of  Veins. — All  injuries  of  veins  are  less  formidable  in  their 
immediate  consequences  than  similar  injuries  of  arteries  of  the  same  cali- 
bre, in  consequence  of  the  diminished  force  of  the  circulation,  and  of  the 
weakness  of  the  walls  of  the  veins,  whereby  the  pressure  of  the  neigh- 
boring parts  and  of  the  extravasated  blood  is  enabled  to  act  on  them 
much  more  powerfully.  It  is,  therefore,  much  easier  to  stop  venous  hsem- 
orrhage  than  arterial,  and  it  is  hardly  ever  necessary  to  tie  any  except 
the  largest  veins  and  those  which  are  kept  open  by-.the  walls  of  the 
canals  in  which  they  lie.  But  contusion,  laceration,  or  any  other  injury 
to  a  vein  may  have  very  serious  and  even  fatal  after-consequences,  quite 


•  For  an  illustrative  case  see  Guthrie,  On  the  Diseases  and  Injuries  of  Arteries,  pp. 
328-9.  A  griulenian  had  cut  his  throat,  inflictiuira  punctured  wound  on  thi-  internal 
jugular  vein  and  a  scratch  on  the  carotid  arlcrv.  Guthrie  took  up  the  punctured 
portion  of  the  vein  with  a  tenaculum,  and  included  it  in  a  ligature.  The  wound  in 
the  vein  Inhaled,  and  the  ligature  canx;  iiway,  leaving  the  vein  pervious  and  without 
a  trace  of  injury.  The  artery  was  not  interfered  with,  and  it  gave  way  on  the  eighth 
day,  causing  so  much  hteniorrhage  that,  altleiugh  hdtli  end- of  the  vessel  were  secured 
as  soon  as  pos.-ihle,  the  patient  died  dl'  exliiiustion  afterwards. 

2  In  Hunter's  works,  vol.  iii,  pp.  157  et  seq.,  will  be  fuuiid  some  very  interesting  ex- 
periments <m  the  contraction  of  the  muscular  lihres  of  arteries  in  the  lower  animals 
under  the  stimulus  of  exposure  and  loss  of  blood,  and  on  the  length  of  time  during 
which  they  retain  their  vital  property. 

3  "  An  artery  of  moderate  dimensions,"  says  Guthrie  (Dis.  and  Inj.  of  Arteries,  p. 
222),  "such  as  the  tibial  or  braehiiil,  and  purtieubirly  all  ladow  these  in  si/,e,  are  in 
general  I'apable,  by  their  own  intrinsic  powers,  of  aire>ting  the  passage  ofllu!  blood 
through  tlieiu,  without  any  assistance  from  art,  or  iVom  the  surrounding  jj.n-ts  in 
which  they  are  situated." 


DIAGNOSIS    OF    ITS    SOURCE.  Ill 

apart  from  any  danger  of  bleeding.  Thus  Mr.  Syme'  has  shown  that 
many  of  the  deaths  after  ligature  of  the  arteries  may  with  great  proba- 
bility be  attriliuted  to  injury  inHic-ted  on  the  accompanying  vein  ;  and 
since  surgeons  have  been  more  alive  to  this  consideration  the  mortality 
after  ligature  of  arteries  has,  I  believe,  decreased  considerably.  Further 
observations  on  this  topic  will  be  found  in  the  chai)ter  on  Diseases  of  the 
Veins. 

Entrance  of  Air. — Another  very  formidable  consequence  which  some- 
times follows  wound  of  a  vein  is  the  entrance  of  the  air  into  it.  When 
the  air  rushes  into  the  vein  in  such  large  quantities  as  to  fill  the  right 
auricle  of  the  heart  with  air  it  usually  produces  instant  death,  for  the  air 
passes  through  the  auriculo-ventricular  valve  and  opens  it;  then,  on  the 
contraction  of  the  ventricle,  the  air,  being  a  much  lighter  fluid  than  blood, 
cannot  shut  the  valve-flaps,"  and  so  the  heart's  action  comes  to  a  stop. 
When  a  smaller  quantity  passes  in  the  patient  faints,  but  recovery  often 
ensues.  The  entrance  of  the  air  (which,  in  practice,  always  occurs  in 
surgical  operations)  is  denoted  by  a  whistling  sound,  after  which  syncope 
at  once  occurs.  As  far  as  I  know  this  has  only  hitherto  occurred  in  oper- 
ations.on  the  neck  or  axilla,  though  it  seems  possible  in  other  regions, 
also  ;■' and  it  appears  to  have  become  much  rarer,  if  not  altogether  un- 
known, since  the  operations  have  been  more  generally  perfoi-med  under 
the  influence  of  full  anaesthesia,  the  accident  being  no  doubt  often  caused 
by  the  patient's  struggles.  The  vein  having  been  imperfectly  divided, 
and  being  prevented  from  entirely  collapsing  by  its  adhering  in  part  to 
the  surrounding  tissues,  some  sudden  movement  draws  the  incision  open 
while  the  motion  of  the  chest  in  inspiration  is  producing  a  tendency  to 
vacuum  in  the  venous  system. 

The  remedies  are  those  for  profound  syncope,  viz.,  the  recumbent  posi- 
tion, forcing  the  blood  towards  the  heart  by  chafing  the  limbs,  exciting 
the  heart  to  action  by  galvanism,  administering  ammonia  by  the  nostrils 
and  brandy  b}'  the  rectum,  and  possibly,  if  there  be  time  for  it,  injecting 
warm  water  into  the  veins  in  quantities  of  about  2  ozs.  at  a  time.  Mr. 
Moore,  who  proposes  this  [)lan  (which  has  not  hitherto  been  tried),  dii-ects 
that  the  head  be  raised  and  a  vein  in  the  neck  be  opened,  in  order  that, 
if  it  be  filled  with  air,  the  air  may  escape.  The  water  is  then  to  be 
injected  vvith  such  force  as  would,  in  the  operator's  judgment,  moderately 
distend  the  auricle.  All  the  cases  which  have  recovered  have  done  so 
under  the  ordinary  remedies  for  profound  syncope  long-continued,  and 
sometimes  after  a  long  period  of  almost  seeming  death. 

The  occasional  occurrence  of  this  terrible  accident  will  of  course  teach 
the  surgeon  caution  in  dissecting  operations  about  the  neck  and  axilla. 

Dmyno^is  of  the  Source. — W^hen  a  surgeon  is  called  to  a  case  of  haemor- 
rhage his  first  care  is  to  stop  it  for  the  moment,  which  is  always  readily 
done,  if  there  is  an  open  wound  and  the  Meeding  comes  from  a  definite 
point,  by  moderate  press.ure  witli  the  finger  on  the  bleeding  spot.     The 


'   Princii)les  of  Surijery,  p.  97. 

'•*  This  is  sometimes  done  experimontiiby  in  ivilling  liorscs.  A  pipe  is  inserted  into 
the  jugular  vein,  and  then,  if  sibout  thriee  as  niuoh  air  is  blown  into  the  vein  as  a 
healthy  man  can  emit  at  one  full  expiration,  the  horse  will  fall  dead.  See  Moore's 
essay  in  Wyst.  of  Surg  ,  vol.  i,  p.  757,  2d  ed.,  to  which  I  must  also  refer  the  reader 
for  a  full  discussion  of  the  various  theories  about  the  manner  of  death  in  these  cases. 
I  have  only  stated  in  the  text  the  one  which  seems  to  me  the  most  satisfactory. 

3  Dr.  Cordwent  has  related  a  case  of  parturition  in  which  he  believes  that  death 
occurred  from  entrance  of  air  into  the  uterine  veins  (St.  George's  Hospital  llcports, 
vol.  vi). 


112  HJEMORRHAGE. 

bleeding  even  from  a  very  large  arter}'-,  if  cleanl}'  exposed  (i.e.,  the 
femoral  in  an  amputation  at  tlie  hip),  requires  remarkably  little  i)rcssure 
to  check  it  for  the  time.  And  if  the  bleeding  point  is  not  plainly  visi- 
ble, well-directed  pressure  on  a  pad  of  some  soft  substance  filling  the 
whole  wound  will  suspend  the  hiiemorrhage  until  time  has  been  obtained 
for  the  definite  treatment. 

Next,  the  question  occurs — Is  the  haemorrhage  arterial,  venous,  or 
capillar}^  ? 

Let  us  suppose  a  large  arter}-  wounded,  and  the  wound  in  the  artery 
corresponding  directly  to  the  skin-wound.  The  blood  leaps  out,  of  a 
bright-red  color,  in  jets  synchronous  with  the  heart's  beats,  and  often  to 
a  distance  of  some  feet  from  the  patient's  body.  In  the  wound  of  a  large 
vein,  on  the  other  hand  (phlebotomy  is  a  faniiliar  instance),  the  blood 
pours  out  in  a  dark  purple  (Modena-red)  stream  which  is  continuous, 
and,  if  jetting  at  all,  the  jets  are  not  interrupted  but  onl^'  augmentations 
of  the  force  and  extent  of  the  stream,  sj'nchronous  not  with  the  heart's 
action,  but  with  expiration  or  with  muscular  efforts. 

So  far  there  is  no  difficulty  in  the  diagnosis.  And  in  the  case  of 
smaller  arteries  there  is  also  no  difficulty  so  long  as  the  How  of  blood  is 
unobstructed  by  tlie  superjaceut  tissues.  But  in  small  wounds,  even  of 
considerable  arteries,  lying  deeply  and  having  a  circuitous  communica- 
tion with  the  exterior,  the  bleeding  may  be  so  gentle  that  there  is  little 
to  distinguish  it  from  venous  oozing  in  its  manner  of  coming  out  or  in 
its  color,  for  venous  blood  quickly  turns  red  on  exposure  to  the  air.  In 
this  case  the  persistence  of  the  hoemorrhage  is  a  valuable  sign  that  it  is 
an  arter}'  which  is  wounded  ;  and  the  effect  of  pressure  above  is  another. 
l*ressure  applied  to  the  nearest  accessible  trunk  between  the  wound  and 
the  heart  will  suspend  arterial  hsemorrhage  ;  while,  if  it  affects  the  venous 
bleeding  at  all,  it  will  augment  it.  If  a  bruit  can  be  heard  it  will  of 
course  be  decisive. 

From  Trunk  Artery  or  Branch? — HaAing  settled  that  the  bleeding  is 
arterial,  the  next  question  is  whether  it  comes  from  a  trunk  artery  or 
a  branch.  The  bleeding  caused  by  a  wound  of  a  branch  close  to  its 
trunk  (as  of  the  supeificial  pudic  near  the  common  femoral,  the  circum- 
flexa  ilii  near  the  external  iliac,  or  the  sural  near  the  popliteal)  has  been 
constantly  mistaken  for  a  wouud  of  the  trunk  itself.  The  main  diagnostic 
sign  is  that  the  pulse  in  the  lower  i)art  of  the  aitery  is  very  much  more 
affected  when  the  artery  itself  is  wouuded  than  when  one  of  its  branches 
is  cut  across,  and  the  persistence  of  the  luemorrhage  is  a  valuable  sign  of 
lesion  of  a  main  trunk. 

Treatment. — When  the  haemorrhage -has  been  diagnosed  to  be  from  a 
trunk  artery  no  lime  should  be  lost  in  securing  it.  If  the  position  of  the 
wound  permits  it  a  tourniquet,  or  finger  pressure,  should  be  placed  on  the 
artery  at  some  distance  above  the  wouud;'  then  the  wound  should  be 
enlarged  sufficiently  to  permit  an  easy  dissection  of  the  wounded  vessel, 
and  the  artery  should  be  tied  al)0ve  and  below  the  hole  in  it.  If  the 
wound  ill  the  artery  is  not  at  once  visil)le,  the  relaxation  of  the  tourni- 
(piet  will  show  the  surgeon  where  the  bleeding  comes  from,  and  will  lead 
him  to  it.  A  ligature  altove  the  wound  only  will  sometimes  stop  the 
bleeding,  especially  in  arteries  of  the  lower  limb;  but  even  here  it  is  far 
more  safe  to  tie  both  ends.  If  this  is  not  done,  the  lower  end  will  prob- 
ably begin  to  bleed  as  soon  as  the  circulation  is  re-established;  and  it  is 


'  I  should  myself  prefer  the  use  of  Esmnrch's  bandage,  but  have  not  hitherto  had 
occasion  to  try  it  in  a  case  of  this  kind. 


LIGATURE    OF    ARTERIES.  113 

an  old  observation,  on  which  Mr.  Guthrie  used  to  lay  very  much  stress, 
that  the  bleeding  from  the  lower  end  is  of  a  venous  character,  both  in 
color  and  flow.^  This  is  cei'tainlj-  true  of  the  arteries  of  the  lower  limb, 
but  in  the  neck,  and  frequently  in  the  upper  extremity,  both  ends  will 
bleed  per  solium.  Having  secured  the  artery,  the  surgeon  must  ex- 
amine the  vein  ;  or  if  there  is  a  wound  of  a  large  vein,  the  bleeding  from 
which  is  increased  by  the  application  of  tl)e  tourniquet  above,  it  may  be 
held  in  check  during  the  operation  by  another  tourniquet  below.  When 
the  wounded  vein  has  been  exposed  the  surgeon  must  choose  for  himself, 
according  to  tlie  size  of  the  wound  and  of  the  vein,  whether  he  will  trust 
to  pressure,  or  tie  the  vein  as  well  as  the  artery.  The  superficial  femoral 
and  its  vein  have  often  been  tied  together  (by  John  Hunter,  Roux,  etc.), 
the  popliteal  artery  and  its  vein  for  a  wound  (by  Mr.  Holthouse),  and  the 
common  carotid  and  internal  jugular  in  removing  a  tumor  (by  Laugen- 
beck),  without  bad  consequences." 

If  no  tourniquet  can  be  applied  above  the  wound  the  operation  becomes 
far  more  difficult  and  dangerous.  The  leading  case  here  is  one  in  which 
Mr.  Syme  tied  the  carotid  artery  when  wounded  at  the  root  of  the  neck." 
Tiie  left  forefinger  must  be  inserted  into  the  wound,  which  is  to  be  cau- 
tiousl}'  enlarged  for  that  purpose  sufliiciently  to  admit  tlie  finger,  so  as  to 
control  all  bleeding.  Then,  with  the  help  of  his  assistant,  the  surgeon 
must  bring  the  artery  into  view  above  his  finger  (i.e.,  between  his  finger 
and  the  heart),  and  when  he  has  scratched  it  bare,  and  tied  the  ligature 
round  it,  he  may  remove  his  finger,  clear  all  the  clots  away,  and  secure 
the  distal  part  of  the  vessel. 

If  the  wound  in  the  skin  has  been  commanded  by  pressure  and  there 
is  no  bleeding,  the  surgeon  may  think  it  better  to  wait,  in  order,  should 
a  traumatic  aneurism  form,  to  treat  it  afterwards.  But  if  the  extrava- 
sation of  blood  be  plainly  increasing,  the  case  should  be  treated  just  like 
a  recent  wound. 

When  the  bleeding  has  been  arrested  by  pressure,  it  is,  as  a  rule,  un- 
advisable  to  disturb  the  dressings  at  all. 

Ligature  of  Artery  above  the  Wound. — There  are  cases  in  which  it  is 
justifiable  to  tie  the  artery  at  some  distance  above  the  wound,  as  in  aneu- 
rism. Thus,  if  the  wounded  vessel  be  inaccessible,  as  when  the  internal 
carotid  has  been  wounded  through  the  mouth,  tlie  common  trunk  has 
been  tied  with  success  ;*  or  when  the  patient  has  already  lost  a  great  deal 
of  blood,  and  the  surgeon  thinks  that  a  prolonged  operation  and  deep 
incisions  would  prove  fatal,  the  artery  has  been  successfully  tied  above, 
where  it  was  more  superficial.^     But  this  must  be  allowed  to  be  only  apis 

^  Guthrie,  Wounds  and  Injuries  of  Arteries,  p    248. 

^  8ee  the  account  of  Mr.  Annandale  (Lancet,  April  24th,  1875),  of  a  case  in  which 
he  tied  the  popliteal  artery  and  vein  in  a  case  of  arterio-venous  aneurism. 

'  Syme's  UI)servations  in  Clinical  Surgery,  p.  154. 

■•  See  Mr.  H.  C.  Johnson's  case,  in  Lancet,  1850,  vol.  ii,  p.  118.  This  case  is  evi- 
dently alluded  to  in  Mr.  Guthrie's  Commentaries,  6th  ed.,  p.  256,  where  he  proposes 
to  secure  the  internal  carotid  artery  when  wounded  from  the  mouth  by  an  operation 
in  which  the  ramus  of  the  jaw  is  to  be  divided  aU)ng  with  the  internal  pterygoid 
muscle,  and  turned  up,  the  styloid  process  audits  muscles  with  theglosso-pharyngeal 
nerve  dissected,  some  of  the  styloid  muscles  divided,  etc.  But  although  a  competent 
anatomist  can  execute  this  dissection  on  the  dead  subject,  its  practicability  in  the  case 
of  a  wounded  artery  is  a  very  different  matter,  and  the  relative  safety  of  the  other 
course  seems  to  be  conceded.  If  after  ligature  of  the  common  trunk  the  internal 
carotid  still  bleeds,  it  might  become  tlje  surgeon's  duty  to  attempt  to  secure  the  bleed- 
ing artery  in  the  manner  Mr.  Guthrie  describes. 

*  See  Mr.  Bujtccl's  case,  L-ancet,  1859,  vol.  ii,  p.  236,  where  a  man  was  found  nearly 
dead  from  hsemorrhage  after  a  wound  of  the  femoral  deep  in  the   thigh,  probably  in 

8 


114  HEMORRHAGE. 

aUer,  and  if  it  fails  to  check  the  bleeding  the  patient  will  be  in  very  se- 
rious danger.  The  only  case  in  which  the  practice  is  recognized  is  that 
of  a  wound  of  the  palmar  arch. 

In  some  cases  also  in  which  the  wound  and  the  limb  generally  are  much 
inflamed  it  may  be  more  prudent  to  tie  the  artery  higher  up ;  as  recom- 
mended by  Dr.  Campbell,  of  New  Orleans  (in  a  paper  referred  to  on 
page  119) ;  and  the  success  of  this  practice  in  such  inflamed  wounds  has 
led  to  the  proposal  of  ligature  of  the  main  arter^''  of  the  limb  as  a  method 
of  treating  complicated  wounds  and  diffuse  inflammation  of  the  limb 
generally. 

There  are  rare  cases  in  which  the  surgeon  departs  from  the  usual  rule, 
of  not  tying  an  artery  unless  it  is  bleeding.  These  are  mainl}'  cases  in 
which  he  judges,  by  the  severit}'-  of  the  previous  bleeding,  that  a  large 
vessel  has  been  wounded,  and  that  the  haemorrhage  will  probably  recur, 
and  when  the  patient  must  be  left  at  a  distance  from  competent  aid. 
Otherwise  it  is  better  to  put  careful  pressure  over  the  wounded  part,  and 
leave  a  tourniquet  loosely  applied  over  the  trunk  above,  with  instructions 
to  the  nurse  to  screw  it  down  if  the  bleeding  recurs,  and  send  at  once  for 
the  surgeon. 

The  ligature  of  arteriea  was  a  method  of  suppressing  haemorrhage  so 
infinitel}^  superior  in  every  wa}^  to  the  cauterj^,  which  was  previously  in 
vogue,  in  freedom  from  pain,  in  ease  of  application,  in  efficacy,  in  safety, 
and  in  immunity  from  future  ill  consequences,  that  it  is  hardly  to  be 
wondered  at  that  Ambroise  Pare,  its  inventor,  declared  that  he  consid- 
ered it  almost  a  divine  inspiration.  Mau}^  attempts  have  been  made  to 
improve  upon  the  original  invention,  so  as  to  avoid  the  division  of  the 
vessel  which  is  involved  in  the  separation  of  the  ligature.  I  shall  pass 
over  most  of  these  in  silence,  but  shall  describe  in  detail  the  most  recent, 
which  we  owe  to  Mr.  Lister's  genius,  and  which  gives  fair  promise  of  com- 
plete success.  First,  however,  I  must  describe  the  method  which  is  still 
in  common  use.  If  a  vessel  is  to  be  exposed  in  its  continuity,  the  skin 
and  all  other  tissues  which  cover  its  sheath  must  be  divided  according 
to  rules  based  on  the  known  anatomical  relations  of  each  arterv,  and 
which  will  be  found  in  the  sequel.  The  sheath  is  recognized  b}'  the  pul- 
sation of  the  vessel  beneath  it,  and  b}'  the  absence  of  the  white  color  of 
the  wall  of  the  arter3\  It  is  i)inched  up  with  a  pair  of  fine  forceps,  and 
a  small  nick  is  made  in  it  with  the  knife  held  horizontal,  so  as  not  to  en- 
danger the  artery.     This  little  opening  is  enlarged  with  the  point  of  the 

Fig.  15. 


Aneurism-neGdle.    The  point  is  roundotl  or  l)Iunt,  and  has  an  eye  in  it. 

director  till  the  aneurism-needle  can  be  easily  passed  round  the  naked 
vessel.  The  sheath  is  only  to  be  disturbed  so  far  as  is  absolutely  neces- 
sary for  this  purpose.     Of  all  ligatures  which  are  intended  to  divide  the 

Hunter's  canal.  The  surgeon,  thinking  that  a  long  and  diflScult  dissection  must 
prove  filial  in  the  dospcriite  state  of  tlie  patient,  tied  the  artery  in  Scarpa's  triangle, 
and  the  patient  recovered  without  further  bleeding. 


LIGATURE    OF    ARTERIES. 


115 


vessel,  the  best,  as  Dr.  Jones'  has  conclusive!}^  shown,  is  a  stout  round 
silk  or  hempen  stinng,  which,  being  tied  firmly  on  the  vessel,  cuts  the  two 
inner  coats  evenly  all  round.  These  divided  inner  coats  ma}'  possibly  re- 
tract a  little  from  the  external,  which  alone  is  left  in  the  grasp  of  the 
ligature.  The  constriction  of  the  vessel  brings  the  cut  edges  of  tlie  inter- 
nal coats  into  apposition.  The  changes 
which  now  ensue  are  intended  to  effect 
(1)  the  separation  of  the  ligature;  (2) 
the  closure  of  the  divided  ends  of  the 
artery,  so  as  to  obviate  haemorrhage ;  and 
(3)  the  restoration  of  the  circulation. 
The  ligature  separates  by  a  process  of 
ulceration  and  sloughing,  and  when  it 
comes  away  a  small  slough,  consisting 
of  the  external  coat,  is  generally  em- 
braced in  the  knot.  There  is,  therefore, 
after  the  fall  of  the  ligature,  a  time  at 
which  the  artery  consists  of  two  parts, 
though  these  soon  unite  again,  and 
though  they  are,  as  a  rule,  glued  to- 
gether by  the  inflammatory  exudation 
which  takes  place  in  the  tissues  around 
the  ligature.  Tlie  separation  of  a  liga- 
ture from  a  large  artery  such  as  the 
femoral  occurs  usually  in  about  a  fort- 
night. The  earliest  recorded  period  in 
that  artery  seems  to  be  eight  days'^  in  a 
case  which  recovered,  but  it  often  re- 
mains fixed  for  a  much  longer  period. 
When  it  separates  very  early  haemorrhage  is  much  to  be  apprehended, 
the  artery  being  probably  diseased. 

The  means  by  which  haemorrhage  is  averted  are  chiefly  threefold:  (1) 
the  blood  coagulates  in  the  interior  of  the  artery,  the  coagulum  extending 
in  many  cases  to  the  nearest  considerable  branch  on  either  side  of  the 
ligature,  filling  tlie  whole  tube,  at  least  at  the  point  where  the  artery  is 
tied,  and  ultimately  acquiring  an  organic  connection  to  the  wall  of  the 
artery;  (2)  the  cut  ends  of  the  internal  coats  are  united  together  by  in- 
flammatory lymph,  and  are  also  united  to  the  lymph  wliich  is  effused  into 
the  interior  of  the  artery  around  the  ligature  ;  (3)  the  tissues  around 
(sheath,  cellular  tissue,  etc.)  are  occupied  by  inflammatory  exudation,  in 
which  tlie  tied  part  of  the  vessel  is  buried.  Ultimately,  after  the  fall  of 
the  ligature,  the  divided  parts  of  the  artery  are  united,  and  the  whole  of 
the  portion  of  the  vessel  along  which  the  coagulum  has  extended  is  con- 
verted into  a  solid  cord. 

During  this  process  the  circulation  has  been  re-established  by  the  in- 
crease in  size  of  the  anastomosing  vessels.  That  increase  is  in  some  cases 
very  rapid,  in  others,  as  it  seems,  very  slow.  The  rapidity  with  which  it 
goes  on  in  the  lower  animals  is  seen  from  an  experiment  of  Broca,  who 
amputated  the  leg  of  a  dog  at  the  knee,  having  previously  placed  a  liga- 
ture under  the  artery  in  the  groin.  The  distance  to  which  the  pulsating 
jet  reached  was  noted  ;  then  the  ligature  was  tied  ;  the  bleeding  of  course 


An  artery  tied  with  a  stout  ligature  and 
then  laid  open,  a  a,  show  the  internal  and 
middle  coats  divided  and  turned  down  for 
a  short  distance  below  the  ligature,  in  order 
to  expose  the  undivided  external  coat. 


1  Treatise  on  the  process  of  nature  in  suppressing  hsemorrhaije  from  divided  arteries, 
and  on  the  use  of  the  ligature.      1805. 

^  In  a  case  of  Eamsden's  tabulated  by  Norris,  No.  45.  Contributions  to  Practical 
Surgery,  p.  288,  from  Kamsden's  Practical  Observations. 


IIG 


HAEMORRHAGE. 


ceased,  but  it  recommenced  at  the  end  of  one  minute,  and  in  five  minutes 
the  jet  (which,  however,  no  longer  pulsated)  had  attained  a  quarter  of  its 
former  maximum  distance,  notwithstanding  that  the  quantity  of  blood  iii 
the  body  had  of  course  been  diminished  by  the  lu\?morrhage.'  And  many 
recorded  facts  show  that,  in  man  also,  the  circulation  is  very  rapidly  re- 
established, particularly  in  the  upper  extremity.  Wardrop  says :  "  The 
enlargement  of  the  anastomosing  vessels  to  a  certain  extent  takes  place 
almost  instantly  al'ter  the  trunk  has  been  tied.    I  observed  this  in  a  child 

in  whom  I  had  secured  the  carotid  arterj'.     I 
Fig.  17.  could  see  the  branches  of  the  temporal  and  oc- 

cipital under  the  delicate  integument  enlarging 
immediately  after  the,  operation."^  And  in- 
stances are  not  wanting  in  which  after  the  liga- 
ture of  the  main  artery  of  a  limb  the  pulse  has 
been  felt  below  the  ligature  in  a  day,  or  on  the 
second  day.  But  the  anastomosing  vessels  con- 
tinue to  enlarge  for  a  considerable  period,  esti- 
mated by  Porta  as  being  usually  under  a  year. 
All  the  time  during  which  the  collateral  circu- 
lation is  deficient,  the  limb  remains  cold,  weak, 
and  liable  to  suffer  from  any  rapid  change  of 
temperature;  and  even  after  it  has  attained  its 
highest  grade  the  limb  in  which  the  main  artery 
has  been  tied  is  weaker,  smaller,  and  less  vigor- 
ous than  natural. 

Secondary  Hsemon-hage. — When  any  of  these 
three  steps  are  incomplete,  the  operation  usu- 
all}'  fails,  either  b3'  secondary  haemorrhage  or 
gangrene.  If  no  clot  forms  in  the  artery — 
which  from  some  unknown  condition  is  not  un- 
frequently  the  case — the  force  of  the  circulation 
in  the  upper  end  of  the  artery  is  resisted  only 
b}'  the  uniting  medium  between  the  edges  of 
the  divided  internal  coats,  assisted  by  the  lymph 
which  is  deposited  in  and  around  the  sheath. 
This,  liowever,  may  be  perfectly  sufficient  for 
the  purpose,  and  accordingly  we  find  cases  in 
whicii  the  patient  has  recovered  without  any 
drawback,  though  only  the  very  portion  of 
Portion  of  a  femoral  artery  tied  artery  embraced  in  the  ligature  has  been  oblit- 
some  months  before  death.  Avery  erated  (Fig.  17).  Still  the  deprivation  of  its 
small  part,  6,  of  the  vessel  (about  14   proper  Support  fVom  the  coagulum  renders  the 

in.)  IS  reduced  to  the  size  of  a  piece  .S  ^      •    1  1  ,         • 

of  whipcord,  being  completely  ob-  "mtiDg  material  uiuch  more  prone,to  give  way, 
literated.  Except  a  viry  small  pale   and  tliis  is  an  indubitable  cause  of  secondary 

haemorrhage.  Another  and  probably  a  more 
frequent  cause  is  the  extension  of  the  ulceration 
(whicli  is  necessary  for  the  sei)aration  of  the 

artery,  the  chief  brancli  above  the     ligature)   bcyoud    itS    proper    bOUllds,  SO  that  it 

lays  open  a  portion  of  the  vessel  not  comj)letely 
filled  with  clot.  Periiai)s  both  causes  of  secon- 
dary hivmorrhage  may  act  at  either  side  of  the 
ligature,  but  obviously  that  form  of  secondary 
haemorrhage  which  depends  on  yielding  of  the  uniting  medium,  must  be 


coagulum  just  below  tliis  narrowed 
part,  the  whole  artery  above  and 
below  this  part  is  quite  pervious 
and  healthy,    a  shows  the  profunda 


ligature;  and  a  large  liranch  wliicli 
comes  off  some  distance  lidow  is 
also  seen. — St.  George's  Hospital 
Museum,  Ser.  vi.  No.  147. 


'    liroca,  Sur  los  Ancvr.,  p.  507,  note. 


Wardrop,  On  Anourisni,  p.  12. 


LIGATURE    OF    ARTERIES.  117 

more  common  at  the  upper  end,  where  it  has  to  bear  the  whole  momentum 
of  the  direct  circulation,  than  at  the  lower,  where  only  the  reflux  circu- 
lation is  actino-.  But  the  form  of  secondary  hremorrhage  ^ich  depends 
on  ulceration  is,  there  can  be  no  doubt,  nwfe  con]^j^n  ^wTe  distal  side 
of  the  ligature,  though  I  am  not  aware  tlraTt  any  Gxplan|PrrDn  of  this  lact 
has  been  offered.  ^« 

Treatment. — Secondary  hpumorrhage  comes  on  about  the  time  that  the 
ligature  is  falling,  though  sometimes  several  days  afterwards,  and  it  usu- 
ally commences  gently,  almost  insidiously,  so  that  the  surgeon  at  first 
tries  to  persuade  himself  that  it  is  merely  a  little  oozing  from  the  granu- 
lations of  the  wound,  and  this  kind  of  secondary  hiiemorrhage  may  often 
be  successfully  treated  by  well-applied  pressure.  Pressure  is  best  applied 
by  graduated  compresses  in  the  wound,  or  by  filling  the  wound  with 
small  shot,  which  is  to  be  firmly  bandaged  on,  and  an  aneurism  com- 
pressor adjusted  over  it;  and  it  may  be  assisted  by  compression  of  the 
trunk  above,  which,  if  done  at  all,  should  be  digital,  much  care  being 
taken  not  to  compress  the  vein.  The  limb  should  be  carefully  bandaged, 
and  some  authors  recommend  putting  a  compres'6  of  lint  on  the  artery 
below  the  wound.  But  if  the  bleeding  begin  furiously,  as  from  the  upper 
end,  which  has  suddenly  given  way,  or  if  pressure  does  not  check  it, 
three  courses  are  open  :  to  tie  a  higher  part  of  the  artery,  to  reopdi  the 
wound  and  place  another  ligature  on  the  bleeding  vessel,  or  to  amf)utate. 
The  ligature  of  a  higher  part  of  the  artery,  which  used  to  be  the  orthodox 
treatment,  almost  always  fails,  and  I  quite  agree  with  Mr.  Erichsen  that 
it  only  adds  to  the  danger  of  the  patient.  In  a  most  interesting  paper 
in  the  St.  Bartholomexv''K  Hoqntal  Reports  (vol.  x)  Mr.  W.  H.  Cripps  has 
shown  that  not  only  has  it  frequently  caused  death  directly,  but  that  it 
has  usually  failed  to  prevent  the  recurrence  of  bleeding,  while  3^et  in 
some  of  these  cases  a  cure  was  obtained  by  the  after-employment  of 
compression.  The  attempt  to  retie  the  vessel  at  the  seat  of  ligature  is  a 
dangerous  and  in  some  cases  a  very  difficult  operation  ;  the  tissues  are 
loaded  with  blood,  the  artery  is  very  difficult  to  recognize  unless  the 
bleeding  is  allowed  to  go  on ;  and  such  renewed  loss  of  l)lood  raa}^  easiW 
prove  fatal  to  one  weakened  by  previous  haemorrhage.  Besides,  the  ar- 
tery may  be  too  rotten  to  bear  a  ligature,  or  the  vein  may  easily  be  in- 
cluded with  it.  Still  the  attempt  has  proved  far  more  successful  than 
the  ligature  above.  Amputation  is,  I  am  persuaded,  the  best  treatment 
in  many  cases  of  aneurism  ;  since  it  removes  a  formidable  disease  which 
is  by  no  means  cured  at  the  time  when  secondary  hemorrhage  occurs  ; 
but  no  one  would  willingly  resort  to  it  in  a  case  of  mere  wound. 

The  result  of  Mr.  Cripps's  inquiries  is  as  follows.  The  paper  includes 
all  the  cases  which  he  could  find  of  secondary  haemorrhage  after  the  liga- 
ture of  the  femoral  in  its  continuity  for  all  causes,  fifty-three  in  number. 
There  were  fourteen  cases  in  which  the  external  iliac  was  tied  ;  twelve 
died,  one  recovered  under  pressure  on  the  recurrence  of  haemorrhage,^ 
and  one  after  amputation  for  gangrene;  five  others  were  amputated,  two 
died,  three  recovered.  In  twelve  cases  the  artery  was  retied  :  seven  died, 
and  five  recovered.  In  fifteen  cases  pressure  was  used,  and  only  three 
died.  In  seven  cases,  from  various  causes,  no  treatment  was  used,  and 
three  of  these  recovered.^ 

1  In  this  case  the  surgeon  in  charge  states  his  opinion  that  the  ligature  of  the  ex- 
ternal iliac  was  a  useless  operation. 

'■^  In  cases  of  secondary  haemorrhage  from  the  stump  of  an  amputation,  the  results 
of  ligature  of  the  artery  higher  up  seem  to  have  been  less  disastrous,  but  the  number 


118  HiEMOrvRTTAGE. 

It  might  be  argued,  in  explanation  of  the  far  more  favorable  results  of 
pressure,  that  that  method  had  onh-  been  used  in  the  mildest  eases;  but 
Mr.  Cripps  says  that,  on  perusing  the  notes  of  the  cases,  he  does  not 
believe  this  lo  kave  been  the  fact.  The  perusal  of  the  paper  has  certainly 
confirmed  my  previous  impression,  that  most  of  the  cases  of  secondary 
hiijmorrliage  which  can  be  saved  will  be  saved  Iw  the  persevering  use  of 
well-applied  pressnre.  But  there  are  unquestionably  in  practice  cases 
where  secondary  htemorrhage  bursts  out  with  such  violence  from  tlie 
upper  end  of  the  artery  that  it  is  useless  to  spend  time  on  the  attempt  at 
compression.  Such  cases  must  be  treated,  I  think,  like  fresh  wounds  of 
the  vessel,  by  retying  it ;  or,  if  the  attempt  to  retie  the  vessel  fails,  by 
amputation.  And  there  are  other  cases  where  the  persevering  use  of 
pressure  has  failed.  Here  the  surgeon  must  be  left  to  choose  between 
retying  the  vessel  and  amputation. 

Secondary  haemorrhage  occurs  also  from  arteries  that  have  been 
wounded  and  not  tied,  in  consequence  of  the  giving  way  of  the  clots,  or 
of  an}'  uniting  medium,  which  may  have  opposed  the  issue  of  blood. 
The  practical  considerations  are  the  same  as  after  ligature.  I  ought  to 
mention  that  secondary  hsemorrhage  is  often  said  to  be  due  to  unhealthy 
ulceration,  caused  by  defective  hygienic  conditions  in  hospital — a  state- 
ment of  which  I  have  found  no  definite  proof,  though  it  is  probable  enough. 
Certainly  the  most  common  cause  of  secondary  haemorrhage  is  disease  of 
the  vessel. 

Recurrent  Hsemorrhage. — There  is  another  form  of  bleeding  which  is 
sometimes  confounded  with  secondary  haemorrhage,  though  it  is  of  quite 
a  different  nature.  I  mean  the  recurrent  haemorrhage,  which  sometimes 
comes  on  an  hour  or  two  after  a  wound,  when  the  patient  becomes  warm 
in  bed,  and  has  recovered  from  the  shock  of  the  operation  or  accident. 
This  depends  merely  on  some  vessel  or  vessels,  which  have  not  been  se- 
cured, bleeding  under  the  influence  of  warmth  and  renewed  circulation. 
The  bleeding  vessels  must  be  exposed  and  treated  just  as  in  primary 
haemorrhage. 

Gangrene  after  Ligature. — The  other  main  cause  of  failure  after  liga- 
ture is  gangrene,  and  it  depends  usually,  as  it  seems,  on  the  failure  of 
development  of  the  collateral  circulation.  This,  however,  is  by  no  means 
the  only  cause  of  gangrene,  for  it  may  be  occasioned  also  by  coagulation 
in  the  vein,  the  result  of  bruising  or  laceration  of  that  vessel  in  the  injury 
or  in  the  operation,  and  in  cases  of  aneurism  it  depends  sometimes  on 
inflammation  of  the  sac,  by  which  the  pressure  on  the  vein  or  veins  is 
increased  and  the  veins  themselves  in  some  cases  also  affected  by  inflam- 
mation. Gangrene  from  the  two  former  causes  commences  early,  usually 
within  four  days  after  the  ligature  ;  the  latter  cause  may  ])e  several  weeks 
in  ])roducing  its  effect.  The  treatment  to  be  pursued  depends  on  the 
rapidity  with  which  tlie  gangrene  spreads.  If  it  comes  on  over  a  large 
surface,  or  in  several  places  at  once,  and  advances  rapidly,  no  delay  should 
be  admitted,  but  the  limb  should  be  removed  at  once,  the  section  of  the 
artery  being  made  as  near  as  possible  to  the  tied  portion — not  above  it.  If 
only  a  small  part  of  the  limb— say  one  or  two  toes — is  affected,  and  the 
gangrene  advances  slowly,  without  constitutional  symptoms,  there  is 
good  reason  to  hope  that  tlie  mortified  parts  will  separate  and  a  useful  limb 
be  preserved. 

Recurrence  of  Circulation. — This  view  of  the  causes  of  failure  of  the 

recorded  here  is  very  smiill.     Three  cases  are  referred  to,  in   two  of  which  the  com- 
mon iliac  was  tied  after  the  external.     All  recovered. 


THE    ANTISEPTIC    LIGATURE.  119 

ligature  would  not  be  complete  without  the  mention  of  what,  however, 
belongs  to  the  subject  of  aneurism,  and  not  of  haamorrhage,  viz.,  that  the 
collateral  circulation  sometimes  errs  from  excess.  When  the  main  artery 
is  tied  in  order  to  cure  an  aneurism,  or  when  the  operation  is  performed 
for  general  inflammation  of  the  limb  (as  recommended  by  Dr.  Campbell 
and  Dr.  Onderdonk,  in  America,  and  in  this  country  by  Mr  Maunder'), 
the  collaterals  may  enlarge  so  rapidly  and  to  so  great  an  extent  as  at 
once  to  reproduce  the  circulation  below,  which  it  was  intended  to  suspend. 
The  treatment  of  aneurisms  when  recurring  from  this  cause  will  be  spoken 
of  in  the  section  on  that  subject. 

Carbolized  Catgut  Ligatm-es. — Viewing  the  great  danger  of  secondary 
haemorrhage  and  its  comparative  frequency  (which,  however,  has  been 
much  diminished  of  late  years,  since  arteries  have  been  more  gently  dealt 
with  in  deligation,  and  the  sheath  disturbed  to  as  small  an  extent  as 
possible'-),  surgeons  have  long  been  seeking  for  some  means  of  tying  an 
artery,  so  as  permanentl}'  to  obliterate  it,  without  dividing  it.  John 
Hunter  attempted  this  in  the  very  first  operation  which  he  performed, 
by  gently  constricting  a  large  extent  of  the  artery  by  means  of  four  broad 
ligatures  ;  but  he  soon  recognized  the  futility  of  that  attempt.  Again, 
the  same  end  was  sought  by  the  use  of  temporary  ligatures'^  tied  over  a 
roll  of  lint,  or  some  such  substance,  laid  on  to  the  artery,  so  that  the 
ligature  could  be  cut  and  removed  two,  three,  or  more  days  after  the 
operation  ;  or  by  nooses  attached  to  an  instrument  left  in  the  wound, 
whereby  the  surgeon  could  tighten  or  relax  the  ligature  as  he  liked.  And 
these  attempts  are  not  yet  entirely  given  up,  though,  as  far  as  I  can  dis- 
cover, only  one  preparation  exists  showing  that  the  artery  has  really  been 
closed  in  this  wa}'  in  the  human  subject,'  while  the  failures  have  been 
numerous  and  disastrous.  Again,  ligatures  made  of  animal  matter  have 
been  used  in  the  hope  that  they  would  be  absorbed  (or  perhaps,  as  some 
have  thought,  that  they  would  unite  with  the  tissues  around)  without 
causing  any  ulceration.  The  only  one  among  the  numerous  experiments 
of  this  kind  to  which  I  need  refer  is  the  ligature  of  the  femoral  with  cat- 
gut, which  Sir  Astley  Cooper  performed  on  an  old  man  affected  with 
popliteal  aneurism,^  and  which  proved  most  successful.  But  he  was  dis- 
appointed in  subsequent  trials  of  the  substance,  and  renounced  its  use. 
Recently  Mr.  Lister  has  revived  the  use  of  catgut,  thoroughly  soaked  in 
carbolized  oil,  as  a  ligature,  and  with  a  success  which  is,  I  think,  undeni- 
able." The  success  depends,  as  1  have  endeavored  to  show,''  not  only  on 
the  material  of  which  the  ligature  is  composed  being  one  which  is  capable 
of  absorption,  and  which  dissolves  without  exciting  suppuration — though 
this  is  an  essential  condition — but  also,  and  perhaps  even  more,  on  the 
rapid  union  by  the  first  intention  of  all  parts  of  the  wound  which  are  in 
contact  with  the  tied  vessel.  We  have  already  seen  that  the  lymph 
eff"used  in  and  around  the  sheath  is  a  great  support  to  the  vessel  and 
protection  against  secondary  hoemorrhage  when  the  artery  is  divided  by 

1  See  Biennial  Eetrospect  of  New  Syd.  Soc,  1867-8,  p.  284. 

•■^  Lancet,  1874,  vol.  ii,  p.  860. 

3  First  used  apparently  by  Cline  and  Scarpa.     See  South's  Cheliiis,  vol.  i,  p.  304. 

■•  Tliis  preparation  is  in  the  Museum  of  the  Irish  Collesfe  of  Surgeons. 

5  The  case  is  related  in  Cooper  and  Travers's  Surgical  Essays,  vol.  i,  p.  12-5. 

*  "During  the  last  three  years,"  says  Mr.  Bickersteth,  "I  have  tied  the  femoral 
artery  five  times,  the  common  carotid  once,  and  the  common  iliac  once,  and  in  every 
case,  with  one  solitary  exception  [one  of  the  cases  of  ligature  of  the  femoral],  the 
wound  has  healed  at  once,  and  without  suppuration." — On  Recent  Progress  in  Sur- 
gery, 1871,  p.  20. 

7'Lancet,  1872,  vol.  ii,  p.  325. 


120 


HEMORRHAGE. 


the  ligature.  If  this  exudation  forms  rapidly,  and  without  destructive 
inflammation,  the  tied  vessel  remains  free  from  any  tendency  to  soften 
or  ulcerate,  and  the  small  knot  of  earbolized  gut  rapidly  disappears, 
keeping  the  artery  closed,  however,  quite  long  enough  (as  we  know  from 
the  experience  of  acupressure)  for  permanent  obliteration  to  occur.  That 
this  is,  at  any  rate,  possible  is  shown  by  a  case  in  which  I  tied  the  sub- 
clavian and  carotid  artery  in  this 
Fi«- 18-  manner,    and    where    the    patient 

died  eight  weeks  afterwards  from 
another  cause.  Neither  wound 
had  healed  by  first  intention,  but 
the  suppuration  seemed  superficial. 
The  external  coat  was  perfect  in 
both  arteries,  which  were  closed  bj' 
a  kind  of  diaphragm  only  at  the 
point  tied.  This  is,  if  I  mistake 
not,  the  first  definite  anatomical 
proof  that  arteries  can  be  obliter- 
ated at  the  seat  of  ligature  without 
being  divided.  If  this  result  could 
be  attained  in  every  case,  second- 
ary haemorrhage  would,  of  course, 
be  unknown.  But  this  is  far  from 
being  the  case,  at  least  as  yet.  In 
some  cases  the  catgut  has  softened 
prematurely,  or  perhaps  has  come 
untied,  and  the  circulation  has  re- 
curred; but  this  is  very  rare,  and 
might  probably  be  avoided  by  care 
in  the  preparation  and  tying  of  the 
ligature.  In  other  cases,  wliere 
suppuration  has  taken  place  around 
the  vessel,  secondar3^  haemorrhage 


A,  the  subclavian,  and  b,  the  common  carotid  ar- 
tery, tied  simultaneously  with  earbolized  catgut  on 
Nov.  16.  Death  took  place  on  Jan.  9.  The  subcla- 
vian has  been  laid  open  above  and  below  the  seat 
of  ligature,  but  not  at  the  precise  point.  The  ex- 
ternal coat  is  seen  to  be  quite  perfect,  and  the  tube 
of  the  vessel  is  closed  by  a  simple  diaphragm.  In 
the  carotid  this  diaphragm  has  been  cut  through 
and  the  artery  opened  in  its  whole  extent.  Two 
small  fissures  or  cracks  are  seen  below  the  ligatured 
part,  one  of  which  (marked  by  a  small  bristle)  leads 
into  a  minute  cavity  outside  the  artery,  containing 
blood-clot.  The  case  is  reported  in  the  St.  George's 
Hospital  Reports,  vol.  vi,  and  the  preparation  is  in 
the  Hospital  Museum. 


has  ensued  ;^  but  the  constant  use 
of  this  form  of  ligature  in  operations  of  all  kinds  for  several  years  has 
convinced  me  that  secondary  hffimorrhage  is  far  rarer  than  witli  the  silk 
ligature,  even  in  wounds  which  suppurate  freely,  while  the  ligature  itself 
does  not  seem  to  be  felt  as  a  foreign  body  at  all,  or  to  interfere  in  any- 
way with  primary  union. 

Great  care  should  be  taken  in  selecting  the  material  for  the  ligature. 
The  catgut  should  not  be  too  thin,  and  it  should  be  steeped  in  thecarl)ol- 
ized  oil  (1  part  of  the  acid  to  5  of  oil)  for  many  weeks  before  it  is  used. 
In  fact,  it  seems  that  it  continues  to  become  tougher  and  more  reliable 
for  an  indefinite  length  of  time.  A  convenient  ligature-case  for  private 
practice  is  made  of  a  thiclc  glass  tube  with  a  silver  cover  screwed  on,  in 
which  a  reel  of  the  catgut  ligature  can  l)e  kept  in  oil  in  the  pocket  for  an 
unlimited  time.  It  is  well  gently  to  wipe  ofiC  the  superfluous  oil  before 
use,  as  otherwise  the  ligatui-e  is  a  little  apt  to  slip  ;  and  it  is  safer  not  to 
cut  the  ligature  too  near  the  knot,  es|)ecially  as  the  substance  is  very 
easily  absorbed  and  creates  no  ap])arent  irritation. 

Wounded  ves.sela  used  in  former  days  to  bo  secured  by  driving  a  sharp 
hook,  called  a  ti^nneiilum,  tlirough  the  blooding  mouth  of  the  vessel  and 
the  tissues  immediately  adjacent,  and   then  tying  a  ligature  under  the 


1  See  a  case  by  Mr.  Holdcn.     St.  Bartholomew's  Hospital  Reports,  vol.  viii,  p.  187. 


ACUPRESSURE. 


121 


convexity  of  the  hook.  The  tenaculiitn  being  now  withdrawn,  the  liga- 
ture of  course  compresses  the  vessel  a  little  above  its  cut  end.  Tliis 
method,  however,  is  somewhat  rough,  since  a  good  deal  more  tissue  is 
included  in  the  ligature  than  is  really  necessary.  It  is,  however,  still 
often  employed  wlien  tlie  vessel  lies  in  the  midst  of  dense  structures  from 

Fig.  19. 


Liston's  tenaculum  (modified). 

which  it  cannot  well  be  separated.  Otherwise  it  is  better  to  pick  up  the 
vessel,  and  separate  it  cleanly  from  the  tissues  around,  drawing  it  slightly 
out  of  its  sheath  with  one  of  the  forms  of  forceps  here  figured.  The  name 
tenaculum  which  used  to  be  appropriated  to  the  sharp  hook  is  now  more 
commonly  applied  to  the  forceps  used  for  tying  arteries.  Each  form  has 
its  advantages.     Liston's,  when  closed,  catches  with  a  spring  which  holds 

Flu.  20. 


Assalini'.s  tenaculum. 


it  on  the  artery,  and  enables  the  surgeon  to  tie  the  vessels  more  easily 
when  he  has  no  assistant.  Assalini's  may  be  ready  armed  witli  the  liga- 
ture, and  I  think  enables  the  surgeon  and  his  assistants  to  secure  the 
vessels  in  a  large  wound  more  rapidly.  But  the  use  of  one  or  other  is 
more  a  question  of  fashion  and  habit  than  of  any  essential  superiority. 

Acupressure. — I  have  spoken  in  the  preceding  sentences  of  "tying" 
arteries,  since  this  is  the  general  and  for  the  moment,  at  any  rate,  the 
most  certain  method  of  securing  thera.     But  there  are  two  other  plans 


122 


HiEMORRHAGE. 


Avhic'h  have  come  much  into  vogue  of  late  years,  viz.,  Acupressure  and 
Torsion.  The  chief  object  of  these  two  methods  is  to  avoid  that  which  is 
the  drawback  of  the  sillc  or  hempen  ligature,  viz.,  the  abiding  irritation 
and  ultimate  ulceration  by  which  the  ligature  is  cast  off.  In  acupres- 
sure the  metallic  foreign  bodies  by  which  the  artery  is  tem25oraril3^  com- 
pressed are  removed  as  early  as  is  judged  safe,  and  the  wound  is  left  free 
to  unite.     In  torsion  tliere  is  no  foreign  body  at  all. 

The  different  methods  of  applying  acupressure  are  reduced  by  Pirrie, 
its  most  ardent  and  considerable  advocate  at  the  present  day,  to  three, 
which  he  has  denominated  C'ircumclusion,  Torsoclusion,  and  Retroclu- 
sion.     In  the  tirst  method  (Fig.  21)  ii  pin  is  passed  below  the  divided 


Fig.  21. 


Acupressure.  First  method,  or  Circum- 
clusion  (after  Pirrie). 


Acupressure. 


Second  method,  or   Torsocltision  (after 
Pirrie). 


arter}',  and  a  loop  of  wire  placed  over  the  end  of  the  pin  compresses  the 
tissues  in  which  the  artery  is  lying,  and  is  twisted  tightly  enough  round 
the  stalk  of  the  pin  to  stop  all  bleeding.  Then  the  point  of  the  pin  is 
passed  into  the  tissues,  while  the  ends  of  the  wire  hang  out  at  the  other 
side  of  the  wound  with  the  head  of  the  pin.  When  the  pin  is  withdrawn 
tlie  wire  of  course  becomes  loose,  and  is  drawn  out  also.     In  the  second 

Fig.  23. 


1  2 

Acuprcs-sure.    Third  mi'tliod,  or  ReJroclusion  (altered  from  Pirrie). 


method  (torsoclusion,  or  the  Aberdeen  twist),  the  pin  is  passed  in  par- 
allel to  the  vessel  (Fig.  22  (1)),  tiien  twisted  round  a  quarter  of  a  circle 
and  driven  across  the  vessel  into  the  tissues  on  its  further  side  tightly 
enough  to  keep  it  in  its  new  i)osition  (Fig.  22  (2)).  In  the  third  method, 
retroclusion,  the  pin  is  passed  first  above  the  artery,  under  a  few  muscu- 


ACUPRESSURE. 


123 


lar  fasciculi  only  (Fig.  23  (1)),  then  twisted  round  half  a  circle  and 
driven  below  the  artery  into  the  tissues  on  the  side  where  it  first  entered 
(Fig.  23  (2)).  The  pins  are  withdrawn  as  early  as  the  surgeon  thinks  it 
safe.  Dr.  Pirrie  gives  eight  hours  for  smaller  arteries,  such  as  the  facial, 
temporal,  radial,  ulnar,  mammary,  and  spermatic,  and  twenty-four  hours 
for  such  as  the  humeral,  axillary,  and  femoral,  as  periods  at  which  the 
l)ins  may  be  safely  withdrawn  ;  and  he  intimates  his  belief  that  it  will  l)e 
found  safe  even  to  shorten  this  period. 

I  have  had  sufficient  experience  of  acupressure  to  testify  that  it  is  a 
perfectly  efficient  means  of  stopping  hfemorrhage,  and  one  which,  with  a 
little  practice,  is  not  difficult  of  application. 

Torsion  is  a  very  old  method  of  stopping  haemorrhage.  It  was  exten- 
sively used  in  the  last  generation,  and  the  readers  of  Porta's  great  work' 
will  know  that  he  emplo^'ed  it  successfully  in  many  of  the  major  opera- 


FiG.  24.  Torsion  forceps.  Tlie  artery  to  be  twisted  being  caught  between  tlie  blades  of  the  forceps, 
they  are  closed  as  far  as  the  thickness  of  the  tissue  embraced  by  them  will  allow,  and  the  catch  on  the 
upper  blade  is  then  pushed  down  as  far  as  it  will  go.  The  wedge-shaped  projection  from  the  lower 
blade  enables  the  catch  to  hold  the  forceps  firmly  closed,  whatever  may  be  the  distance  between  the 
blades.  This  is  one  of  the  most  convenient  and  efficient  of  the  many  forms  of  catch  forceps  for 
torsion. 

Fig.  25.  Torsion.  Taken  from  a  large  artery  which  was  i-emoved  from  the  body  before  it  was  twisted. 
The  internal  and  middle  coats  are  seen  to  be  separated  from  the  external  and  pushed  up  the  tube  of 
the  artery  like  a  plug. 

tions ;  but  it  passed  out  of  practice,  probabl}'  in  consequence  of  the  loss 
of  time  which  it  sometimes  occasions,  and  which  was  a  very  important 
consideration  in  operations  performed  without  anaesthetics.  It  was  re- 
vived by  Mr.  Syme,  and  is  now  used  by  many  of  the  best  surgeons.  The 
action  of  torsion   is  very  easy  to  understand.     If  the  divided  end  of  a 


1  Sulle  Alt.  pat.  delle  Arterie,  published  in  1845. 


124  H.T5MORRHAGE. 

large  artery  be  taken  hold  of  with  a  pair  of  forceps,  all  other  tissues 
being  carefully  avoided,  and  twisted  round  four  or  five  times  till  its  coats 
are  felt  to  give  way,  it  will  be  found  on  laying  it  open  that,  its  internal 
coat  has  been  torn,  and  tlie  middle  coat  has  also  been  separated  from  the 
external,  torn,  and  twisted  up  into  the  tube  of  the  vessel,  which  is  there- 
fore closed  by  a  firm  plug,  while  the  external  coat  I'emains  uninjui'ed, 
though  more  or  less  twisted.  Even  in  the  dead  subject  the  vessel  is  so 
firmly  closed  that  no  fluid  can  be  forced  through  it.  In  a  large  wound, 
such  as  that  of  an  amputation,  when  all  the  divided  arteries  have  been 
thus  treated,  the  wound  is  left  entirely  without  any  foreign  body.  It  is 
true  that  the  twisted  ends  of  the  vessels  may  slough  and  come  away,  but 
it  seems  certain  that  this  does  not  always  even  if  it  does  often  occur. 

Torsion  is  not  easy  to  perform  successfully,  and  this  difficulty  is  felt 
even  more  with  tlie  smaller  arteries  than  the  larger  ones.  This  depends 
on  the  difficulty  of  isolating  the  latter  from  the  tissue  around,  especially 
while  they  are  bleeding  ;  and  it  is  on  this  proper  isolation  that  the  prompt 
success  of  torsion  in  stopping  bleeding  depends.  A  large  artery  can  be 
easily  drawn  out  of  its  sheath,  and  then  two  methods  of  twisting  it  are 
employed,  called  limited  and  free  torsion.  In  the  former  the  artery  is 
drawn  out  of  its  sheath,  seized  with  forceps  about  an  inch  above  the 
divided  end,  and  then  twisted  with  a  second  pair  of  forceps  so  that  only 
the  part  between  the  two  pairs  of  forceps  is  twisted  ;  in  the  latter  it  is 
merely  drawn  out  and  twisted  freely.  Small  vessels  can,  of  course, 
hardly  be  twisted  in  an}'  other  than  the  latter  way. 

If  it  is  necessary  for  me  to  express  an  opinion  on  the  value  of  these 
methods  of  arresting  arterial  hffitnorrhage,  I  must  commence  by  saying 
that  both  acupressure  and  torsion  are  perfectly  reliable  methods  of  arrest- 
ing ha?morrhage.  They  have  been  used  for  many  years  together  by  emi- 
nent surgeons  in  large  operative  practice,  without  any  accident  or  bad 
result.  It  is,  therefore  merely  as  a  matter  of  private  opinion  that  I  say 
that  neither  acupressure  nor  torsion  seems  to  me  so  convenient,  so  safe, 
or  so  likely  to  promote  tlie  rapid  union  of  the  wound  as  the  carbolized 
ligature.  The  latter,  as  I  have  tried  to  show  in  the  preceding  descrip- 
tion, is  perfectly  easy  to  apply,  takes  up  no  appreciable  space  in  the 
wound,  liolds  the  arterj'  closed  as  firmly  as  the  silk  ligature  does,  and  for  a 
longer  time  than  it  is  found  necessary  to  keep  the  largest  artery  com- 
pressed, excites  no  irritation  or  suppuration  as  it  gradually  melts  away, 
and  does  not  interfere  in  any  degree  with  primary  union.  Both  the  other 
methods  are  more  diflicult  to  practice.  If  a  great  number  of  vessels  re- 
quire to  be  secured,  the  mass  of  pins  and  wire  loops  renders  acupressure 
very  inconvenient,  distending  the  cavit}'  of  the  wound,  and  effectually 
preventing  all  primary'  union  ;  and  when  bleeding  proceeds  from  a  num- 
ber of  small  vessels,  torsion  is  a  very  tedious  business  even  in  the  hands 
of  those  most  versed  in  it.  Secondary  hremorrliage  is  certainly  rare  after 
either  method  when  practiced  by  experienced  surgeons  ;  yet  I  should 
hardly  think  any  one  could  leave  a  large  artei  y  after  either  acupressure 
or  torsion,  in  a  i)atient  not  under  his  immediate  eye,  with  the  same  com- 
fortal)lc  security  as  lie  would  feel  if  the  vessel  were  properly  tied  ;  and  I 
have  certainly  seen  very  acute  and  sudden  hfcmorrhage  a  few  days  after 
torsion,  in  all  prol)ability  from  detachment  of  the  crushed  end  of  the 
artery. 

In  London  we  have  taken  up  this  question  with  no  prejudice  for  or 
against  either  method,  and  the  result  has  been  that  acupressure  is  as  far 
as  I  know  universally  disused  after  a  fair  trial,  and  torsion  is  onl}'  prac- 
ticed at  a  few  of  our  hospitals. 


CAPILLARY    HAEMORRHAGE.  125 

Had  I  to  choose,  however,  between  the  silk  ligature  and  torsion,  I  do 
not  think  that  I  could  speak  with  equal  coniidence,  for  the  ulceration  and 
slonghing  caused  by  the  silk  ligature  must  of  necessity  prevent  complete 
union  by  the  first  intention  ;  while  torsion,  if  dexterously  and  rapidly 
etTected,  usually  does  not  do  so. 

Other  Means  for  Arresting  Hsemorrhacje. — There  are  cases  in  which  a 
considerable  artery  is  wounded,  yet  where  it  can  neither  be  tied,  com- 
pressed, nor  twisted.  In  some  such  cases,  as  before  stated,  it  is  justi- 
fiable to  tie  the  artery  or  arteries  higher  up,  as  is  often  done  in  wounds 
of  the  palm.  Yet  it  must  be  allowed  that  the  practice  is  an  uncertain  one, 
and  has  often  led  to  loss  of  limb  or  life.  No  dmd)t  in  many  such  cases 
more  accurate  pressure  would  have  been  successful.  Professor  Vauzetti 
has  lately  proposed  for  such  cases  a  plan  which  he  calls  "uncipression," 
and  which  I  think  is  well  worthy  of  a  trial.  A  pair  of  sharp  hooks,  double 
or  single,  according  to  circumstances,  are  dug  into  the  two  sides  of  the 
wound,  so  as  to  make  pressure  on  the  bleeding  point  or  points,  and  these 
hooks  are  fixed  by  an  elastic  band  to  a  splint  on  which  the  limb  rests,  or 
to  something  at  the  side  of  the  bed.  The  hooks  may  be  mounted  on 
handles  or  on  a  chain,  like  the  ordinary  dissecting-hooks.  See  Med. 
Record,,  March  3,  1875,  where  another  plan  of  applying  compression  may 
also  be  seen  described  by  M.  Yerneuil  under  the  name  of  "forcipression," 
which  consists  simply  in  embracing  the  bleeding  j^oint  or  points  in  the 
blades  of  a  catch  forceps  or  ordinary  dressing  forceps,  tying  the  blades  of 
the  forceps  together  if  necessary,  and  leaving  them  in  the  wound  till  they 
drop  off",  or  till  the  surgeon  thinks  it  safe  to  remove  the  instrument.  And 
this,  or  something  like  this,  is  often  done  after  amputation.  Obstinate 
bleeding  from  a  point  which  cannot  be  fairly  brought  into  view,  or  where 
the  tissues  are  too  rotten  to  bear  a  ligature,  may  frequently  be  suppressed 
by  taking  up  all  the  tissues  around  with  a  tenaculum  or  sharp  hook,  under 
which  a  common  or  an  elastic  ligature  is  passed,  and  which  is  left  in  the 
wound  for  a  day  or  two,  or  allowed  to  fall  off"  l)y  itself. 

Capillary  Hsemorrhage. — Such  are  the  surgical  means  for  combating 
those  formidable  attacks  of  haemorrhage  which  result  from  injury  to  the 
larger  vessels.  But  the  common  htemorrhage  which  proceeds  from  small 
arteries  or  capillaries  and  veins,  when  it  does  not  cease  of  itself,  as  in  the 
great  majority  of  cases  it  does,  is  usually  treated  by  one  of  three  methods, 
— pressure,  cold,  or  styptic  applications — and  sometimes  by  a  combina- 
tion of  them. 

Pressure  is  the  most  effectual  haemostatic  when  it  can  be  applied  evenly 
over  the  whole  wounded  surface  ;  in  fact,  we  have  seen  above  how  potent 
it  is  in  repressing  hsiemorrhage  even  from  the  femoral  artery  after  ligature. 
In  some  cases  pressure  can  only  be  applied  with  the  finger.  Thus,  in  a 
case  under  Sir  B.  Brodie's  care,  where  the  internal  pudic  artery  had  been 
wounded  inside  the  ramus  of  the  ischium,  pressure  was  made  by  a  rela3'^ 
of  students  for  forty-eight  hours  successfully.  But  ordiiuirily  i)ressure  is 
made,  as  directed  on  p.  11 T,  with  graduated  compresses,  kept  in  position 
by  strapping,  and  assisted  if  need  be  by  a  horseshoe  tourniquet.  The 
limb  in  all  cases  should  first  be  evenly  and  firmly  bandaged. 

Cold  is  usually  applied  by  exposing  the  i)art  to  the  air,  as  in  opening 
bleeding  abscesses  (see  p.  57),  or  in  operations  where  a  good  deal  of 
oozing  is  going  on  and  cannot  be  repressed.  In  such  cases  the  operator 
passes  his  sutures  through  the  edges,  but  does  not  tie  them,  and  leaves 
the  part  exposed  to  the  air  for  a  few  hours,  when  any  clot  which  has  col- 


126  JJJEU  O  R  R  IT  A  G  E, 

lected  may  be  gently  removed  and  the  stitches  drawn  togethei*.  The  ap- 
plication of  ice  in  a  bladder  to  the  wound,  and  the  irrigation  of  the  wound 
with  iced  water,  are  also  powerful  hfemostatics. 

Of  styptics  the  one  in  most  use  at  present  as  a  local  application  to 
■wounds  is  the  perchloride  of  iron.  Lint  steeped  in  the  Tinct.  Ferri 
Perchlor.  is  laid  on  the  bleeding  surface  and  gently  pressed  into  it.  An- 
other very  useful  styptic,  especially  when  it  is  desired  to  produce  a  super- 
ficial slough  as  well  as  to  stop  bleeding,  is  blue  lint,  i.e.,  lint  which  has 
been  steeped  in  a  saturated  solution  of  sulphate  of  copper,  and  is  kept  at 
hand  dry  for  use.  Matico  leaves  are  often  used  with  success  to  fill  bleed- 
ing cavities,  such  as  those  of  cancerous  ulcers. 

Finally,  the  most  powerful  of  all  styptics  is  the  actual  cautery  lightly 
used  at  a  white  heat.  The  shape  and  size  of  the  cauteries  should  be 
adapted  to  the  surface  to  which  they  are  to  be  applied,  so  that  a  good  many 
ought  to  be  at  hand  at  once.  They  should  not  be  used  too  cool,  otherwise 
the  tissues  are  apt  to  stick  to  them,  nor  be  pressed  too  hard  or  too  long 
on  the  bleeding  surface,  for  the  same  reason.  If  the  charred  tissue  sticks 
to  the  cauter}-  the  parts  will  be  torn  in  dragging  it  away,  and  the  bleed- 
ing will  most  likely  recur.  Many  surgeons  think  that  this  adherence  of 
the  tissues  is  less  probal)le  when  the  canter}'  is  heated  only  to  a  dull  red; 
but  whatever  be  the  method  of  applying  the  canter}',  the  surgeon  should 
not  be  contented  till  he  has  seen  that  every  point  from  which  free  bleed- 
ing came  has  been  perfectly  and  completel,y  charred,  and  then  the  tissue 
may  even  be  returned  into  the  interior  of  the  body  (as  in  piles  or  ova- 
riotomy) with  full  security  against  recurrent  haemorrhage.  Nor  is  second- 
ary htiemorrhage  at  all  common  on  the  falling  of  the  slough. 

The  actual  cautery  is  also  used  extensivel}'^  as  a  counterirritant,  as 
will  be  pointed  out  in  the  chapter  on  Minor  Surgery. 

Tronfifiision  of  Blood. — In  some  cases  of  the  most  extreme  exhaustion 
from  lijeniorrhage  the  patient  has  been  rescued  from  death  by  injecting 
blood  into  the  veins.  This  blood  is  taken  instantly  before  injection  from 
the  arm  of  a  healthy  person.'  There  are  two  chief  methods  of  transfu- 
sion,— the  indirect,  and  the  direct  or  immediate.  In  the  latter  the  blood 
is  passed  directly  from  the  arm  of  the  person  who  furnishes  the  blood  into 
that  of  the  patient ;  while  in  indirect  transfusion  the  blood  is  received  into 
a  vessel,  and  may  be  defibrinated  before  it  is  injected  into  the  patient's 
vein. 

The  operation  is  not  a  difficult  one,  if  the  patient's  veins  are  well- 
marked.  A  free  incision  is  to  be  made  over  the  largest  of  the  veins  at 
the  bend  of  the  elbow,  so  as  to  expose  it ;  it  is  then  opened  with  a  V- 
shaped  cut  of  the  scissors  and  the  nozzle  of  the  syringe  inserted.  This 
nozzle  should  be  warmed  to  the  temperature  of  the  body  and  filled  with 
warm  water.  Then  the  blood  is  procured  as  rapidly  as  possible  from  a 
healthy  man,  whose  vein  is  opened  in  a  similar  w^y.  If  the  immediate 
method  is  followed  the  nozzles  of  the  two  syringes  are  connected  by  a 
warmed  tube,  in  the  middle  of  which  there  is  an  elastic  bulb,  the  capac- 
ity of  whicii  should  be  accurately  known.  IMie  nozzles  being  inserted  in 
the  two  veins,  in  the  course  of  the  circulation,  the  tube  is  fixed  on  to  the 

'  In  America  lately  lamb's  blood  seems  to  bavo  been  transfused  in  eiises  of  con- 
sumption. I  Unow  notliinn  wliatevcr  of  tlie  practice  except  from  one  casi-,  in  which 
it  is  spoken  of  with  reprobation — Hostim  Med.  and  Siirs:ij.  Jour.,  Jan  14,  1875,  p. 
38.  In  the  Med.  Times,  Sept.  o,  1874,  will  be  found  a  resume  of  some  experiments 
on  transfusion  troni  oncanitnal  to  anotiier,  from  tiie  Centraiblatt  f.  Chir.,  of  the  same 
year. 


TRANSFUSION. 


127 


nozzle  in  the  bloodgiver's  arm,  and  the  operation  proceeds  as  described. 
The  blood  is  injected  by  successive  discharges  of  the  bulb,  until  about 
0  ozs.  has  been  passed  in.  It  is  not  generally  considered  necessary  or 
desirable  to  inject  a  larger  quantity  at  once. 

For  indirect,  or  mediate,  transfusion  numerous  instruments  are  in  use. 
The  blood  may  l)e  simply  received  in  a  warmed  vessel,  tlie  fibrin  rapidly 
whipped  out  of  it,  if  the  operator  thinks  this  desirable,  and  the  residue 
injected  with  a  common  anatomical  injecting  syringe,  well  warmed  ;  or 


Aveling's  apparatus  for  immediate  or  direct  transfusion.  The  more  muscular  arm  on  the  right  of 
the  figure  is  the  bloodgiver's  ;  the  one  on  the  left  the  patient's.  The  course  of  the  veins  is  dotted  down, 
as  if  the  skin  and  the  hands  lying  in  front  of  them  were  transparent.  B  represents  the  hand  of  an 
assistant  holding  the  eflerent  tube  and  the  lips  of  the  small  wound  together,  and  a  shows  the  atfc-rent 
tube  secured  in  the  same  manner.  The  bevelled  end  of  the  afferent  tube,  which  is  made  so  in  order 
that  it  may  the  more  easily  go  into  the  collapsed  vein  of  t)ie  patient,  is  shown  in  Fig.  2.  The  noz- 
zles having  been  secured  in  the  two  veins,  the  india-rubber  portion  of  the  apparatus,  filUd  with  water, 
and  kept  so  by  turning  the  cocks  at  each  end  of  it,  is  now  fitted  into  the  tubes.  Then  the  cocks  are 
turned  and  the  operation  commenced  by  compressing  the  india-rubber  tube  on  the  efferent  side,  d, 
and  squeezing  the  bulb  c.  This  forces  5ij  of  water  into  the  patient's  vein.  Next  shift  the  hand  d  to  d', 
and  compress  the  tube  on  the  afferent  side.  The  bulb  will  expand  slowly  and  draw  blood  in  from  the 
bloodgiver's  vein,  which  is  then  to  be  passed  into  the  patient's;  and  by  repeating  this  manoeuvre  as 
often  as  required  any  amount  of  blood  may  be  injected,  so  long  as  the  tube  is  not  clogged  by  coagulum. 
See  Obstetric  Soc.'s  Trans.,  vol.  vi,  May  4,  1874. 


some  apparatus  may  be  used,  consisting  of  a  bowl  or  cup  to  receive  the 
blood,  and,  communicating  with  tliis,  an  appai'atus  something  like  a 
stomach-pump.  But  the  presence  of  valves  is  very  undesirable  in  any 
instrument  intended  for  the  transfusion  of  blood  not  defibrinated,  since 
tilery  are  liable  to  clog;  and  the  defibrination  of  the  blood  does  not  seem 
at  all  to  be  recommended,  for  it  necessitates  much  exposure  of  the  blood 
without  any  proved  advantage.  The  simpler  the  apparatus  the  better ; 
and  if  the  simple  instrument  of  Dr.  Aveling,  or  something  of  the  same 
kind,  is  not  at  hand,  it  would  be  better,  I  think,  to  use  a  common  ana- 
tomical syringe,  taking  care,  of  course,  that  it  is  carefully  warmed  to  a 
heat  of  100°  before  commencing  the  operation. 

Various  maladies,  and  especially  intermittent  fever,  have  been  treated 
by  transfusion  in  foreign  countries  (for  which  see  the  Medical  Times, 
as  above),  but  we  have  no  experience  of  the  practice  here,  and  not  much 
encouragement  from  the  published  reports  to  try  it. 

Lately  Mr.  Wagstaffe  has  used  milk,  and  milk  mixed  with  an  equal 


128  COLLAPSE. 

quantity  of  dcfibrinated  blood,  for  injection  into  tlie  veins,  using  an  ap- 
paratus originally  proposed  by  Dr.  Hamilton,  of  Ayr,  in  which  the  fluid 
is  injected  by  means  of  a  funnel  with  about  two  feet  of  tubing  attached 
to  it,  so  that  tlie  weight  of  the  fluid  forces  it  with  an  equable  pressure 
into  the  vein.'  But  neither  of  Mr.  Wagstaffe's  cases  were  successful,  so 
that  the  substitution  of  any  other  fluid  for  blood  in  these  cases  must  at 
present  be  looked  upon  as  at  best  a  doubtful  experiment. 


COLLAPSE. 

The  condition  called  collapse  is  that  of  total  suspension  of  some  and 
extreme  weakness  of  others  of  the  functions  of  the  nervous  system,  to- 
gether with  great  disturbance  of  the  circulation,  from  the  action  of  some 
sudden  cause.  This  cause  may  be  mental  emotion,  hjemorrhage,  violent 
injury  (and  especially  injury'  of  certain  organs,  such  as  the  abdominal 
viscera,  the  large  joints,  the  testicle,  the  mamma),  severe  pain,  and  cer- 
tain poisons. 

The  shock  may  be  so  great  as  to  prove  fatal  at  once.  Short  of  this  the 
state  is  that  of  "  extreme  collapse,"  which  is  thus  well  described  by  Mr. 
Savory  :'^ 

"  The  patient  lies  in  a  state  of  utter  prostration.  There  is  a  striking 
pallor  of  the  whole  surface,  most  marked  from  its  contrast  to  the  natural 
color  of  the  face  ;  the  lips  even  are  quite  pale  and  bloodless.  There  is  a 
cold,  clammy  moisture  on  the  skin,  and  often  distinct  drops  of  sweat  upon 
the  brow  and  forehead.  The  countenance  has  a  dull  aspect,  and  appears 
shrunken  and  contracted.  There  is  a  remarkable  languor  in  the  whole 
expression,  and  especially  in  the  eye,  which  has  lost  its  natural  lustre, 
and  is  partially  concealed  by  the  drooping  of  the  upper  lid.  The  nostrils 
are  usually  dilated.  The  temperature  is  considerably  reduced,  and  if  the 
person  be  a1)le  he  will  complain  of  feeling  cold,  and  perhaps  shudder. 
Muscular  debility  is  extreme — apparent  at  a  glance  in  the  condition  of 
the  lips  and  hands  ;  occasionally  even  to  the  relaxation  of  the  sphincters. 
The  pulse  is  generally  frequent,  sometimes  irregular,  always  very  feel^le, 
perha[)S  quite  imperceptible.  In  this  latter  case,  although  the  ear  may 
detect  the  fluttering  action  of  the  heart,  the  pulse  does  not  reach  the 
wrist.  The  respiratory  movements  are  short  and  feeble,  or  panting  and 
gasping,  'wanting  the  relief  of  sighs,' sometimes  imperceptible;  although 
in  the  majority  of  such  cases  some  action  of  the  diaphragm  maj'  be  de- 
tected by  careful  observation.  Vertigo,  with  dimness  of  vision,  super- 
venes. As  the  rule,  there  is  not  complete  insensibility,  although  there  is 
much  variability  in  this  respect,  depending  no  doubt  on  the  nature  of  the 
injury  ;  but  tlie  person  is  drowsy  and  bewildered,  yet  conscious,  and 
perliaps  rational,  when  roused.  Sometimes  the  intellect  is  singularly  clear 
and  the  senses  perfect ;  the  hearing  occasionally  even  painfully  acute.  In 
the  less  extreme  cases  theie  are  often  nausea  and  vomiting,  with  hiccough. 
The  last  is  very  variable  in  its  occurrence. 

"The  signs  of  syncope  arc  those  of  collapse.  Travers  says:  'The 
signs  of  syncope  and  the  recovery  from  it  present  an  epitome  of  tlie  phe- 
nomena of  shock.'  So  far  as  they  extend,  the  symi)toms  of  an  ordinary 
fainting  fit  are  analogous  to  those  of  collapse.  'They  differ  in  degree 
and  duration  more  than  in  kind.'  It  is  true  that  in  syncope  there  is  more 
uniformly  a  suspension  of  the  mental  faculties,  as  well  as  of  the  senses 


1  London  Med.  Record,  April  14,  1875  ^  Sygt.  of  Surg.,  vol.  i,  765-6,  2d  od. 


PROSTRATION    WITH    EXCITEMENT.  129 

and  voluntary  powers;  but  this  maj^  perhaps  be  explained  by  the  fact 
that  causes  which  produce  syncope  act  more  uniformly  on  the  brain." 

From  this  extreme  condition  of  collapse  there  are  all  possible  grada- 
tions, down  to  a  mere  transient  impression  on  the  heart,  pulse,  and  senso- 
rium,  such  as  is  familiar  to  everyone  who  has  ever  received  a  severe  blow 
or  felt  any  great  emotion. 

lieaclion  after  Collcqii^e. — The  immediate  symptoms  of  collapse  are 
followed  by  reaction,  and  in  this  stage  the  surgeon  forms  his  prognosis 
mainly  upon  the  rapidity  of  the  recovery  and  on  the  character  of  the 
pnlse  when  reaction  is  established.  Cases  in  which  the  patient  hovers 
long  between  life  and  death,  and  in  which  the  pulse  when  restored  is  weak, 
rapid,  and  excitable  ("prostration  with  excitement,"  as  Travers  desig- 
nated it),  are  very  unfavoi-able  ;  whilst  those  in  which  the  patient,  after 
transient  collapse,  recovers  his  senses  rapidlj',  and  in  which  the  pulse  be- 
comes gradually  more  and  more  firm  and  regular,  will  probably  terminate 
in  recovery. 

The  condition  of  prostration  with  excitement  is  one  which  we  have  only 
too  frequent  occasion  to  see  after  great  railway  injuries  and  otiier  fright- 
ful lesions  which  do  not  prove  fatal  at  once.  I  cannot  do  better  than 
again  quote  Mr.  Savory's  description  of  its  symptoms  ■} 

"  This  state  is  marked  at  first  by  dry  heat  of  the  skin,  a  flushed  face  and 
anxious  expression,  a  rapid  and  bounding  pulse,  which  is  sometimes  even 
sharp  but  always  easily  compressed.  The  respiration  is  hurried  and  im- 
perfect, with  partial  and  irregular  sighs.  The  tongue  is  tremulous;  there 
is  often  urgent  thirst;  vomiting  is  a  frequent  and  sometimes  most  obsti- 
nate s3mptom  ;  there  are  occasionally  rigors.  The  languor  or  stupor  of 
collapse  is  succeeded  b}*  restlessness,  jactitation,  tremor,  and  twitchings 
of  the  muscles,  prrecordial  anxiety,  often  but  not  always  delirium  of 
various  degrees,  from  occasional  incoherence  to  wild  and  fierce  excite- 
ment. This  most  frequently  occurs,  and  is  more  marked  during  the  night. 
There  is  either  an  entire  absence  of  sleep  or  it  is  partial  and  interrupted, 
and  it  is  succeeded  by  no  relief.  As  the  exhaustion  increases  the  skin 
becomes  covered  with  a  cold  and  clammy  sweat,  which  is  very  often  pro- 
fuse. The  face  becomes  pale  and  the  expression  haggard;  the  pulse 
innumerably  rapid,  irregular,  fluttering;  subsultus  comes  on  ;  slight  con- 
vulsions; coma  more  or  less  profound;  and  death." 

Treatment. — The  treatment  of  collapse  is  naturally  divided  into  two 
parts, — the  avoidance  of  immediate  death  in  the  first  shock,  and  the  treat- 
ment directed  to  carrying  the  patient  through  the  subsequent  reaction. 

The  first  care  of  the  surgeon,  when  called  to  a  case  of  collapse,  is  to  save 
the  patient  from  the  danger  of  instant  death.  For  this  purpose  warmth 
is  one  of  the  most  essential  requisites,  and  especially  applied  to  the  head; 
towels  wrung  out  of  hot  water  should  be  bound  round  the  head,  or  hot 
aff'usion  sedulously  employed,  together  with  heat  to  the  epigastrium  and 
the  extremities,  while  the  other  means  of  supporting  animation  are  in 
practice.  Galvanism  over  the  pr?ecordial  region  is  a  most  efficacious 
measure.  Small  quantities  of  brandy  are  to  be  given  by  the  mouth  if  the 
patient  can  swallow,  and  by  the  recium  if  he  cannot,  and  ammonia  is  to 
be  applied  to  the  nostrils.  If  the  heart  is  acting,  but  the  patient  seems 
otherwise  dead,  transfusion  is  clearly  indicated.  The  efforts  at  revival 
should  not  be  hastily  given  up  ;  recovery  after  long  seeming  death  is  not 
by  any  means  rai'e. 

Operations  in  Collapse — Ansesthetics. — Many  of  the  patients  whom  we 

1  Syst.  of  Surg.,  vol.  i,  2d  ed.,  p.  768. 
9 


130  COLLAPSE. 

see  in  the  hospital  practice  of  large  cities  are  collapsed  from  grievous  inju- 
ries which  must  call  ultimately  for  severe  operations  if  the  patient  is  to 
have  any  prospect  of  life.  In  such  cases  the  question  first  occurs  whether 
to  operate  at  once^  or  to  postpone  the  operation  till  the  patient  has  some- 
what rallied,  and  with  this  is  connected  the  question  whether  antesthetics 
are  desirable.  1  have  seen  operations  performed  in  conditions  of  extreme 
collapse,  without  any  manifestation  of  pain  on  the  patient's  part,  or  any 
apparent  increase  of  the  shock ;  but  wdien  the  operation  is  a  severe  one, 
such  as  a  large  amputation,  it  is  better,  I  think,  to  give  an  anaesthetic; 
nor  is  anaesthesia  under  these  circumstances  attended  with  danger.  1 
have  often  seen  the  pulse  improve  as  the  patient  came  under  the  influence 
of  the  anaesthetic.  Ether  is,  1  think,  preferable  to  chloroform  in  these 
eases,  and  it  is  well,  if  the  patient  can  swallow,  to  give  him  a  little  alcohol 
first.^  Such  operations  are  rarely  attended  with  any  danger  from  haemor- 
rhage, and  I  think  are  best  performed  as  soon  as  the  surgeon  believes 
that  the  patient  can  live  through  them. 

Treatment  of  Reaction. — When  the  danger  of  instant  death  is  over  the 
patient  has  still  to  be  kept  alive,  a  most  difticult  task  in  many  of  the  more 
formidable  cases.  "Stimulants  alone,"  as  Mr.  Savory  says,  "may  be 
required  in  the  first  emergency,  but  they  soon  prove  useless  if  unaccom- 
panied by  nourishment,"  and  in  these  cases  the  patient's  power  of  taking 
and  of  assimilating  food  is  too  often  suspended;  and  we  often  see  in 
cases  which  survive  that  the  first  effect  of  recovery  is  that  the  stomach 
rejects  the  fluid  which  has  been  poured  into  it,  and  which  it  is  unable  to 
digest,  showing  that  the  supply  has  been  excessive,  and  therefore,  to  some 
extent,  injudicious ;  yet  the  patient  has  been  in  so  alarming  a  condition 
that  the  surgeon  has  believed  that  without  stimulants  and  support  he 
must  die.  On  this  subject  Travers  speaks  as  follows:  "If  we  neglect  to 
supply  stimulus  when  called  for  the  spark  of  life  goes  out.  The  signs  of 
its  indication  must  therefore  be  vigilantly  observed.  We  are  maintain- 
ing action  upon  inadequate  power,  in  the  hope  that  the  natural  resources 
may  come  to  our  relief,  and  that  we  may  gradually  diminish  stimulus  and 
increase  nutriment,  which  is  our  only  method  of  raising  power  to  a  balance 
with  action.  The  respondence  of  the  circulating  forces  to  an  increased 
supply  of  stimulus  must  serve  as  a  caution  against  over-supply.  Since 
power  is  deficient,  we  must  carefully  husband  our  only  resource,  and  not 
waste  it  in  inordinate  action.  When  the  signs  of  reaction  are  manifested, 
its  excess  is  much  to  be  apprehended  if  such  reaction  has  been  obtained 
by  over-stimulation.  Excessive  reaction  so  induced  is  '  prostration  with 
excitement'  in  its  most  perilous  form.  When  such  a  state  is  the  original 
form  of  the  malady  it  is  probabl}^  less  dangerous,  because  in  this  case  the 
inequality  between  power  and  action  is  less."" 

The  practical  rule  to  be  deduced  from  these  considerations  is,  that 
whilst  death  from  collaijse  is  imminent,  the  circulation  must  be  main- 
tained by  artificial  heat,  galvanism,  and  by  the  administration  of  alcohol, 
but  that  the  supply  of  the  latter  should  be  carefully  graduated  by  the 
state  of  the  i)ulse  ;  that  it  should  be  given  in  small  quantities  as  frequently 
as  seems  necessary  ;  and  that  as  soon  as  the  itatient  can  bear  it  small  and 
frequently  repeated  doses  of  concentrated  fluid  nutriment  should  be  given 
by  the  mouth,  being  preceded  by  similar  nourishment  given  per  rectum 

'  Mr.  R.  Ellis  devised  an  apparatus  for  administering  the  vapor  of  alcohol,  ether, 
and  chloroform  successively,  first  pure  and  then  mixed.  I  used  this  method  in  a  case 
of  double  amputation  at  thl;  shoulder  and  near  thi;  hip  for  severe  railway  injury,  and 
the  patient's  pulse  was  certainly  better  aftc^r  than  before  the  operation. 

2  Syst.  of  Surg.,  vol.  i,  p.  770,  from  Travers,  On  Constitutional  Irritation. 


BURNS    AND    SCAT.DS.  131 

in  such  quantity  as  will  not  provoke  an  action  of  the  bowel,  and  that  the 
supply  of  alcohol  should  be  gradually  withdrawn  as  early  as  is  found  to 
be  possible. 

When  the  stage  of  reaction  is  established,  if  the  patient  passes  into  a 
condition  of  ordinary  traumatic  fever,  all  will  probably  go  well.  Hut  when 
the  stage  of  "prostration  with  excitement "  is  strikingly  manifested — i.  e., 
when  the  weakness  of  the  pulse  is  as  striking  as  its  rapidity,  when  the 
temperature  does  not  rise  in  correspondence  to  the  rise  in  the  i)iilse-rate, 
when  the  stomach  rejects  all  or  most  that  is  put  into  it,  and  the  patient 
is  sleepless,  restless,  and  more  or  less  delirious — then,  as  Mr.  Savory 
says,  "  the  indications  of  treatment  are  clear  and  simple  enough,  but  un- 
happily most  difficult  to  fulfil ;  to  support  and  increase  power,  and  to 
moderate  and  reduce  action."  The  patient  will  not  survive  if  worn  out 
by  restlessness,  which  must  therefore  be  combated  by  morphia  injected 
subcutaneously,  or  by  chloral  or  opium  in  full  doses,  if  the  stomach  will 
bear  it.  Mr.  Savory  speaks  highly  of  the  virtues  of  henbane  in  such  cases 
in  combination  with  opium,  if  the  latter  drug  can  be  tolerated.  The 
warmth  of  the  body  and  extremities  must  of  course  be  sedulously  main- 
tained, and  the  most  diligent  nursing  must  be  procured,  so  that  the  pa- 
tient may  not  be  exhausted  by  any  unfulfilled  craving  or  by  any  unneces- 
sary exertion.  The  irritability  of  the  stomach  must  be  lessened  by  the 
application  of  mustard  poultices,  by  sucking  small  morsels  of  ice  con- 
stantly, and  by  the  administration  of  dilute  hydrocyanic  acid,  three  or 
four  minims  in  a  small  quantity  of  some  vehicle,  or  creasote  trijij  in  pil. 
every  three  hours.  At  the  same  time  both  food  and  stimulants  must  be 
supplied,  and  must  be  assimilated  if  the  patient  is  to  be  kept  alive;  and 
there  lies  the  difficulty,  which  must  be  met  by  giving  the  food  in  the  most 
grateful  and  most  nourishing  form,  in  small  quantities  very  often  repeated, 
and  the  stimulant  (which  ought  not  to  be  more  than  is  absolutel}^  neces- 
sary) in  varied  kinds,  according  to  the  patient's  tastes  and  habits,  and 
with  similar  precautions  as  to  quantity  and  repetition. 


CHAPTER    V. 

BURNS   AND   SCALDS. 

Burns  and  scalds  are  the  most  commonly  fatal  of  all  injuries,  especially 
in  cold  climates,  alad  among  the  poor,  whose  children  are  frequently  left 
for  long  periods  in  the  neighborhood  of  fires  and  kettles  with  no  proper 
attendance.  Scalds  are,  as  a  rule,  less  fatal  than  burns,  since  the  hot 
liquid  is  soon  shaken  off"  the  body,  and  itself  soon  cools ;  but  there  are 
accidents  somewhat  resembling  scalds,  produced  by  the  contact  of  molten 
metal,  which  are  even  more  fatal  than  an  ordinary  burn,  because  the 
molten  mass  adheres  to  the  charred  parts  and  retains  its  heat  for  a  long 
period. 


132  BURNS    AND    SCALDS. 

Dupui/h'e)i-x  Claf<sificati'ou. — The  fatalit}'  of  bums  varies  according  to 
their  extent,  their  depth,  the  part  burnt,  and  the  age  of  the  patient,  be- 
sides a  number  of  other  miscellaneous  circumstances.  The  classification 
of  burns  according  to  their  depth,  which  is  usually  followed,  is  tliat  pro- 
posed long  ago  by  Dupuytren,  and  it  is  no  doulU  a  very  useful  and  prac- 
tical one,  though  it  only  indicates  the  depth  of  the  burn  at  its  deepest 
part;  and  it  must  be  recollected  that  a  large  superficial  burn  ma}' be  even 
more  dangerous  than  a  small  deep  one,  particularly  if  the  latter  is  situated 
on  an  unimportant  part.  But  deep  burns  must  be  followed  by  cicatrization 
and  deformity,  which  is  not  the  case  where  the  whole  of  the  thickness  of 
the  skin  is  not  destroyed. 

The  jfii-st  degree  of  burns  is  a  mere  scorch,  where  onl}-  superficial  red- 
ness is  produced  but  the  epidermis  is  not  separated  from  the  true  skin. 
The  scorched  epidermis  will  desquamate  afterwards,  but  beyond  a  little 
temporary  discoloration  no  trace  of  the  injury  will  remain. 

In  the  .second  degree  the  epidermis  is  raised  up  from  the  cutis  in  blis- 
ters or  bullfe,  which  are  produced  b_y  the  effusion  of  serum  from  the 
vessels  of  the  papillae,  showing  that  the  cutis  itself  is  scorched.  If  the 
epidermis  is  dragged  off' accidentally,  as  happens  often  in  removing  the 
clothes,  this  scorched  part  of  the  skin  will  inflame,  and  an  angry  sore  will 
result. 

In  the  third  degree  the  cutis  is  not  only  scorched  but  is  disorganized 
by  the  burn,  though  not  in  its  whole  thickness.  A  part  of  the  skin  (viz., 
the  papilla?  and  a  portion  of  the  thickness  of  the  corium)  is  charred  and 
dead,  and  this  part  must  separate  as  a  slough,  exposing  a  granulating 
surface  of  cutis  below^,  which  heals  by  cicatrization,  but  without  any  con- 
traction, since  the  uninjured  part  of  the  skin  maintains  the  shape  of  the 
parts. 

In  the  fourth  degree  the  whole  skin  is  burnt,  and  the  subcutaneous 
tissue,  of  course,  shares  to  some  extent  in  the  destruction ;  consequently, 
the  cicatrization  which  follows  on  the  separation  of  the  eschar  must 
involve  a  very  strong  tendency  to  contraction,  as  the  elastic  cellular  tissue 
is  replaced  by  the  inelastic  contractile  scar. 

In  the  fifth  degree  the  destruction  extends  below  the  fascia,  and  the 
muscles  and  other  subjacent  parts  are  burnt  to  a  variable  depth. 

In  the  sixth  degree  the  whole  of  the  limb  is  charred  and  consumed 
down  to  the  bone. 

Thus  the  first  degree  of  burn  involves  no  necessary  deformity  ;  the 
second  and  third  only  a  scar,  which  remains  during  life,  but  without  any 
change  in  the  shape  of  the  parts  ;  while  the  deeper  burns  are  accompanied 
by  a  tendency  to  contraction  and  deformity  which  can  only  be  averted 
b}'  very  great  care  in  api)lyiug  extension  and  counter-extension  while  the 
surface  is  healing,  and  as  this  is  frequently  impossible  (since  the  part  where 
counter-extension  should  be  applied  may  itself  be  burnt),  deformity  often 
ensues,  and  that  to  a  very  lamentable  degree. 

Hymptoma  and  Stages. — Burns  are  attended  with  great  pain  ;  and  when 
they  are  more  than  mere  local  injuries  they  are  followed  by  prostration 
or  total  collapse,  the  temperature  falls,  tiie  pulse  becomes  small  or  imper- 
ceptil)le,  tiie  tongue  and  mouth  are  dry;  the  patient  is  delirious,  and  rigors 
take  place  in  the  severer  cases.  This  is  the  first  stage,  or  that  of  collapse, 
prostration,  or  congestion  ;  aud  in  this  stage  many  cases  prove  fatal,  par- 
ticularly in  early  childhood,  death  being  sometimes  preceded  by  convul- 
sions. No  post-mortem  ajjpearances  will  be  found  except  congestion  of 
various  viscera,  particularly  the  brain — the  result  apparently  of  revulsion 
of  the  blood  from  the  surface. 


PATHOLOGY    OF    BURNS.  133 

The  next  stage  is  that  of  reaction,  or  of  inflammation.  It  may  be  said 
(very  rouglily )  to  follow  the  Hrst  after  an  interval  of  about  two  (la3's. 
The  burnt  surface  begins  to  sujipnrate,  usually  with  a  vcr}'  offensive  odor, 
the  i)ul^e  rises  in  force  and  freciuency,  and  tiiere  maybe  some  amount  of 
general  fever.  The  various  internal  inflammations  which  may  be  set  up 
by  the  proximity  of  the  burn  to  the  great  cavities  of  the  body  now  begin 
to  declare  themselves,  pleurisy  and  peritonitis  being  the  most  frequent. 
The  signs  of  such  internal  inflammation  are  usually  obscure  at  first,  es- 
pecially as  physical  examination  is  generally  impossible.  Disturbances 
of  tlie  digestive  system,  such  as  constipation,  followed  by  diarrlujea  or 
obstinate  vomiting,  are  common  in  this  stage  of  burns.  These  syn)ptoms 
may  be  caused  by  incipient  peritonitis,  or,  as  it  seems,  by  the  foulness  of 
the  discharge.  As  the  sloughs  separate  htemorrhage  may  take  place,  but 
it  is  very  rare.  In  fatal  cases  various  inflammatory  ai)pearances  are  found, 
chiefly  of  the  thoracic  and  abdominal  viscera,  for  the  brain  is  rarely  in- 
flamed in  burns  even  of  the  scalp.  Amongst  these  must  be  noted  the 
inflammation  and  ulceration  of  the  mucous  membrane  of  the  intestines 
which  sometimes  takes  i)lace.  It  is  usually  limited  to  the  duodenum, 
though  the  stomach,  or  the  rest  of  the  small  intestine  may  be  also  aflected, 
or  ma}'  even  be  ulcerated  in  eases  in  which  the  duodenum  is  intact.  The 
sul>ject  of  ulceration  of  the  duodenum  will  be  resumed  with  the  third  pe- 
riod, in  which  it  is  perhaps  most  common. 

The  third  period,  that  of  suppuration  and  exhaustion,  is  held  to  com- 
mence about  a  fortnight  after  the  accident,  or  else  is  said  to  begin  after 
the  slouglis  have  separated.  The  acute  symptoms  which  may  have  fol- 
lowed the  injury  will  have  subsided,  but  chronic  inflammation  is  not  by 
any  means  uncommon,  and  is  often  the  chief  cause  of  death.  The  pa- 
tient becomes  gradually  weaker  and  weaker,  and  in  this  stage  he  often 
succumbs,  perhaps,  after  exhausting  diarrhoia,  which  is  sometimes  accom- 
panied by  blood  in  the  motions.  Post-mortem  examination  may  show  no 
definite  visceral  lesion,  or  low  inflammation  of  the  lungs,  pleura,  perito- 
neum, or  intestines  may  have  been  present.  The  duodenum  may  be 
found  ulcerated  ;  and  in  this,  as  in  every  other  injury,  pyaemia  or  erysip- 
elas may  be  the  direct  cause  of  death;  but  neither  is  relatively  common 
in  burns.     1'etanus,  again,  sometimes  follows  the  irritation  of  a  burn. 

The  ulceration  of  the  duodenum  is  a  singular  and  hitherto  unexplained 
sequela  of  burns. ^  As  stated  above,  the  ulcerative  action  is  not  absolutely 
limited  to  the  duodenum,  but  the  instances  of  its  occurrence  in  other 
parts  of  the  intestine  are  purely  exceptional.  It  is  not  necessarily  fatal, 
for  cicatrized  ulcers  have  been  found  in  the  duodenum  where  death  has 
occurred  from  other  causes.'-'  It  occurs  at  different  periods  after  the  burn, 
the  earliest  hitherto  recorded  being  four  days  ;  but  it  is  rarely  so  early, 
and  is  more  common  after  than  before  the  first  fortnight.  It  occurs  after 
burns  of  the  extremities  as  well  as  those  of  the  chest  and  abdomen.  It 
is  found  in  a  tolerabl}'^  large  proportion  of  fatal  cases  (in  125  post-mortem 
examinations  16  presented  this  lesion),  and  may  very  possibly  be  present 

1  The  explanation  given  that  the  destruction  of  the  sweat-glands  of  the  skin  throws 
a  strain  on  Briinner's  ghinds,  which  are  then  charged  with  the  office  of  separating 
watery  elements  from  the  blood,  seems  to  me  more  ingenious  than  probable.  The 
traces  of  irritation  are  not  confined  to  Briinner's  glands,  for  the  solitary  glands  of 
the  rest  of  the  intestines  are  sometimes  found  enlarged  ;  and  there  is  no  proof  that 
either  Briinner's  or  the  other  glands  are  capable  of  any  such  vicarious  office  as  is  here 
assigned  to  them,  nor  is  the  transition  from  such  unnatural  activity  to  inflammation 
and  {)erforating  ulceration  at  all  obvious. 

2  Syst.  of  Burg.,  vol.  ii,  p.  23. 


134 


BURNS    AND    SCALDS. 


in  many  of  those  which  recover.  The  lesion  is  not  known  to  be  accom- 
panied by  any  definite  symptoms  in  its  early  stage.  Pain  on  pressure 
near  tlie  pit  of  the  stomach,  and  diarrhcea,  with  blood  in  the  motions, 
naturally  arouse  a  suspicion  of  this  ulceration,  and  vomiting  is  not  un- 
likely to  be  an  accompaniment  of  it;  but  there  are  many  other  ways  in 
which  pain  and  tenderness  of  the  stomach,  vomiting  and  diarrhoea,  may 

occur  in  burns,  and  even  some  blood  may 
^^•^'•27-  be    passed  in    the    motions   without    any 

breach  of  surface ;  obstinate  diarrhoea, 
however,  and  copious  loss  of  blood  would 
point  strongly  to  ulceration.  When  the 
lesion  proves  fatal  it  is  either  by  h.nemor- 
rhage  or  by  perforation  through  the  coats 
of  the  bowel  into  the  peritoneal  cavity. 
The  accompanying  illustration  shows  a 
large  artery,  the  pancreatico-duodenalis 
superior,  laid  open  b}'  an  ulcer  of  this  kind  ; 
and  our  museums  contain  plenty  of  speci- 
mens of  perforation.  The  ulcer  is  gener- 
ally single,  cleanly  punched  out  of  the 
mucous  membrane,  and  situated  close  to 
the  pylorus. 

I  have  purposely  abstained  here  from 
any  reference  to  a  very  common  cause  of 
death  in  burns  and  scalds — viz.,  the  injur^'^ 

Ulceration  of  the  duodenum  in  a  burn,    which    is    SO    oftCU    douc    tO    the  larynx  by 

causing  death  by  ha^morrh^^^^^^^  inhaling  the  flame  or  the  hot  fluid— think- 

large  branch  of  the  paucreatico-duode-  c 

naiis  artery,  a.  The  pylorus.  6.  The  ui-  ing  it  better  to  treat  the  subject  aloug  with 
cer  on  the  duodenum,  close  below  the  the  Other  injuries  of  the  air-passagcs  (see 
pylorus.   c,d.  Bristles  passed  through  the   ^i^g    chapter    ou    Iniurics   of   the  "  Neck)  1 

artery  and  vein,  which  are  seen  to  open     ,,,,  ,.      ..  i-i       i        in 

freely  on  the  ulcer.-From  Syst.  of  Surg.,     t>Ut  the  SUbjeCt  IS    OUC  whlch  should  never 

vol.  ii,  p.  22, 2d  ed.  be  absent  from  the  surgeon's  mind.     The 

mouth  and  pharj^nx  should  be  closely  in- 
spected, if  it  can  be  done  without  difficult}^,  in  every  case  where  the  burn 
or  scald  is  at  all  near  the  lips.  If  this  cannot  be  managed  without  too 
much  disturbance  to  the  patient,  a  good  idea  of  the  immunity  or  other- 
wise of  the  interior  of  the  mouth  will  be  obtained  by  watching  the  patient 
swallowing  and  breathing,  and  every  precaution  should  be  taken  to  have 
help  promptly  at  hand  in  an}^  case  which  may  be  likel}^  to  require  trache- 
otomJ^  If  the  mouth  be  much  burnt  it  n:ay  be  right  to  feed  the  patient 
through  tlie  nose,  and  to  eke  out  the  support  and  stimulants  which  can 
be  given  through  the  pharynx  by  nutrient  injection  into  the  rectum. 

Local  Treatment. — The  treatment  of  burns  is  directed — 1.  To  the  im- 
mediate lesion  ;  and,  2,  to  its  after  consequences.  At  tlie  time  of  the 
accident  the  main  indications  are  to  exclude  the  air  from  the  burnt  sur- 
face, to  allay  pain  by  opiates,  and  to  give  stimulants  in  such  ([uautities 
as  ma}'  be  necessary.  The  applications  which  are  in  use  for  burns  are 
too  numerous  to  mention,  and  the  choice  of  one  or  other  of  them  will 
depend  in  a  great  measure  on  the  depth  of  the  burn.  A  mere  superficial 
scorch  is  best  treated  by  some  warm  lotion  applied  on  a  thick  rag  and 
kept  constantly  moist.  Goulard  water  with  a  little  laudanum  is  perhaps 
as  grateful  as  anytliing.  Painting  the  surface  witli  iidc  soon  relieves  the 
pain  of  a  small  superficial  burn,  or  covering  it  with  whitewash  or  some 
other  similar  substance  which  will  crust  over  it  and  completely'  exclude 
the  air  from  it.     Common  flour  thickly  dredged  on  the  part  is  a  very  good 


TREATMENT    OF    BURNS.  135 

and  handy  application.  But  such  crusts  should  not  be  applied  over  iuirnt 
surfaces  of  the  second  desjree,  since  their  removal  would  soon  become 
necessai'v,  and  this  would  drag  off  the  epidermis.  The  bullje  should  be 
pricked,  the  epidermis  gently  smoothed  down,  and  some  simple  ointment 
put  next  the  skin,  or  some  oily  substance  whicli  will  not  stick  when  it  is 
necessary  to  change  it.  A  very  favorite  ap[)lication  to  these  burns  and 
to  others  of  greater  depth  is  the  Carron  oil,  made  by  mixing  lime-water 
and  linseed  oil  in  equal  parts,  and  deriving  its  name  from  its  having  come 
into  extensive  use  at  the  great  Carron  Foundry  in  the  numerous  burns 
occurring  there.  Oil  of  turpentine  is  a  very  good  application  to  those  in 
which  the  surface  of  the  skin  is  quite  destroyed.  But  for  the  first  days 
I  doubt  whether  anytliing  is  better  than  simply  swathing  the  part  in  thick 
layers  of  cotton-wool,  vvhich  is  prevented  from  sticking  to  the  burnt  sur- 
face by  some  simple  ointment  (Cerat.  Calaminse  is  generally  used)  spread 
on  thin  soft  linen  or  Cambric,  and  covering  the  whole  burnt  surface. 
When  after  a  few  days  the  discharge  becomes  foul,  this  dressing  should 
be  changed  for  some  deodorizing  or  antiseptic  oily  application,  or  the 
latter  may  be  used  from  the  first;  but  all  the  antiseptics  I  have  yet  seen 
used  have  been  stimulating,  and  for  the  first  few  days  it  is  desirable,  I 
think,  to  avoid  any  local  stimulation.  The  carbolized  oil  answers  every 
indication  better  than  any  other  substance  which  I  know  of,  but  it  should 
not  be  used  too  strong;  for  it  may  both  prove  too  stimulating,  and  thus 
increase  the  discharge,  and  it  may  be  absorbed,  producing  a  black  con- 
dition of  the  urine^  and  other  symptoms  of  incipient  poisoning.  It  is 
Avell,  then,  to  begin  with  a  very  weak  solution  (about  1  to  12),  and  if  this 
does  not  correct  the  fetor  its  strength  may  be  gradually  increased,  or  a 
stronger  solution  of  carbolic  acid  may  be  placed  over  the  dressings.  If 
carbolic  acid  is  not  tolerated,  some  preparation  of  benzoin,  or  Condy's 
solution,  or  the  Lot.  Sodae  Chlorinatfe  may  be  applied  either  directly  to 
the  burnt  surface  or  over  the  dressings.  As  the  sloughs  separate  they 
should  be  removed  at  once,  and  any  part  of  the  slough  which  is  hanging 
loose  should  be  cut  away,  so  that  fetor  may  be  diminished  as  soon  and 
as  much  as  possible.  It  is,  in  fact,  to  the  foul  air  which  fills  the  sick-room 
that  many  surgeons  with  much  reason  attribute  a  great  share  in  produc- 
ing the  mortality  of  the  latter  stage  of  burns.  It  keeps  the  patient  in  a 
low  condition,  destroys  his  appetite,  and  very  probably  keeps  up  or  pro- 
duces diarrhoea.  And  in  hospitals  it  often  poisons  the  whole  air,  not  only 
of  the  ward  itself,  but  of  all  parts  of  the  house  which  communicate  with 
it.  Hence  the  importance  of  remedying  it  in  all  possible  ways.  So  long 
as  there  are  offensive  burns  in  a  sick  chamber  or  hospital  ward  the  atmos- 
phere may  be  partially  sweetened  by  carbolic  acid,  by  burning  cascarilla 
bark  or  by  exposing  chips  of  iodine,  by  diffusing  Condy's  solution  or 
other  deodorizing  fluids  in  the  pulverized  condition  about  the  room,  but 
it  cannot  be  doubted  that  some  mephitic  gases  will  still  remain  uncor- 
rected. After  all  sloughs  have  come  away  the  patient  has  still  to  undergo 
all  the  troubles  incident  to  a  long  cicatrization,  and  often  the  filling  up 
of  a  deep  cavity.  The  greatest  care  should  now  be  bestowed  to  keep  the 
parts  in  such  a  position  as  to  obviate  contraction  if  possible  ;  and  the 
recent  happy  invention  of  skin-grafting  has  provided  us  with  a  means  of 
hastening  the  process  of  healing  when  tardy,  and  of  providing  the  ma- 
terials of  a  scar  when  the  surface  is  too  extensive  to  fill  up  naturally, 
which  is  of  the  greatest  utility  in  burns  (see  the  section  on  Skin-grafting). 
General  Treatment. — At  tlie  time  of  the  accident  opium  should  be  lib- 

1  See  St.  George's  Hospitiil  Reports,  vol.  vi,  p.  98. 


136  LIGHTNING-STROKE. 

erally  given  to  adults,  and  even  in  the  case  of  children  it  is  usually  neces- 
sary, though  more  caution  should  be  used  ;  or  it  may  be  thouglit  desirable 
to  administer  chloroform  for  tlie  removal  of  the  clotlies  and  the  first  dress- 
ing, and  to  keep  up  partial  insensibility  by  injecting  morphia  subcutane- 
ously  before  the  patient  has  quite  recovered  from  the  auixjsthesia.  Stim- 
ulants must  also  be  given  if  there  is  mnch  collapse,  but  they  should  not 
be  poured  down  indiscriminately,  for  the  administration  of  an  excessive 
quantity  of  alcohol  is  always  followed  by  reaction  and  renewed  prostra- 
tion ;  the  pulse  must  be  carefully  watched,  and  only  so  much  brandy  or 
wine  given  as  is  required  to  keep  it  at  a  moderate  rate  and  strength.  If 
the  patient  can  take  food  in  good  quantity  this  is  a  better  source  of 
warmth  and  power,  and  the  power  of  assimilating  food  afibrds  a  good 
augury  of  recovery.  If  the  patient  be  a  child  convulsions  are  to  be 
dreaded,  and  are  a  frequent  cause  of  death.  They  appear  to  depend  on, 
or  to  be  connected  with,  congestion  of  the  brain,  and  are  therefore  better 
treated  bj^  warmth  to  the  surface  than  by  an)'  other  plan.  The  warm  bath 
being  here  inadmissible,  warm  affusion  to  the  head,  or  cloths  wrung  out 
of  hot  water,  should  be  tried.  Diarrhoea  must  be  treated  by  opium  or  by 
calomel  and  opium,  or  by  starch  and  laudanum  enema,  the  air  being- 
changed  as  often  as  possible,  if  foul.  Vomiting  is  to  be  controlled  if  pos- 
sible b}'  prussic  acid  or  by  creasote.  It  is,  however,  of  the  last  impor- 
tance in  severe  cases  of  burn  not  to  exhaust  the  patient's  strength  need- 
lessl)'  by  too  frequent  changes  of  dressing,  and  this  is  still  more  impor- 
tant in  childhood,  when  terror  and  screaming  add  to  the  exhaustion  which 
is  necessarily  caused  by  the  pain  and  the  change  of  posture,  besides  prob- 
ably causing  some  bleeding  from  the  granulations.  So  that  burns  ought 
never  to  be  dressed  too  frequentl)'- ;  and  the  surgeon  has  often  great  dif- 
ficulty in  steering  his  way  between  these  contrary  indications,  since  if  he 
puts  off  the  renewal  of  the  dressing  too  long  the  foulness  of  the  atmos- 
phere becomes  a  source  of  danger. 

Amputation  in  Burns. — Finally,  it  may  become  a  question  in  some 
cases  whether  amputation  is  ilesirable.  This  question  occurs  commonly 
only  in  the  case  of  single  fingers  or  toes,  or  of  parts  of  the  foot.  It  is 
but  rarel}'  that  anything  is  gained  by  amputation,  for  the  parts  around 
the  burn  for  some  distance  are  sure  to  be  more  or  less  injured  and  prone 
to  inflammation,  so  that  the  surgeon  could  not  get  materials  for  a  healthy 
stump  without  going  too  high  above  the  seat  of  injury;  and  burns  so 
severe  as  to  disintegrate  a  large  portion  of  a  limb  are  also  attended  with 
an  amount  of  prostration  whicli  forbids  amputation,  at  least  at  the  time. 
After  the  patient  has  rallied  the  surgeon  may  think  it  better  to  relieve 
him  of  a  member  wliicli  can  only  be  a  useless  incumbrance,  but  such  cases 
must  be  conducted  on  the  same  general  principles  as  those  which  are  ap- 
plicable to  secondary  amputation  for  other  kinds  of  injury. 

Plastic  Operations. — When  recovery  has  been  completed  and  the  sur- 
face has  cicatrized,  great  deformity  is  often  left,  requiring  i^lastic  opera- 
tion, or  gradual  extension,  or  some  otiier  proceeding  by  which  the  parts 
may  be  restored  to  tlieir  normal  appearance  and  function  as  far  as  may  be 
possible.  But  1  think  it  better  to  reserve  tiiis  topic  for  discussion,  under 
the  head  of  Plastic  Surgery,  in  a  future  chapter. 


LIGHTNING-STROKE. 

A  stroke  of  lightning  produces  injuries  wliich  are  the  combined  effect 
of  electric  shock,  mechanical  concussion,  and  burn.     The  symptoms  vary 


FRACTURES.  137 

from  instant  death  to  a  very  trivial  amount  of  shock.  The  effects  are 
very  various.  The  surface  of  the  body  may  be  burnt  more  or  less  severely ; 
it  may,  as  is  said,  be  marked  by  arborescent  lines,  which  are  believed  to 
be  in  a  sort  of  way  photographed  from  neighboiing  trees  or  other  objects  ; 
the  hairs  may  be  removed  or  may  fall  out  soon  afterwards  ;  the  special 
senses,  especially  that  of  sight,  may  be  more  or  less  impaired  or  even 
totally  destroyed;  the  other  functions  of  the  brain  may  be  variously  af- 
fected, sometimes  to  the  extent  of  total  paralysis;  and  other  less  definite 
and  less  certain  effects  have  been  described. 

In  cases  of  sudden  death  from  lightning  it  appears  that  the  muscles 
are  usually  made  rigid  at  once,  though  this  rigor  is  sometimes  so  transient 
that  some  writers,  notably  John  Hunter,  teach  that  there  is  no  rigor  mor- 
tis in  such  cases;  but  the  amount  and  duration  of  rigor  vary.  In  some 
cases  there  is  excessive  and  long-continued  stiffness,  the  blood  is  often 
uncoagulated,  and  the  heart  flaccid  and  empty. 

The  indications  for  surgical  treatment  in  cases  of  apparent  death  from 
lightning  are  thus  given  by  Brodie:'  "Expose  the  body  to  a  moderate 
warmth,  so  as  to  prevent  the  loss  of  animal  heat,  to  which  it  is  alvva3^s 
liable  when  the  functions  of  the  brain  are  suspended  or  impaired  ;  and 
inflate  the  lungs,  so  as  to  imitate  the  natural  respiration  as  nearly  as 
possible." 

The  minor  injuries  must  be  treated  on  general  principles.  Galvanism 
appears  the  most  appropriate  remedy  for  any  partial  loss  of  cerebral 
power,  and  should  be  used  in  a  mild  form  for  a  very  long  time,  combined 
with  small  doses  of  strychnia  and  other  tonics.  It  has  often  been  noticed 
that  success  has  attended  this  treatment,  when  long  persevered  in,  even 
in  cases  where  the  special  senses  had  at  first  been  very  seriously  impaired. 


CHAPTER    VI. 

GENERAL  PATHOLOGY   OF   FRACTURES   AND   DISLOCATIONS, 
INCLUDING  THE  PROCESS  OF  UNION  IN  HARD  PARTS. 

FRACTURES. 

A  FRACTURE  is  defined  as  being  a  sudden  and  violent  solution  of  con- 
tinuity in  a  bone.  The  force  which  produces  it  (its  immediate  cause)  is 
generally  external,  though  in  some  cases  muscular  action  causes  fracture. 
Occasionally  disease  of  the  bones  acts  as  a  predisposing  cause  of  fracture, 
such  diseases  being  rickets,  senile  atrophy,  cancer,  mollities  ossium, 
necrosis,  strumous  or  syphilitic  inflammation. 

Classification. — Fractures  are  always  divided  by  English  authors  into 
simple.,  which  do  not  communicate  with  the  external  air;  and  compound, 

1  Works,  edited  by  Charles  Hawkins,  vol.  i,  p.  442. 


138 


FRACTUKES. 


which  are  exposed  to  the  air  through  a  wound  in  the  soft  parts  ;  and  the 
distinction  is  an  important  one,  since,  as  a  rule,  the  two  kinds  of  frac- 
tures involve  a  very  different  amount  of  danger,  and  unite  in  a  very 
different  manner. 

Fractures  are  also  divided,  according  to  the  nature  of  the  separation, 
into  single,  multiple,  incomplete,  and  complicated,  and  these  are  again 
subdivided. 

Transverse,  Oblique,  and  Dentated  Fracture. — Thus  single  fractures 
may  be  tranaverse,  oblique,  or  dentated.  It  may  be  true,  as  stated  by 
Malgaigne,  that  the  fractures  of  long  bones  are  never  truly  transverse, 
3-et  the  distinction  is  very  important  in  practice  between  a  fracture  which 
runs  in  a  tolerably  transverse  direction  and  one  which  is  perceptibly 
oblique,  since  the  latter  is  so  much  more  liable  to  displacement  than  the 
former.  The  terms  explain  themselves,  but  good  examples  of  each  form 
of  fracture  will  be  found  in  some  of  the  illustrations  in  the  sequel.  Trans- 
verse fracture  is  best  illustrated  by  the  common  fracture  of  the  patella 
(q.  v.).  A  good  specimen  of  oblique  fracture  is  figured  in  the  section  on 
fractures  of  the  lower  end  of  the  femur,  and  of  dentated  fracture  on  p.  147. 

To  these  classes  of  single  fractures  separations  of  the  epiphj'ses  should 
be  added ;  they  will  be  further  treated  of  below. 


Fig.  28. 


Incomplete  or  "green-stick  "  fracture  of  the  clavicle,  from  a  preparation  (Ser.  1,  No.  76)  in  the  Museum 
of  St.  George's  Hospital  (Syst.  of  Surg.,  2(i  ed.,  vol.  ii,  p.  43). 

Splintered  and  Comminuted  Fractures. — Multiple  fractures  are  those 
in  which  the  same  bone  is  broken  in  two  or  more  different  parts  of  the 
limb,  or  in  which  there  are  fractures  of  two  or  more  different  bones  ;  or 
in  which,  along  with  a  complete  fracture,  a  splinter  has  been  separated 
from  the  rest  of  the  bone  ("splintered  fracture"),  or  in  which  there  are 
several  lines  of  fracture  comminuting  the  bone,  i.  e.,  separating  one  or 
several  large  portions  from  it  ("comminuted  fracture"). 

Incomplete  fractures  are  either  simple  fissures,  very  common  in  the 
flat  bones,  such  as  the  skull,  and  seen,  though  rarely,  in  the  bones  of  the 
limbs  ;  or  bending  of  tlie  bone,  which  is  usually  the  result  of  green-stick 
fracture,  i.  e.,  of  fracture  of  a  portion  of  the  fil)res  of  the  bone,  while  the 
remainder  are  unljroken  (Fig.  28),  such  as  occurs  when  a  soft  bough  is 
bent;'  or  perforations,  though  tliose  are  better  described  as  wounds  of 
bone,  or  splintering,  when  a  small  piece  only  is  detached  from  the  bone, 
its  continuity  as  a  whole  being  uninterrupted.  The  bone  itself  may  be 
entirely  fractured,  but  the  periosteum  may  remain  untorn,  and  this  seems 
more  common  in  fractures  of  tlie  ribs  than  in  any  other  bone. 

Complicated  fractures  are  those  in  which  a  joint  or  some  neighboring 


'  Bending  is  helioved  .sometimes  to  occur  in  tho  skulls  of  infants  without  the  rup- 
ture of  any  of  the  bony  fibres. 


FRACTURES. 


139 


cavity  is  injured  (as  the  pleura  in  fractured  ribs)  or  where  there  is  lesion 
of  some  large  vessel,  or  a  wound  not  expos- 
ing the  fracture. 

Sej^arations  of  the  epiphyses  are  injuries 
which  it  is  frequently  dilticiilt,  sometimes  im- 
possible, to  distinguish  from  fracture;  in  fact, 
pure  separation  of  the  epiphysis  occurs  ver}' 
rarely,  for  in  the  injuries  which  are  so  de- 
nominated the  fracture  usually  involves  the 
shaft  to  some  extent,  as  well  as  the  epiphysial 
cartilage.*  In  a  pure  separation  of  the  epiphy- 
sis (t. «.,  where  the  line  of  the  fracture  runs 
through  the  cartilage  only,  and  does  not 
trench  on  the  bony  tissue  either  of  the  shaft 
or  the  epiphx'sis)  it  is  presumable  that  there 
would  not  be  the  true  bou}'  crepitus,  though 
there  might  be  some  analogous,  but  less  dis- 
tinct, sensation.  Where  the  line  of  junction 
is  broad,  as  in  the  upper  end  of  the  humerus 
or  lower  end  of  the  femur,  there  will  be  no 
shortening,  but  the  lower  fragment  will  most 
likely  project.^  If  the  line  of  junction  be 
within  a  joint,  swelling  of  the  joint  will  take 
place.  The  nature  of  the  accident  will  then 
be  marked  by  the  loss  of  power  following  in- 
jury in  a  patient  of  appropriate  age,  the  posi- 
tion of  the  displacement,  the  mobility  of  the 
epiphysial  fragment  (which,  however,  cannot 
be  always  ascertained),  and  possibly  by  the 
character  of  the  crepitus,  with  the  symptoms 
of  injury  to  the  joint.  The  treatment  must 
be  the  same  as  for  fracture.  The  chief  im- 
portance of  the  subject  is  that  such  injuries 
are  sometimes  followed  b\'  suspended  growth 
of  the  bone,  producing  deformity,  apparently 
as  the  result  of  degeneration  of  the  cartilage 
after  the  injury,  whereby  it  loses  its  power  of 
ossification.  Further  remarks  on  these  in- 
juries will  be  found  under  the  heads  of  frac- 
ture of  the  various  bones. 

The  symptoms  of  fracture  are  divided  into 
the  rational  and  the  sensual.  The  former  are 
inferential  only,  and  are  given  either  by  the 
lesion  which  the  fracture  produces,  such  as 
the  injury  to  neighboring  viscera  (of  much  im- 
portance in  the  chest,  head,  and  pelvis),  or  by 
the  loss  of  power  caused  by  the  fracture. 

The  sensual  symptoms  are  further  divided 
into  those  which  are  equivocal,  such  as  pain, 
swelling,  and  ecchymosis;  and  those  which  are 
uue(iuivocal,  the  latter  being  («)  the  crack  heard  or  felt  by  the  patient 


A  preparation  in  St.  George's 
Hospital  Museum  (Ser.  i,  No.  137), 
showing  ttie  lower  epiphyses  of  the 
femur  and  tibia  and  both  epiphyses 
of  the  fibula  separated  in  the  same 
injury. — From  Holmes's  Surg.  Dis. 
of  Childhood. 


1  See  Holmes's  Dis.  of  Childhood,  2d  ed.,  p.  238. 

2  See  a  figure  in  the  section  on  fractures  of  the  upper  end  of  the  humerus. 


140  FRACTURES. 

at  the  time  of  the  accident,  wliich,  for  obvious  reasons,  is  not  commonly 
observed;  (6)  the  unnatural  mobility  of  tlie  fragments,  which,  however,  is 
absent  when  the  fragments  are  impacted.,  i.  e.,  one  fragment  di'iven  into 
the  su])stance  oftlie  other, ^  and  in  all  fractures  of  the  skull,  most  of  tliose  of 
the  ribs  and  pelvis,  besides  many  others;  (c)  the  deformity  or  displace- 
ment :  which  is  decisive  in  all  cases  where  it  exists,  but  it  is,  of  course, 
very  often  absent.  The  disi)lacement  of  fractures  is  divided  for  purposes 
of  description,  into  (1 )  lateral  or  transverse,  wdien  the  fragments  lie  more 
or  less  by  the  side  of  each  other ;  (2)  shortening,  or  riding,  or  vertical 
displacement,  when  the  lower  fragment  ascends  above  the  lower  end  of 
the  upper;  (3)  angular  displacement,  when  one  or  both  deviate  from  the 
axis  of  the  limb ;  (4)  rotation,  when  one  or  both  are  twisted  on  tlieir 
own  axis;  and  (5)  absolute  separation.  It  will  be  obvious  that  all  the 
forms  of  displacement  may  be  variously  combined.  Displacement  is 
produced  by  the  action  of  the  original  violence,  aided  in  some  cases 
by  the  weight  of  the  bod}',  or  by  subsequent  violence  or  by  muscular 
action,  (d)  The  last  and  the  most  imi)ortant  of  the  sensual  symptoms 
of  fracture  is  the  crepitus,  or  the  crackling  sensation  and  sound  pro- 
duced b}'  rubbing  the  two  fragments  on  each  other.  This  crepitus  is  the 
sign  commonly  looked  for,  and  when  found  is  usually  decisive  of  the 
nature  of  the  injury ;  but  it  is  not  always  present,  and  in  some  excep- 
tional cases  its  presence  is  not  decisive  of  the  existence  of  fracture.  It 
is  a  grating  sensation  which  a  little  practice  soon  makes  familiar  and 
unmistakable  to  the  surgeon  ;  but,  as  it  is  produced  by  rubbing  the 
fractured  ends  on  each  other,  it  cannot  be  felt  when  these  are  immovable, 
as  in  all  impacted  and  many  dentated  fractures,  or  when  the  fragments 
are  not  in  apposition,  as  when  they  ride  on  each  other  (though  in  this 
case  and  in  some  cases  of  impaction  they  may  be  brought  into  apposition 
or  made  movable  by  extension),  or  are  entirely  separated,  as  in  many 
cases  of  fractured  patella;  and  in  some  cases  where  one  of  two  bones  of 
a  limb  is  broken,  and  the  sound  bone  prevents  any  movement  being  im- 
pressed on  the  broken  fragments  of  the  other.  It  seems- also  that  some 
fragment  of  muscles  or  blood-clot  may  get  between  the  fragments  and 
prevent  crepitus.  Taken  altogether,  however,  it  may  be  said  that  such 
cases  are  exceptional,  and  that  in  most  of  them  the  presence  of  frac- 
ture may  be  made  out  b}-  the  other  signs.  Crepitus  may  be  present 
in  cases  where  there  is  no  fracture.  Effusion  into  the  sheaths  of  ten- 
dons or  into  the  cavit}'  of  a  joint  will  produce  a  sensation  much  resem- 
bling crepitus.  Effusion  round  the  dislocated  head  of  a  bone  sometimes 
leads  to  a  crepitus  which  very  closely  simulates  that  of  fracture;  and 
caries  of  the  joint  surfaces  is  accompanied  by  a  crepitus  under  passive 
motion  which  is  identical  with  that  of  broken  bone.  So  that  cases  do 
occur  in  wliich  dislocation  with  considerable  swelling,  or  a  contusion  or 
sprain  of  a  diseased  joint  is  accompanied  with  crepitus,  like  tliat  of  frac- 
ture. ]5ut  sucii  cases  can  be  distinguished  b}'  careful  examination,  espe- 
cially witli  the  aid  of  chloroform.  It  may  be  occasionally  im})ossible  to 
be  quite  certain  of  the  absence  of  fracture  in  cases  of  severe  contusion 
and  in  injuries  of  the  chest,  but  in  such  instances  it  is  more  prudent  to 
treat  the  cases  as  a  fracture.  In  injuries  oftlie  head  also  it  is  impossible 
to  aflirm  the  absence  of  a  simple  fracture  without  displacement.  But  the 
point  is  one  of  little  moment.  Tlius  it  ma}^  be  confidently  stated  that 
fractures  constituting  substantial  injuries  are  usually  easy  to  diagnose. 
Treatme.nt. — The  general  indications  of  treatment  are  very  simple,  but 

*  Characteristic  illustrations  of  impacted  fracture  are  furnished  by  the  extra-cap- 
sular  fracture  of  the  cervix  femoris.     See  the  section  on  that  subject. 


TREATMENT.  141 

the  method  of  carrying  them  out  in  practice  can  onl_y  be  understood  1)3^ 
studying  each  fracture  separately.  These  general  indications  are:  (l)to 
reduce  or  "set  "  the  fracture,  i. «.,  to  place  both  fragments  in  tlie  position 
which  tiiey  occupied  before  the  accident;  (2)  to  maintain  the  fractured 
ends  in  position  for  a  period  wliich  experience  shows  to  be  sufficient  to 
avoid  further  displacement,  and  which  varies  for  different  fractures  and 
at  dirterent  ages;  (3)  to  counteract  unfavorable  symptoms  and  com- 
plications. 

1.  Setting  the  Fracture. — A  patient  known  or  suspected  to  have  re- 
ceived a  fracture  ought  to  be  conveyed  home  with  all  possible  care, 
having  the  limb  defended  by  some  temporary  contrivance  from  all  risk 
of  further  movement,  whereby  many  simple  fractures  ave  made  com- 
pound. For  this  purpose  pieces  of  tliin  board  or  of  sticks  or  of  paste- 
board may  be  used,  witli  such  impromptu  bandages  as  can  easily  be 
made  out  of  the  clothes.  He  should  he  placed  in  bed  (in  cases  at  any 
rate  of  fracture  of  the  lower  limbs)  before  any  serious  examination  is 
made,  and  the  clothes  carefully  cut  off  the  injured  limb.  Then,  in 
order  to  reduce  the  displacement,  its  nature  should  first  be  carefully 
ascertained,  and  steady  gradual  fxtem^ion  made  in  the  appropriate  direc- 
tion by  the  surgeon,  or,  if  necessary,  by  an  assistant.  Another  assistant 
\t\QkQ&  cowiter-exteni^ion^  i.e.,  steadies  and  fixes  the  upper  part  of  the 
limb  and  body  so  that  the  extending  force  acts  on  the  lower  fragment 
only.  When  by  these  means  the  proper  length  is  restored,  a  little  judi- 
cious manipulation  will  remedy  any  angular,  lateral,  or  rotatory  displace- 
ment. In  impacted  fracture  more  [)owerful  extension  may  be  required  in 
order  to  disengage  the  fragments  and  restore  the  length  of  the  limb,  for 
whicii  purpose  chloroform  is  to  be  given.  But  the  violence  necessary  to 
disengage  an  impacted  fracture  often  produces  disastrous  consequences, 
and  in  most  cases  the  patient  will  be  well  advised  to  submit  to  the  de- 
formity wliich  must  ensue  rather  than  run  the  risks  incidental  to  violent 
extension. 

In  setting  a  compound  fracture  there  is  often  great  difficulty  from  the 
protruding  fragment  being  tightly  girt  by  the  skin  and  other  parts,  or 
from  the  irregular  projection  and  interlocking  of  comminuted  fragments. 
It  must  be  remembered  that  there  are  two  ways  in  which  a  fracture  may 
be  made  compound,  which  are  best  illustrated  by  fractures  of  the  leg. 
In  one  case  a  cart-wheel  may  have  passed  over  the  limb,  crushing  and 
tearing  the  soft  parts  off  the  bone  at  the  same  time  that  the  latter  is 
fractured.  In  this  case  tliere  will  most  likely  be  a  large  wound,  giving 
free  access  to  the  fragments,  which  are  not  likely  to  be  embraced  by  tiie 
wound,  though  comminuted  portions  may  require  removal  or  replace- 
ment before  they  can  be  accurately  adjusted.  In  another  case  a  man  re- 
ceives a  simple  fracture,  and  in  his  efforts  to  raise  himself  or  in  other 
muscular  efforts  he  drives  one  fragment  (generally  the  upper)  through 
the  skin.  The  fragment  often  protrudes  to  a  great  distance,  and  is  tightly 
grasped  by  the  skin;  but  the  wound  is  much  smaller  and  less  contused, 
and  tlie  chance  of  its  rapid  union  much  greater.  Whenever  there  is  any 
difficulty  in  the  reduction  of  a  compound  fracture  chloroform  should  be 
administered,  and  the  cause  of  the  difficulty  carefully  ascertained.  If  it 
be  the  small  size  of  the  wound  probably  a  free  division  of  the  skin  will 
enable  the  surgeon  to  reduce  the  fragment,  otherwise  the  latter  must  be 
sawn  or  clipped  away.  If  comminuted  portions  interpose  the}'  may  be 
occasionally  pushed  aside;  but  as  they  are  generally  much  loosened  from 
the  soft  pails  it  is  better  to  take  them  away.  If  portions  of  muscles  or 
fasciae  are  wedged  in  between  the  bones  they  can  be  drawn  aside  with  a 


142  FRACTURES. 

blunt  hook  or  director.  When  the  fracture  is  fairly  set  it  must  be  put  up 
so  as  to  leave  the  wound  exposed,  in  order  that  the  dressings  may  be  ap- 
plied without  disturbing  the  fracture. 

Anipulntion  is  required  in  cases  where  the  main  arteries,  nerves,  or 
joints  are  also  injured,  or  where  the  laceration  of  the  soft  parts  is  so 
great  that  gangrene  is  inevitable.  But  the  indications  for  amputation 
vary  much  in  the  lower  and  upper  limb.  Thus,  in  compound  fractures 
la^'ing  open  tlie  knee-joint,  amputation  is  usually  (though  by  no  means 
alwa3's)  necessary  in  the  adult ;  while,  in  compound  fracture  of  the  elbow 
and  shoulder,  amputation  is  only  performed  in  exceptional  cases  ;  and 
similarly  with  injuries  to  the  vessels  or  nerves,  the  surgeon  is  much  more 
disposed  to  recommend  amputation  in  the  lower  than  in  the  upper  limb; 
and  in  all  cases  injuries  which  in  the  adult  are  a  decided  motive  for  am- 
putation may  be  brought  to  a  perfectly  successful  issue  in  a  healthy 
child  without  any  operative  interference. 

2.  Reductiuii  Splints. — When  the  fracture  has  been  reduced  the  next 
care  of  the  surgeon  is  to  maintain  reduction.  The  general  nature  of  the 
apparatus  used  for  this  purpose  need  alone  be  treated  of  in  this  place, 
since  the  special  contrivances  applicable  to  each  form  of  fracture  will  be 
described  with  each. 

Fractures  communicating  with  the  cavities  of  the  head  and  trunk,  as  a 
rule,  require  no  special  apparatus.  In  fractured  ribs,  and  sometimes  in 
fractured  pelvis,  a  bandage  is  applied  to  maintain  the  parts  at  rest;  but 
even  this  is  often  found  unnecessary. 

In  the  extremities,  however,  some  firmer  basis  is  usually  required,  in 
order  to  maintain  the  extension,  and  to  prevent  accidental  displacement. 
This  is  provided  by  sjj/inte,  i.  e.,  pieces  of  wood  or  metal,  or  of  some 
malleable  compound,  such  as  pasteboard,  adapted  to  the  size  and  shape 
of  the  limb,  embracing  it  more  or  less  completely,  and  fixed  on  by  band- 
ages, webl)ing  straps,  or  otherwise,  so  as  to  keep  the  fractured  ends  as 
accurately  as  possible  in  position,  and  immovable  during  the  whole  time 
of  treatment.  Many  of  these  apparatus  will  be  found  figured  or  described 
in  the  sequel,  under  the  head  of  the  Special  Fractures  ;  and  I  do  not  know 
that  it  is  worth  while  to  give  any  general  description  beyond  what  is  to 
be  found  in  the  chapter  on  Minor  Surgery  as  to  the  art  of  splint-making. 
Its  main  principles,  however,  can  hardly  be  too  often  recapitulated. 
They  are  these:  the  splints  should  fit  the  limbs  as  evenly  as  possible,  ex- 
tending as  far  on  either  side  of  the  fractured  part  as  is  necessary  to  keep 
the  fracture  quiet,  without  limiting  the  movement  of  the  neighboring 
joints,  unless,  indeed,  it  is  necessary,  with  a  view  of  obviating  displace- 
ment of  the  fractured  bones,  to  include  the  joint  in  immediate  contiguit}' 
to  the  fracture,  and  this  is  ver}'  often  the  case.  The  splints  should  not 
be  so  ai)[)lied  as  to  impede  the  return  of  blood  from  the  limb  and  produce 
oedema,  still  less  so  as  to  oppose  the  supply  of  blood,  by  which  gangrene 
and  the  loss  of  the  limb  has  sometimes  been  caused.  The  splints  must 
not  press  anywhere  on  the  soft  parts  so  sharply  as  to  cause  ulceration. 

Another  form  of  retentive  apparatus  is  the  junk.  It  is  used  only  in 
fractures  of  the  lower  extremity.  Its  name  is  derived  from  juncus^  a 
reed  ;  and  it  used  to  be  formed  of  a  [)iece  of  thick  cane  or  reed  (for  which 
a  stick  is  now  substituted)  sewn  into  each  side  of  a  square  piece  of  cloth. 
The  leg  is  wrapped  in  a  thin  pillow  (the  "junk-pillow")  after  the  fracture 
has  been  set,  and  the  whole  is  steadied  by  being  encircled  in  the  junk, 
which  prevents  any  lateral  or  vertical  displacement.  The  angular  dis- 
placement which  might  result  from  the  toes  dropping,  and  thus  project- 


TREATMENT.  143 

iiig  the  upper  end  of  the  lower  fragment  forwards,  is  obviated  by  ban- 
daging the  foot  at  right  angles. 

Hyponarthetic  apparatus,  or  fracture-boxes,  as  they  are  more  familiarly 
termed,  are  troughs  in  which  the  limb  is  fixed  by  various  contrivances  of 
straps,  bandages,  etc.,  screwed  to  the  framework,  so  that  the  limb  is  main- 
tained in  the  precise  position  in  which  it  has  been  placed  after  extension. 
The  trough  is  often  formed  of  two  pieces  jointed  together,  so  as  to  keep 
up  extension  by  means  of  a  rack  and  pinion. 

Extension  Apparatus. — The  usual  means  of  maintaining  a  permanent 
extending  force,  by  which  the  lower  fragment  may  be  drawn  away  from 
the  upper,  is  by  means  of  a  weight  and  pulley  passing  over  the  end  of  the 
bed,  as  is  so  commonly  done  now  in  disease  of  the  hip,  and  which  will  be 
found  delineated  in  the  section  on  that  subject.  This  plan  is  much  in 
use  in  America,  I  believe,  in  fracture  of  the  femur;  but  the  numerous  at- 
tempts which  have  been  made  to  introduce  it  into  English  practice  do 
not  seem  hitherto  to  have  been  very  successful. 

Sivings. — One  of  the  most  painful  and  distressing  features  in  the  ordi- 
nary treatment  of  fracture  of  the  lower  extremity,  when  the  limb  is  kept 
immovable  on  the  bed,  is  that  this  immobilit}^  prevents  the  patient  from 
making  any  but  the  most  restricted  movements  of  the  rest  of  the  body. 
Hence  the  invention  of  the  sioing,  of  which  the  kind  now  in  almost  uni- 
versal use  for  the  lower  extremity,  is  that  devised  b}^  Mr.  Salter,  which 
will  be  found  described  in  the  section  on  Fracture  of  the  Leg.  Injuries 
of  the  arm  and  excisions  of  the  elbow  are  often  found  treated  with  great 
comfort  to  the  patient  by  swinging  the  forearm  I)y  means  of  a  pulley  from 
a  pole  projecting  over  the  bed  or  from  the  bedstead  (see  Excision  of  the 
Elbow). 

3.  Treatment  of  Complications. — After  the  fracture  has  been  set  and 
put  up,  the  only  thing  necessary  is  to  keep  watch  for,  and  counteract,  any 
complication  whicli  may  ensue.  In  cases  of  simple  fracture  these  are 
commonly  few  and  trivial,  so  that  these  fractures  are  hardly  ever  danger- 
ous to  life,  and  with  moderate  care  are  usually  brought  to  unite  without 
serious  deformity.  The  chief  points  are  :  to  see  that  the  displacement  is 
not  reproduced,  through  slipping  or  imperfection  of  the  apparatus,  and  to 
that  end  to  I'enew  the  measurement,  and,  if  possible,  examine  the  seat  of 
fracture  from  time  to  time — say  every  week;  to  combat  the  painful  sj^asms 
which  sometimes  attack  fractures,  for  which  purpose  even  pressure,  as  by 
careful  bandaging  or  strapping,  is  the  most  efficient  treatment;  to  relieve 
the  neuralgic  pain  which  is  occasionally  very  distressing,  by  blisters 
dusted  with  opium  or  morphia,  b^' hypodermic  injections,  and  by  the  usual 
remedies  for  neuralgia;  to  treat  the  very  distressing  itching  which  some- 
times attacks  the  skin  by  sedative  ointments  or  lotions  ;  and  to  open  ab- 
scesses, should  any  unfortunately  form,  as  early  as  necessary. 

Compound  fractures  are  much  more  difficult  to  treat  with  success,  and 
far  more  exposed  to  complications  of  all  kinds.  They  usually  unite  by 
suppuration  and  granulation,  especially  in  the  lower  extremity  ;  the  in- 
flamed bone  often  dies  ;  ihe  matter  frequently  burrows  about  the  limb, 
requiring  incisions  in  various  parts,  which  interfere  with  the  application 
of  the  splints.  The  surgeon,  therefore,  has  to  be  constantly  on  the 
watch  to  provide  free  exit  for  retained  matter,  to  remove  sequestra,  to 
incise  tense,  inflamed  parts,  and  to  combat  all  other  complications.  I 
have  elsewliere  expressed  m}'  strong  sense  of  the  value  of  the  so-called 
"  antiseptic  "  method  in  cases  of  this  nature  (see  page  49). 

Wounds  of  the  hone  are  not  exactly  the  same  thing  as  fractures,  yet  it  is 


144  UNION    OF    FRACTURES. 

\ 

difticult  to  establish  any  essential  difference.  As  seen  in  practice  they 
are  generally  caused  by  gunshot,  which  sometimes  perforates  the  bone, 
punching  a  hole  more  or  less  cleanl}^  through  it,  or  else  splinters  and 
comminutes  its  substance,  causing  a  compound  fracture.  In  rarer  cases 
the  bones  are  cut  into  by  a  sharp-edged  weapon,  without  an}'  solution 
of  continuity  of  the  entire  bone,  though  very  probabl}'  fissures  may 
run  down,  radiating  from  the  wound  to  some  distance  in  its  substance. 
Tliese  wounds  of  bone  are  liable  to  many  of  the  same  dangers  as  com- 
pound fractures,  and  the}'  unite  by  the  same  process. 

Closel}'  connected  also  with  the  subject  of  fractures  of  the  bones  is  that 
of  injur}'  of  cartilages.  In  many  cases  of  fracture — in  all  those  which 
communicate  with  joints,  and  in  many  of  those  of  the  ribs — cartilages 
are  also  fractured  ;  and  man}-  wounds  involve  the  cartilages  to  a  greater 
or  less  extent.  Some  of  these  injuries  are  definite  subjects  of  surgical 
treatment — as,  for  instance,  fracture  of  the  costal  cartilages — which  will 
be  found  treated  of  in  the  sequel;  but  as  a  general  rule  the  injury  is  an 
unnoticed  and  a  subordinate  complication  of  a  graver  lesion.  The  pro- 
cess of  union  will  be  spoken  of  hereafter. 


UNION    OF    FRACTURES. 

The  union  of  simple  fractures  is  generally  effected  by  a  process  of 
inflammatory  exudation  and  organization  analogous  to  that  of  union  by 
first  intention  in  soft  parts  ;  while  compound  fractures  usually  unite  by 
a  process  of  suppuration  and  granulation  (second  intention);  but  excep- 
tions occur  to  both  these  rules,  ?.  e.,  we  meet  sometimes  with  simple  frac- 
tures which  heal  by  suppuration,  and  with  compound  fractures  which 
unite  by  simple  adhesion. 

Tlie  process  of  union  of  a  simple  fracture  may  be  thus  described : 

The  injury  causes  effusion  of  blood  around  the  fractured  ends,  and 
between  the  bone  and  periosteum,  as  far  as  the  latter  is  torn  away  from 
the  bone.  The  muscles  also  are  more  or  less  lacerated.  All  this  is  re- 
paired in  tlie  usual  way;  the  blood  being  gradual!}' absorbed,  and  the 
muscular  fibres  united  Ijy  fibrous  tissue.  This  process  is  going  on  simul- 
taneously with  that  of  the  repair  of  the  fracture  itself. 

Supposing  the  fracture  to  be  placed  in  good  o.jipoaition,  and  kept  quiet^ 
a  fibrinous  material  is  exuded  between  the  fractured  ends.  The  period 
at  whicli  this  exudation  commences  varies  with  many  circumstances, — 
the  patient's  age,  the  size  of  the  bone,  etc.  For  a  large  bone  in  an  adult 
it  may  be  given  at  about  ten  or  twelve  days.  The  exudation  (teclinically 
termed  "callus")  is  furnished  by  the  vessels  botli  of  the  bone  and  of  the 
periosteum. 

Fibrous  tissue  and  eartliy  material  are  developed  in  this  exudation 
almost  simultaneously  in  many  cases;  and  sometimes,  especially  in 
cliildren,  fibro-cartilage.  True  cartilage  is  met  with  in  animals,  but  its 
occurrence  in  man  is  doubtful.  The  "callus,"  or  uniting  material,  is 
then  developed  into  bone,  as  in  the  intramembranous  process  of  ossifi- 
cation. Tlie  new  bone  is  spongy  and  porous  at  first,  but  gradually 
hardens. 

If  the  fragments  are  not  in  good  position  this  tissue  may  fill  up  the 
angle  between  them,  or  even  extend  into  the  medullary  tube.  It  fills  all 
the  space  internal  to  tlie  periosteum  {i.e.,  the  whole  medullary  canal); 
and  if  the  periosteum  lias  been  torn,  that  membrane  is  at  first  lost  in 


UNION    OF    FRACTURES. 


145 


Fio.  30. 


Fio.  31. 


a  mass  of  newly  formed  callus.     Gradually  this  mass  is  modelled  down, 
the  medullary  tube  restored,  and 
the    periosteum    again    becomes 
recoonizable. 

When  the  fragments  overlap, 
the  uniting  medium  is  developed 
only  between  them — not,  as  a 
rule,  over  the  exposed  ends  or 
in  the  medullary  canal ;  but  as 
to  the  latter  point  there  is  con- 
siderable variety  in  different 
cases.  The  annexed  figui'e  shows 
a  simple  fracture,  where  the  pa- 
tient died  before  the  union  was 
quite  firm.  The  callus  which 
was  thrown  out  has  become  ossi- 
fied, though  the  ossification  is 
not  yet  complete.  The  bony  de- 
posit, however,  is  seen  to  extend 
over  the  end  of  the  medullary 
canal  of  the  upper  fragment ;  and 
this  is  the  case  in  the  lower 
fragment  also.  If  the  reader 
will  compare  some  of  the  illus- 
trations to  the  chapter  on  In- 
juries of  the  Lower  Extremity  he 
will  find  that  the  condition  of 
the  medullary  canal  varies  con- 
siderabl3\  The  uniting  material 
usually  fills  up  only  the  angle 
between  the  fragments  and  the 
space  which  is  left  between  the 
detached  periosteum  and  the 
bone,  and  this  is  not  often  great. 
But  there  are  cases  where  sucli 
periosteal  deposits,  uniting 
with  separated  splinters,  form 
substantial  bridges  across  the 
fracture,  and  afford  a  great  deal 
of  the  solid  uniting  material 
(Fig-  31). 

Inammah    and  in  man  Xvhen  f,«.  3o._a  badly  set  fracture  of  the  femur.   Thetwo 

the  fractured  ends    are   not    kept  fragments  are  united  by  a  bridge  of  soft  bone,  which  at 

qriiei,  this  process  is  modified  l)y  thetimeof  the  patient's  death  (ten  weeks  after  the  ac- 

the    formation    around    the    frac-  "dent)  was  so  porous  as  to  give  way  in  part  during 

.           1          IP          •                     -t-    A.      e  maceration.    The    ends  of  the  medullary  canal   are 

tured  ends  of  a  ring  or  splint  of  ^^^^^^^     ^j^^    ^^^^^   fragment   is  lying  on   the  inner 

"  provisional   callus."  side  of  the  lower;  the  lower  fragment  is  directed  from 

The    process    of    formation    of  below  outwards  and  backwards.— From  St.  George's 

provisional  callus    has    been   arti-  Hospital  Museum,  Ser.  i,  No.  167               ^^^,^.    . 

1                  T    •  1     1   •           n  Fig.  31. — Union  of  fracture  by  the  attachment  to 

flCially  divided  into  fivc^  stages  :  each  fragment  of  a  bridge  formed  by  a  separated  splin- 

1.    The  first  is  that  of  exudation  ter.— From  a  preparation  (No.  2938)  in  the  Museum  of 

of   reparative    material,    external  the  Royal^College  of  Surgeons.    (Syst.  of  Surg.,  2d  ed., 

and  internal  to    the  fragments,   ^  ■^'   ■ 

i.e.,  between  the  fragments  and  the  periosteum,  and  between  the  medullary 

10 


146 


FRACTURES. 


membrane  and  the  bone.     This  occupies  a  period  averaging  from  eight  to 
ten  days. 

2.  The  provisional  calhis  then  acquires  tlie  firmness  and  structure  of 
fibro-cartilagc  or  cartilage  in  from  ten  to  t\vent3'-tive  days. 

3.  Both  the  external  and  internal  callus  then  ossify  into  spongy  bone 
in  from  twenty-five  to  sixty  daj's. 


Fig.  32. 


Union  by  provisional  callus  in  the  human  subject.  The  provisional  callus  has  ossified,  the  fractured 
ends  being  still  united  by  fibrous  tissue  only.  A  fractured  rib  three  months  after  the  accident. — St. 
George's  Hospital  Museum,  Ser.  i.  No.  72.    (System  of  Surgery,  2d  ed.,  vol.  ii,  p.  73.) 

4.  The  provisional  bony  callus  is  then  modelled  down  and  becomes 
compact  bone,  the  ends  of  the  fracture  being  still  distinct  from  each  other 
(Fig.  32). 

5.  Lastl}^  the  permanent  bond  of  bony  union,  or  "  permanent  callus,'' 
forms  between  the  broken  ends,  and  the  provisional  callus  is  more  or  less 
completely  reabsorbed  ;  so  that  the  periosteal  swelling  disappears,  and 
the  medullary  canal  is  restored.  The  period  occupied  b}^  these  two  latter 
stages  of  the  process  is  too  uncertain  to  be  stated  even  approximatel}-. 

In  some  cases  the  provisional  bony  callus  remains  permanent,  and 
the  fractured  ends  lie  within  it,  either  ununited  or  only  connected  by 
ligament. 

As  the  formation  of  provisional  callus  is  the  result  of  the  irritation  pro- 
duced by  motion  of  the  fragments,  it  is  exceptional  in  man,  though  b}- 
no  means  unknown  ;  while,  on  the  other  hand,  its  absence  is  rare,  though 
also  not  unknown,  in  animals.  In  the  human  subject  the  ribs,  which 
cannot  be  kept  immovable,  usually  unite  in  this  manner,  and  the  clavicle 
for  the  same  reason  ver}'  generally.  Any  fracture,  however,  which  from 
accidental  circumstances  cannot  be  treated  in  the  usual  manner  may 
undergo  this  process,  of  wliieh  the  humerus  represented  in  the  annexed 
figure  (Fig.  33)  is  a  good  example.  For  obvious  reasons  it  is  more  com- 
mon in  childhood.  The  buttresses  of  bone  which  are  sometimes  found 
around  fractures,  particularly  near  the  hip,  are  analogous  to  the  pro- 
visional callus. 

The  uuion  of  ill  flamed  i^imjjJe  fracturea  and  of  compound  fractures  is 
by  granulation.  The  IVactured  ends  are  inclosed  in  an  imperfect  capsule 
formed  by  the  tiiickened  and  inflamed  soft  parts  within  which  tiie  injured 
ends  of  the  bone  suppurate,  and  often  become  necrosed  in  part;  granu- 
lations spring  up  from  them  ;  the  medullary  canal  is  more  or  less  trenched 
upon,  and  perhaps  filled  u[)  with  ossifying  material,  in  which  bone  is 
slowly  and  irregularly  dei)osited.  The  medullary  canal  is  often  perma- 
nentl}'  closed,  especially  when  it  has  been  freel}'  exposed  (as  113'  the  pro- 
jection of  the  fragment)  ;  but  occasionally  after  a  long  period  it  ma}'  be 


UNION    OF    FRACTURES. 


147 


Fig.  3;5. 


restored.  This  union  l\y  granulation  is  a  far  more  tedious  process  than 
that  by  adhesion,  generally  occupying  as  many  months  as  the  other  does 
weeks  ;  and  it  is  liable  to  all  kinds  of  irregularities  from  the  separation 
of  fragments  which  become  necrosed  in  consequence  of  the  sui)puration 
of  the  parts  which  surround  and  nourish  them,  from  erysipelas  or  diffuse 
inflammation,  from  burrowing  of  matter  in  the  limb — in  fact,  from  all  the 
complications  incidental  to  severe  injuries  involving  bone.  And  such 
suppurating  compound  fractures  are  one  of 
the  most  fruitful  sources  of  p^^jemia.  It  is 
therefore  important  to  procure  the  imme- 
diate union  of  the  wound — whenever  that 
is  possible — so  as  to  convert  the  compound 
into  a  simple  fracture  ;  and  this  is  the  more 
important  the  more  vital  is  the  organ  which 
is  in  contact  with  the  fractui'ed  bone.  Hence 
the  care  with  which  surgeons  endeavor  to 
procure  the  union  of  a  scalp-wound  which 
exposes  a  fracture  of  the  skull,  or  a  wound 
of  the  chest  communicating  with  a  fractured 
rib.  Butit  must  be  added  that  such  attempts 
are  of  very  doubtful  utility  in  cases  where, 
from  extensive  laceration  and  contusion,  the 
wound  must  almost  inevitably  suppurate, 
and  where  the  consequent  suppuration  will 
be  prevented  from  finding  an  exit  by  the 
material  used  in  sealing  the  wound.  Much, 
however,  may  doubtless  be  done  by  care- 
fully sealing  wounds  with  some  antiseptic 
substance,  and  keeping  all  their  parts  in 
gentle  apposition  by  appropriate  bandag- 
ing ;  but  in  so  treating  the  wound  of  a  com- 
pound fracture  the  surgeon  should  watch 
vigilantly  for  any  indication  of  burrowing 

matter,  and  give  it  instant  vent.  Uniou  of  fracture  by  ensheatlnng  or 

Irreqular      C^riZOn.— Irregularities     occur    Provisional  calU.s  in  the  human  subject 

,,  .y  ,        %  .    ,  The  patient  was  admitted  into  hospital 

in  all  these  processes,  whereby  special  pases   ^uh  fracture  of  the  humerus,  which 

are    made    to    differ    from    that    which    is    re-    could   never   be   kept   quiet,   in   conse- 

garded  as  the  typical  course  of  each  kind   i"'^'^'^^  "^  !>>«  suffering  from  repeated 

r.         .  mi       ■  1  •    i>     J?  xi  •  1       -i-  attacks  of  delirium   tremens,  of  which 

of  union.     1  he  chief  of  these  irregularities   ^^  ^^^^^  ^i,^^^  ^  .^^^t,,  ^ft,r  ^he  acci- 

which  needs  notice  here  is  the  absor[)tion   dent. 

which  sometimes  goes  on  in  the  neighbor-      ^  dentated  fracture  was  found  just 

ing  bone  contemporaneously  with  the  union 

of  the  line  of  fracture  itself.     This  is  often 

seen  in  thin  papery  bones  like  those  of  the 

orbit  (see  Injuries  of  the  Head).     And  it 

is  often  noticed  that  fractures  of  the  base 

of  the  skull,  though    they  may  unite,  do   so     pointed    end  of   the    lower    fragment, 

very   imperfectly,    and  "that  "parts    of  the   which  is  seen  to  be  quite  ununited  to 

„      "^  '  n^  .  I  ,  . ,  .      .       the  upper  fragment,  and  its  surface  is 

fissure  are  often  wider  when  the  repair  is   ^^^^  ^^^^  ^^p^^it  ^^  ^  ^^^^  distance 
complete  than  they  were  at  the  time  of  the  below  the  actual  fracture.   The  frag- 

iniury.  ments    are    freely    movable    on    each 

rpi  t-      c  i.\  c         •  L  other  to  the  extent  permitted  by   the 

i  he  arrest  of  the  process  of  union  at  any     ,,    ,  "       -  „      .„;.;„„, i  ^.11,,. 

Ill  p  attachment  of  the  provisional  callus. — 

stage  Will    lead    to  the  various    forms  of   Un-    gt.   George's  Hospital   Museum,   Ser.  i, 

united  fracture,  as  will  be  obvious  from  the   No.  105. 
sequel. 


below  ths  insertion  of  the  deltoid  mus- 
cle, and  the  fractured  ends  were  encased 
in  a  sheath  or  ferule  of  fibrous  tissue 
about  a  quarter  of  an  inch  thick,  and 
extending  about  an  inch  above  and  be- 
low the  fracture.  A  hole  has  been  cut 
in  this  sheath  in  order  to  show  the 


148 


FRACTURES. 


Fig.  34. 


Delayed  Union. — The  usual  period  for  the  union  of  each  fracture  is 
specified  in  treating  of  each.  But  it  must  be  understood  that  these  periods 
are  averages  only.  Various  disturbances  of  health  may  cause  delay  in 
union — such  are  acute  diseases,  as  fever,  or  chronic  affections,  as  scurvy, 
possibly  syphilis,  and  frequently  disease  of  the  kidneys  leading  to  a  phos- 
phatic  state  of  the  urine. ^  All  such  causes,  however,  allowing  the  reality 
of  all  of  them  (which  is  a  matter  of  considerable  doubt),  are  rare  ;  far 
more  commonly  the  union  of  fracture  is  dela3'ed  or  prevented  by  inju- 
dicious treatment,  as  b_y  tight  bandaging,  obstructing  the  blood-supply, 
or  the  other  extreme  of  negligent  apposition,  allow- 
ing movement.  But  cases  of  dela_yed  union  are  met 
with  in  which  no  such  cause  can  be  traced,  where 
the  patient  seems  to  be  in  his  usual  health,  and  the 
fracture  to  have  been  properly  treated. ■' 

In  such  instances  of  delayed  union  the  indications 
for  treatment  are  obviousl}',  in  the  first  place,  to 
examine  the  patient's  local  and  general  condition, 
with  a  view  to  correct  alkalescence  of  urine  by  the 
exhibition  of  mineral  acids,  to  neutralize  the  syphil- 
itic condition  by  mercury  or  iodide  of  potassium, 
and  to  improve  the  general  health  by  fresh  air  if 
possible.  The  local  condition  must  be  improved  by 
correcting  any  obvious  defect  in  the  apparatus  em- 
ployed, and  by  gently  rubbing  or  shampooing  the 
parts  around  the  fracture.  Some  fractures  of  the 
lower  limb,  which  have  remained  movable  beyond 
the  usual  time,  will  unite  if  the  patient  is  allowed  to 
get  up  and  move  about  a  little  with  the  limb  in  a 
case  firm  enough  to  prevent  it  from  bending,  yet  not 
so  tight  as  to  make  it  swell.  In  other  cases  (whether 
in  the  upper  or  lower  limb)  union  may  be  procured 
by  fixing  the  two  fragments  in  an  apparatus  made 
of  two  parts  movable  on  each  other,  and  provided 
with  a  screw  and  ratchet,  by  which  the  fragments  can  be  pressed  together. 
The  aim  of  all  these  devices  is  to  excite  a  little  more  action  in  the  parts, 
and  thus  stimulate  the  fractured  ends  to  throw  out  bone. 


Ununited  fracture  (soft 
union)  of  the  ulna.  —  St. 
George's  Hospital  Museum, 
Ser.  i,  No.  202  a. 


Ununited  Fracture. — By  some  such  means  as  these  union  ma}-  be  pro- 
cured, even  after  considerable  delay,  when  there  is  no  definite  obstacle 
to  it.  There  will  still  remain  a  small  proportion  of  cases  in  which  the 
fragments  continue  permanently  ununited — at  least  by  bone — and  there- 
fore are  freely  movable  on  ea(!h  other. 

This  takes  place  in  one  of  three  ways,  i.  e.,  the  fragments  are  either 
united  by  a  soft  material  (which  is  sometimes  called  ligamentous  union) 
or  by  a  false  joint;  or  they  are  truly  ununited,  ?".  e.,  are  in  no  apposition 
whatever. 


1  Pregnancy  and  lactation  are  said  .sometimes  to  retard  union,  though  they  cer- 
tainly do  not  commonly  di)  so.  The  subject  is  discussed,  tmd  several  interesting  cases 
quoted,  in  Norris'.-*  Contributions  to  Practical  Surgery,  pp.  25,  28.  Tlic  cutting  oft' 
of  the  blood-suppl)' through  the  nutrient  artery  is  also  believed  b^^  Mr.  Curling  to 
retard  union  (Med.-Chir.  Trans  ,  vol.  xx).  And  Mr.  Callcnder  has  pointed  out  the 
frequency  of  obstruction  of  the  main  vein  from  contusion  in  the  injury,  causing 
oedema,  as  a  condition  involving  delay  in  the  union  of  the  fracture  (Med.-Chir.  Trans., 
vol.li,  p.  152). 

'^  On  the  far  greater  frequency  of  the  local  causes  of  non-union,  especially  bad  treat- 
ment, than  the  constitutional,  see  Callcnder,  op.  cit. 


UNUNITED    FRACTURE. 


149 


Ligamentous  Union. — The  first  form  of  ununited  fracture  is  seen  in  Fig. 
34,  and  a  comparison  of  Fig,  33  (p.  147)  will  sliow  its  striking  similarity 
to  the  condition  of  a  provisional  callus  before  ossification.  Sometimes, 
indeed,  in  these  cases  of  soft  union  there  is  a  regular  provisional  callus, 
inclosing  the  broken  ends  in  a  splint  or  ferule,  just  as  is  seen  in  animals, 
and  possibly  containing  fibro-cartilage.  This  soft  or  ligamentous  union 
is  the  most  common  condition  of  ununited  fracture. 


Fig.  36. 


Fig.  35. — An  ununited  fracture  (false  joint)  of  the  tibia.  The  fracture  had  existed  seventeen  years, 
and  the  utility  of  the  limb  had  been  almost  perfect,  the  patient  having  gained  his  livelihood  by  walk- 
ing as  a  messenger  at  one  of  the  clubs  ;  he  merely  used  a  stick.  The  ends  of  the  fracture,  a,  are  rounded, 
the  lower  end  being  worn  into  a  kind  of  cup  to  receive  the  upper  end.  They  are  lined  by  a  fibro-car- 
tilaginous  substance,  and  were  inclosed  in  a  firm  fibrous  capsule,  which  has  been  removed  in  order  to 
display  the  false  joint.  There  was  even  a  membrane  lining  the  ends  and  secreting  a  substance  some- 
thing like  synovia.  A  false  joint  also  exists  between  the  tibia  and  fibula,  near  the  fracture.  The  fibula, 
6,  is  much  curved,  and  is  very  much  thickened,  so  as  to  bear  the  weight  of  the  body.  The  tibia,  as 
shown  at  c,  is  considerably  atrophied,  so  that  a  thin  shell  only  remains  to  represent  its  compact  ex- 
terior.— From  a  specimen  in  St.  George's  Hospital  Museum,  Ser.  i.  No.  202. 

Fig.  36.— Ununited  fracture  of  both  bones  of  the  leg  in  a  child  set.  10,  for  which  amputation  was  per- 
formed. The  leg  had  been  fractured  eight  years  before,  and  had,  it  was  said,  been  refractured  on  two 
subsequent  occasions,  a.  The  atrophied  upper  end  of  the  lower  fragment  of  the  tibia.  «'.  The  lower 
end  of  the  upper  fragment.  This  is  not  in  any  contact  with  the  former,  but  is  united  to  the  back  of 
the  lower  fragment  below  by  a  kind  of  capsular  membrane.  This  is  the  case  also  with  the  fibula.  The 
upper  end  of  the  lower  fragment  of  the  fibula  is  not  plainly  seen,  being  buried  in  the  fibres  of  the  ex- 
tensor long.  dig.  The  tendons  of  the  tib.  auticus  and  extr.  prop,  pollicis  are  seen,  pushed  outwards  by 
the  fragment  of  the  tibia,  h.  Shows  the  heel  and  the  atrophied  tendo  Achillis.— From  St.  George's 
Hospital  Museum,  Ser.  i.  No.  203. 


Fahe  Joint. — Another  form  of  the  lesion  is  that  which  is  shown  in  Fig. 
35,  in  which  by  the  movement  of  the  two  parts  of  the  fracture  on  each 
other  2i,  false  joint  ("  pseudarthrosis  ")  has  been  formed  in  the  centre  of 


150  FRACTURES. 

the  soft  uniting  medium,  which  tlien  takes  the  form  of  a  more  or  less  regu- 
lar capsule.' 

True  Non-Union. — Again,  the  broken  ends  may  be  in  no  apposition  at 
all.  A  familiar  example  is  that  of  a  fracture  of  the  patella,  where  the 
fragment  is  sometimes  drawn  far  up  tlie  thigh,  and  is  quite  unconnected 
with  the  part  which  remains  attached  to  the  tibia.  Fig.  36  shows  another 
example  of  something  of  this  kind.  In  tliat  preparation,  however,  though 
the  upper  ends  of  the  lower  fragments  are  in  no  connection  whatever 
with  the  lower  ends  of  the  upper  fragments,  yet  these  latter  have  an  im- 
perfect fibrous  connection  to  a  lower  part  of  each  lower  fragment,  so  that 
it  ma}'  be  said  that  some  attempt,  though  very  imperfect  and  ineffectual, 
has  been  made  to  re-establish  the  solidity  of  the  limb. 

It  is  not  easy  daring  life  to  give  a  confident  opinion  as  to  the  exact 
anatomical  condition  of  a  case  of  ununited  fracture;  but  if  the  fractured 
ends  are  widel}'  separated,  and  no  motion  of  one  is  produced  by  moving 
the  other,  we  may  suspect  entire  non-union  ;  if  they  move  freely  on  each 
other  with  grating,  or  pseudo-crepitus,  like  that  felt  in  an  old  rheumatic 
joint,  we  conclude  that  the  case  is  probably  one  of  false  joint;  if  they  are 
more  or  less  freel^^  movable  on  each  other,  but  without  grating,  we  may 
put  it  down  as  probably  an  instance  of  ligamentous  union,  remembering 
also  that  this  is  b}'  far  the  most  common  condition,  as  it  is  also  tlie  most 
favorable  for  treatment. 

In  cases  of  true  non-union,  and  frequently  in  those  of  false  joint,  the 
fragments  are  greatly  atrophied,  as  shown  in  the  figures. 

Treatment. — The  treatment  of  ununited  fracture  must  be  regulated  in 
the  first  place  by  the  utility  of  the  limb,  and  in  the  next  place  by  the  age 
and  health  of  the  patient.  The  former  varies  very  greatly.  Thus  Fig.  35 
shows  a  case  in  which  the  fibula  having  remained  unbroken  (or  having 
united),  and  having  also  become  sufficiently  hypertrophied  to  bear  the 
weight  of  the  bod_y,  the  leg  was  so  useful  that  the  patient  could  earn  his 
living  by  walking.  In  such  a  case  it  is  needless  to  say  that  there  is  no 
motive  for  surgical  interference.  Mr.  Prescott  Hewett  told  me  a  short  time 
ago  of  a  case  wliich  he  had  seen  in  private,  where  a  lady  had  an  ununited 
fracture  of  the  femur.  This  was  most  freely  movable  when  she  laid  down, 
and  wlien  she  stood  up  the  two  fragments  locked  together  in  such  a  wa^'that 
she  could  walk  fairly  well,  though  with  a  limp.  In  such  a  case,  and  in  fact 
generally  when  the  patient's  life  is  not  made  wretched  by  his  infirmity,  it 
is  better  to  avoid  any  serious  operation,  for  all  such  operations  involve  a 
good  deal  of  danger.  All  operations  on  the  upper  limb  are  both  more 
likely  to  succeed  and  much  less  dangerous  than  similar  operations  in  the 
lower  extremity.  As  there  is  no  absolute  separation  between  cases  of 
delayed  union  and  those  of  non-union,  it  is  better  to  treat  ever}'  case  when 
first  seen,  if  at  any  reasonable  period  after  tiie  injur}',  by  the  milder 
measures  whicli  have  been  recommended  in  cases  of  delayed  unic^n.  I 
have  seen  judicious  apposition  and  mutual  pressure  of  tlie  fragments  on 
each  other  l)y  means  of  a  rack  and  pinion  apparatus  successfully  employed 
in  many  such  cases.  Shampooing  the  part,  slight  rubbing  of  the  frag- 
ments on  each  other,  occasional  slight  inflammation  set  up  by  blisters  and 
other  means,  have  been  recommended.  And  of  course  careful  attention 
to  the  general  health,  and  especially  the  condition  of  the  urine,  is  under- 
stood to  be  a  necessary  preliminary  to  all  kinds  of  treatment. 

'  There  is  iin  interestincj  proparation  in  the  Museum  of  the  College  of  Surgeons, 
showing  numerous  loose  boiii(!S  ("  loo.se  curtilages  "j  in  one  of  these  false  joints.  See 
Syst.  of  Surg.,  2cl  ed.,  vol.  ii,  p.  80. 


UNUNITED     FRACTURE.  151 

If  these  means  fail,  and  if  the  loss  of  power  is  not  grave  enough  in  the 
surgeon's  judgment  to  justify  his  exposing  the  patient  to  any  risk  of  his 
life,  or  if  the  patient  is  in  such  a  condition  of  health  that  he  can  hardly 
be  expected  to  survive  the  operation,  the  case  must  be  abandoned,  with 
such  palliation  as  an  apparatus  can  provide. 

In  cases,  hovvever,  which  are  more  hopeful  as  far  as  the  patient  is  con- 
cerned, and  where  the  infirmity  is  grave  enough  to  justify  the  risk,  the 
surgeon  must  very  carefully  examine  the  relations  of  the  fragments  to 
each  other;  their  connection,  as  far  as  he  can  make  it  out,  their  size,  and 
the  possibility  of  bringing  their  ends  into  apposition  by  extension.  He 
then  has  the  choice  of  a  great  number  of  expedients.  There  are  cases  of 
false  joint  in  which  the  cavity  between  the  fragments  maybe  obliterated 
by  scraping  the  ends  with  a  tenotomy  knife,  keeping  them  afterwards  at 
rest  in  the  natural  position  ;  and  other  cases  where  union  seems  to  be 
prevented  by  some  piece  of  muscle  or  fascia  which  has  got  between  the 
fragments  where  a  similar  operation  will  succeed.  There  are  cases  (appar- 
ently both  of  false  joint  and  of  ligamentous  union)  where  ossification  has 
ensued  on  the  passage  of  a  seton  between  the  ends,  which  should  not  be 
allowed  to  remain  in  much  above  a  week.  The  measure  appears  to  have 
had  little  success  in  England.  Dr.  Norris,  however,  says  of  it  that 
"results  in  America  have  proved  it  one  of  the  safest,  least  painful,  and 
most  etlicacious  of  the  numerous  operations  that  are  performed  for  the  cure 
of  pseudarthrosis"  (op.  cit.,  p.  90).  Sometimes  the  surgeon  has  cut  down 
on  the  fractured  ends  in  order  to  pass  the  seton ;  but,  as  a  general  rule, 
when  a  seton  cannot  be  passed  without  previous  exposure  of  the  bone, 
the  probably  more  effectual  and  certainly  less  dangerous  expedient  is 
adopted  of  driving  ivory  pegs  into  the  fragments,  as  recommended  by 
Dietfenbach.  The  fragments  are  sufficiently  exposed  to  drill  holes  into 
them,  and  then  into  these  holes  ivory  pegs  are  driven,  and  the  projecting 
ends  cut  off.  The  buried  part  excites  an  effusion  of  bone  around,  and  by 
such  effusion  the  fracture  is  united,  much  as  it  is  by  the  periosteal  bridge 
of  bone  figured  on  p.  145.  The  buried  part  of  the  peg  sometime  makes 
its  wa}'  out,  sometimes  perhaps  is  absorbed,  and  probably  is  sometimes 
encapsuled,  and  remains  as  lodged  bullets  do.  The  number  of  pegs  to  be 
driven  into  each  fragment  will  depend  on  the  size  of  the  bone,  and  other 
circumstances.  Mr.  Erichsen  speaks  of  having  successfully  used  five 
pegs  in  a  fracture  of  the  humerus.  Mr.  Bickersteth  has  used  copper  nails 
in  the  same  way,'  or  has  driven  a  drill,  the  end  of  which  is  removable, 
from  one  fragment  into  but  not  through  the  other,  and  left  the  drill  in 
the  bone  until  it  fell  out.  If  one  drill  be  not  enough  to  support  the  frag- 
ments two  or  even  more  can  be  employed,  a  plan  which  has  the  advan- 
tage of  requiring  no  external  incision.  The  drills  are  simply  driven  in 
from  the  surface  of  the  body. 

Another  plan  is  to  drive  a  metal  suture  from  one  end  into  the  other  by 
means  of  the  drill,  which  is  made  to  perforate  both  fragments  obliquely;^ 
but  this  is  commonly  combined  with  the  next  plan,  viz.: 

Resection  of  Ends. — To  cut  down  on  the  fracture  and  to  remove  a  slice 
from  either  fragment,  after  which  the  ends  may  be  wired  together,  if  the 
surgeon  thinks  right.  Mr.  Mason  suggests  that  a  needle  may  he  driven 
through  the  ends,  and  the  wire  cast  in  a  loop  or  figure  of  8  round  the 
needle,  and  this  may  be  necessary  when  the  sutures  are  very  oblique, 

1  Med.  CUn.  Trans  ,  vol.  xlvii,  p.  115. 

2  Mason,  Med.-Chir.  Trans.,  vol.  liv,  p.  313. 


152  FRACTURES. 

otherwise  the  simple  insertion  of  a  peg  or  pin  is  sufficient  to  keep  the 
fragments  in  apposition. 

Buhpe7-iOiifeal  Besectioi}. — The  late  Mr.  Jordan  of  Manchester  suggested 
the  subperiosteal  resection  of  the  fragments,*  a  tube  of  periosteum  being 
dissected  up  first,  and  the  portions  of  bone  removed,  as  far  as  possible 
bare  of  periosteum ;  and  though  this  may  not  always  be  practicable,  yet 
there  is  no  doubt  of  the  desirability  of  saving  any  periosteum  which  can 
be  recognized  and  separated  from  the  bone. 

Transplantation  of  Bone. — Lately  an  operation  has  been  prescribed  by 
Professor  Xussbauni  of  Munich  in  a  case  of  non-union  of  the  ulnar,  the 
result  of  loss  of  bone  from  gunshot  fracture,  which  he  denominates 
"  transplantation  of  bone.""  It  consists  essentially  in  cutting  otf  from 
the  rest  of  the  bone  a  portion  of  itb  external  shell  covered  by  the  perios- 
teum, and  leaving  this  shell  of  bonf»  attached  to  the  remainder  by  means 
of  the  periosteum  covering  its  terminal  extremity,  which  is  to  be  care- 
fully preserved  from  injur}',  since  it  is  the  medium  of  the  future  repair. 
The  semi-detached  and  now  quite  movable  bone  is  next  displaced  into  the 
gap  in  the  same  vfay  as  a  flap  of  skin  is  twisted  in  a  plastic  operation  and 
fixed  in  the  indurated  soft  tissues  of  which  the  gap  is  formed.  The 
uniting  ligament  and  the  atrophied  ends  of  the  fracture,  together  with 
the  cartilaginous  [fibrous  ?]  tissue  which  covered  them  are  removed,  as 
being  in  the  way.  This  operation  could  only  be  attempted  in  cases  where 
the  separation  between  the  fragments  is  unusually  great ;  and  its  utility 
must  be  tried  by  further  experience. 

After  all  operations  for  ununited  fracture  it  will  be  recollected  that 
careful  support  in  a  firm  splint  or  case  of  leather,  plaster  of  Paris,  or 
other  material,  is  indispensable. 

Tiiere  are  many  cases  where  subcutaneous  section  of  the  muscles  which 
displace  the  fragments  must  be  added  to  the  other  operative  proceedings. 

Amputation. — Finally,  there  are  cases  so  complicated,  or  of  such  long 
standing,  or  where  previous  operations  have  so  far  failed,  that  amputation 
ma}'  be  best. 

Vicious  Union. — The  fracture  maj'  have  united  by  bone,  but  with  con- 
siderable deformity  and  loss  of  the  functions  of  the  limb.  Tlie  kinds  of 
vicious  union  spoken  of  are  union  of  two  contiguous  bones,  union  with 
displacement,  and  projection  of  one  of  the  fragments.  The  first  and  last 
may  be  summarily  dismissed.  Union  of  two  contiguous  bones  is  of  no 
importance  in  the  ribs,  and  of  com[)arativel_y  little  in  the  leg.  In  the 
forearm  it  has,  in  one  recorded  case,  been  held  to  justify  the  resection  of 
the  bone.''  Projection  of  one  of  the  fragments,  or  possibly  of  a  com- 
minuted piece,  is  to  be  dealt  with  like  an}'  other  exostosis,  i.  e..,  when 
sufliciently  inconvenient  the  projecting  piece  must  be  removed.  But  the 
cases  we  are  f)rdinaril}'  called  upon  to  treat  are  those  in  which,  IVom  neg- 
lect, from  unruliness  on  the  part  of  tlie  patient,  or  from  yielding  of  the 
union  after  supposed  cure,  the  deformity  has  citlier  never  been  corrected 
or  has  recurred,  and  the  limb  is  more  or  less  entirely  useless.  Such  cases 
are  l)y  no  means  hopeless.  If  only  a  short  time  has  elapsed  after  the  in- 
jury tlie  deformity  will  often  yield  to  extension  by  the  pulleys,  combined 
vvitii  firm  pressure  on  the  part  under  chloroform  ;  or  it  may  be  reduced 
more  gradually  (as  bent  bones  are  in  childhood)  by  pressure,  with  pads, 

^  Traitement  des  Pseudarth roses  par  I'Autoplastie  p<Sriostique,  Paris,  18G0. 

«  Loud.  Med.  Kccord,  March  31,  1875. 

'  By  Gardeil,  quoted  by  Malgaigm;,  p.  272.  Packard's  translation. 


PATHOLOGY    OF    DISLOCATION.  153 

etc.,  on  the  angle  ;  the  pressure  being  antagonized  by  a  splint  on  tlie  op- 
posite side  of  the  limb.  In  many  cases  refracture  of  the  limb  is  justifi- 
able, and  in  almost  all  when  it  is  indicated  the  attempt  ma}^  be  made 
with  impunity.  The  danger  of  producing  fresh  fracture  at  the  wrong 
place  is  so  slight  that  it  need  hardly  be  taken  into  account.  Mr.  Skey' 
has  shown  that  even  the  smaller  bones,  such  as  the  radius  or  the  fibula, 
are  not  easily  broken,  even  when  out  of  the  bod}^,  by  the  utmost  force 
which  a  strong  man  can  exert ;  and,  when  covered  by  soft  parts,  they 
would  be  still  less  easy  to  break ;  while  the  larger  bones,  on  whicli  the 
attempt  is  usually  made,  the  femur  or  tibia,  are  of  course  quite  secure. 
But  at  the  seat  of  fracture,  and  especially  in  cases  of  vicious  union,  the 
uniting  material  remains  long  imperfectly  ossified,  and  will  give  way  in 
some  cases  more  than  a  year  after  the  injury.  I  have  seen  the  femur  re- 
fractured,  thirteen  months  after  the  accident,  with  perfect  ease.  The 
operation  is  a  very  simple  one.  The  limb  is  brought  over  the  edge  of  the 
table  a  little  beyond  the  fracture  ;  its  upper  part  is  steadied  by  assistants, 
and  the  surgeon  leans  on  it  with  all  the  force  he  can  exert  till  it  gives 
way,  changes  of  position,  rotation,  etc.,  being  employed  as  may  be  neces- 
sary. Mr.  Skey  says  "  the  act  of  disuniting  the  bone  is  effected  by  slow 
laceration  rather  than  by  a  snap  or  fracture ;"  in  fact,  its  possibilit}-  de- 
pends on  the  ossification  of  the  callus  being  incomplete.  After  it  has 
been  eflfected  the  limb  must  be  extended  as  near  as  possible  to  the  original 
length,  by  pulleys  if  necessary,  and  fixed  by  splints  in  that  position. 

There  may  be  cases  in  which  the  surgeon  may  think  it  right  to  divide 
a  fracture  perfectly  united,  but  in  a  vicious  position,  at  any  time  after  the 
injury,  and  when  the  bone  can  no  longer  be  refractured.  This  may  be 
done  either  by  direct  incision-  or  by  subcutaneous  section,  as  is  done  in 
vicious  anchj'losis  of  joints  (see  below,  the  section  on  anchylosis)  ;  or,  as 
has  latel}^  been  ingeniously  suggested  by  Langenbeck,''  the  projecting 
portion  of  the  bone  may  first  be  considerably  weakened,  by  boring  a  large 
hole  through  it,  and  extending  this  hole  by  means  of  a  keyhole  saw  till 
only  a  small  bridge  remains  on  either  side.  Then  the  wound  is  dressed, 
and  the  limb  put  into  a  plaster  of  Paris  splint  until  it  has  healed,  when 
the  weakened  part  is  easily'  fractured  and  put  straight,  and  there  remains 
onl}'  a  simple  fracture  to  treat. 


DISLOCATION. 

The  word  "  dislocation,"  when  used  by  itself  in  surgical  works,  is  in- 
tended to  signify  the  forcible  displacement  of  one  articular  surface  of  a 
joint  from  another.  Other  organs  also  are  subject  to  dislocation  ;  thus 
dislocation  of  the  lens  and  of  the  testicle  are  spoken  of,  but  in  such  cases 
the  name  of  the  displaced  organ  is  always  added.  Dislocation  of  joints 
also  occurs  as  a  consequence  of  disease  (pathological  dislocation,  frequent 
in  the  knee  and  hip),  and  sometimes  as  the  result  of  malformation  (con- 
genital dislocation).  Traumatic  or  true  dislocation  may  be  complete — i.  e., 
where  no  portions  of  the  two  articular  surfaces  ai'e  in  contact — or  incom- 
plete, when  a  part  of  one  still  remains  applied  to  the  articular  surface  of 
the  other  bone.  When  the  bone,  besides  being  dislocated,  is  exposed  by 
a  wound,  the  dislocation  is  said  to  be  compound.     It  is  universal  in 

1  Med.-Chir.  Trans.,  vol.  xlii.     A  most  valuable  paper  on  this  subject. 

2  See  Lister,  Brit.  Med.  Journal,  Oct.  31,  1868,  p.  462. 

3  Lond.  Med.  Record,  March  31,  1875,  p.  198. 


154  DISLOCATION. 

modern  surgical  works  to  describe  dislocations  as  being  of  the  more 
movable  bone,  or  of  that  bone  which  is  situated  furthest  from  tlie  trunk, 
but  in  the  older  writers  this  rule  is  not  followed.  Thus  Sir  A.  Cooper 
described  the  dislocations  of  the  ankle  as  being  of  the  tibia  and  fibula, 
which  are  now  described  as  dislocations  of  the  foot.  This  difference  of 
nomenclature  of  course  reverses  the  direction  in  which  the  part  is  said  to 
be  dislocated,  since  a  displacement  which,  if  described  with  reference  to 
the  leg  is  inwards,  becomes  outwards  when  the  foot  is  said  to  be  dis- 
placed. 

General  Symptoms. — There  are  a  few  points  which  ought  to  be  mentioned 
as  concerning  dislocations  in  general  before  the  individual  injuries  are 
described.  The  signs  of  a  dislocation  are,  loss  of  the  natural  shape  of 
the  part,  loss  of  the  movements  of  the  joint,  both  active  and  passive,  in 
diflerent  degrees,  and  alteration  of  the  relations  of  the  bony  prominences 
to  each  other,  together  with  an  absence  of  the  signs  of  fracture,  when  the 
dislocation  is  pure  ;  but  it  is  not  uncommon  for  the  dislocation  to  be  ac- 
companied b_y  fracture  of  some  bony  process,  or  even  of  the  shaft  of  the 
bone  in  the  neighborhood. 

Re.ductioii. — Having  diagnosed  the  existence  of  dislocation,  the  sur- 
geon's aim  is  to  reduce  it,  i.  e.,  to  restore  the  displaced  bone  to  its  natural 
position.  As  a  general  rule  all  dislocations  are  accompanied  by  more  or 
less  laceration  of  the  capsule  of  the  joint,  or  some  of  its  special  liga- 
ments and  of  the  muscles  around  it,  while  others  of  the  muscles  are  put 
on  the  stretch  and  others  shortened.  After  a  time  the  displaced  heacl  of 
the  bone  contracts  adhesions  to  the  other  bones  and  to  the  parts  around, 
and,  especiall}'  where  there  has  been  much  motion  of  the  bones  on  each 
other,  a  kind  of  new  articulation  may  be  formed,  while  the  old  articular 
cavity  may  be  more  or  less  completely  filled  up.  The  obstacles  to  the 
return  of  recent  dislocations  depend  on  the  resistance  of  the  displaced 
muscles,  on  the  interlocking  of  the  bones,  or  on  the  interposition  of  the 
capsule  or  some  of  its  accessor}^  structures  between  the  dislocated  bone 
and  the  cavity  to  which  it  is  to  be  returned.  Many  of  these  obstacles 
are  more  easil}^  overcome  by  appropriate  manipulation  than  by  force,  so 
that  dislocations  of  the  hip,  for  which  it  used  to  be  thought  necessary  to 
exhaust  the  muscular  force  by  bleeding  and  antimony,  and  then  to  use 
violent  extension  by  means  of  pulleys,  are  now  usuall_y  reduced  under 
chloroform  with  extreme  facility  by  simply  disengaging  the  head  of  the 
bone  from  its  acquired  position,  when  the  muscles  at  once  restore  it  to  its 
natural  one. 

In  old  dislocations  the  ditRculty  of  reduction  depends  on  the  formation 
of  adhesions  between  the  two  bones,  on  the  permanent  contraction  of  the 
shortened  muscles,  and  on  inflammatory  deposit  filling  up  the  old  articu- 
lar cavity,  which  sometimes  renders  the  return  of  the  bone  impossible, 
and  at  others  even  fills  up  the  cavity  altogether.  The  shape  of  the  dis- 
placed bone  itself  also  l)ecomes  altered  by  pressure  or  by  inflammation. 

As  these  difficulties  increase  very  si)eedil3'  in  the  first  week  or  two 
after  the  injury,  it  is  of  tlie  greatest  importance  to  recognize  the  nature 
of  tlie  accident,  and  apph^  the  api)ropriate  remedy  as  earl}-  as  possible. 
When  a  dislocatifui  has  existed  for  a  very  long  time  it  is  very  doubtful 
whether  its  reduction  is  physically  possible,  or  whether,  if  it  were  re- 
duced, the  limb  would  gain  or  lose  in  utilit}'. 

Wiien  a  dislocation  has  been  successfully  and  completely  reduced  the 
lacerated  capsule  and  muscles  quickly  heal,  and  everything  returns  to  a 
condition  of  health,  the  joint  regaining  its  normal  movements,  and  to  a 
great  extent  its  normal  stability,  but  often  not  completely,  for  dislocated 


REPAIR    OF    INJURIES    OF    CARTILAGE.  155 

joints,  and  particularly  the  shoulder  and  the  lower  jaw,  are  very  liable  to 
renewed  dislocation  ;  and  the  oftener  they  are  dislocated  the  weaker  and 
more  lax  the  capsule  becomes,  and  the  more  easily  may  the  dislocation 
be  reproduced.  And  it  must  also  be  recollected  that  the  laceration  of 
the  capsule  in  a  dislocation  is  often  very  extensive — at  least  it  seems  so 
from  experiments  on  the  dead  subject — and  that  the  healing  of  an  exten- 
sive rent  in  a  structure  so  lowly  organized  as  a  thick  aponeurosis  must 
be  a  somewhat  slow  process  ;  so  that  for  a  time  which  it  is  not  very  easy 
to  calculate  the  laceration  either  remains  unhealed  or  so  weakly  united 
that  it  jnay  easily  give  way  again.  Hence  the  care  which  surgeons 
always  exhibit  to  keep  the  joint  at  perfect  rest  for  two  or  three  weeks 
after  a  dislocation,  and  to  enjoin  on  the  patient  great  caution  in  move- 
ment and  the  wearing  of  some  retentive  apparatus  for  a  considerable  time 
after  this.  Want  of  care  and  sudden  motion  soon  after  a  dislocation, 
even  irrespective  of  any  violence,  will  ver}^  often  reproduce  the  disloca- 
tion, which,  however,  is  always  easily  reduced.  So  also  in  old  disloca- 
tions which  are  lial)le  to  recur,  they  are  alwa3's  reduced  with  proportion- 
ate facility. 

Repair  of  Injuries  of  Cartilage. — It  remains  to  say  a  few  words  as  to 
the  method  of  repair  in  wounds  or  fractures  of  cartilage.  The  method  of 
union  of  fractures  is  best  studied  in  those  of  the  costal  cartilages  and 
those  of  the  articular  cartilage  of  the  femur,  which  is  so  often  involved 
in  the  fractures  which  run  into  the  knee-joint.  The  uniting  medium 
seems  to  differ  somewhat  in  accordance  with  the  different  qualities  of  the 
cartilage  involved.  Thus  the  costal  cartilages,  which  are  naturallj'^  prone 
to  ossify,  unite  very  commonly  by  bone,'  or  by  a  mixture  of  bone  and 
cartilage.  Fracture  of  articular  cartilage  is  usually  \e\y  slow  of  healing, 
and  the  cartilage  is  found  unchanged  close  to  the  seat  of  fracture ;  ulti- 
matel}'  the  breach  of  surface  is  usually  repaired  by  a  layer  of  fibrous  tissue 
or  by  a  mixture  of  fibrous  tissue  and  cartilage.'^  In  wounds  of  cartilage 
made  for  purposes  of  experiment  on  the  lower  animals  Dr.  Redfern  has 
found  that  the  resulting  changes  affect  both  the  cells  and  the  intercellular 
substance,  though  only  to  a  slight  distance  from  the  seat  of  injur}'.  They 
display  a  very  strong  tendency  to  heal  without  any  further  destructive 
changes,  and  this  repair  is  brought  about  either  by  the  production  of 
fibrous  tissue  or  by  calcareous  deposit  leading  to  calcification  of  the  en- 
tire cartilage.  Dr.  Redfern  describes  both  the  cells  and  the  intercellular 
substance  of  the  injured  cartilage  as  taking  part  in  the  production  of  the 
fibrous  tissue,  the  intercellular  substance  fibrillating  and  becoming  re- 
placed by  a  material  exactly  resembling  white  fibrous  tissue,  while  the 
cartilage-cells  increase  in  size,  and  their  nuclei  give  place  to  a  number  of 
corpuscles.  Then  the  wall  of  the  cell  becomes  identified  with  the  hyaline 
intercellular  substance  and  the  corpuscles  are  set  free,  and  while  the 

1  In  the  Museum  of  St.  George's  Hospital  are  three  specimens  of  fracture  of  costal 
cartilages  (Ser.  I,  Nos.  67,  68,  69),  all  united  by  bone.  Mr.  Poland  refers  to  three 
in  St.  Bartholomew's  Hospital  Museum,  in  one  of  which  the  union  is  entirelj'  and  in 
another  partially  bony,  cartilage  being  mixed  with  the  bone;  in  the  third  the  frac- 
ture is  repaired  by  the  growth  of  a  new  cartilaginous  substance. 

2  In  the  Museum  of  St.  George's  Hospital  (I,  193)  is  the  preparation  of  a  fracture 
runninginto  the  knee-joint,  received  twenty-eight  days  before  thepatient's  death.  "On 
the  articuhir  surface  a  thin  layer  of  firm  fibrin,  of  a  light-brown  color,  is  interspersed 
between  the  cartilaginous  margins  of  the  fracture,  the  cartilage  itself  having  as  yet 
undergone  no  change."  A  preparation,  exactly  similar  to  this,  is  figured  in  the  sec- 
tion on  fracture  of  the  femur. 


156  INJURIES    OF    THE    HEAD. 

hyaline  intercellular  substance  is  becoming  fibrillar  and  forming  the 
white  fibrous  substance,  the  corpuscles  are  developed  into  the  nuclear  or 
elastic  fibres.' 

From  these  researches  Dr.  Rediern  concludes  that  ''  uncomplicated 
lesions  of  cartilages  (especiall}^  such  as  have  been  artificially  produced 
in  tiie  lower  animals)  manifest  a  very  decided  tendency  to  spontaneous 
cure  by  the  production  of  fibrous  tissue,  or  by  calcification  of  the  whole 
cartilage  left  after  the  injury ;"  and  that  the  "  diseased  action  arising 
from  circumscribed  destruction  of  the  articular  cartilages  of  the  lower 
animals  evinces  no  tendency  to  extend  to  the  remaining  parts  of  these 
textures,  nor  to  involve  other  structures,  and  lead  to  serious  disease  of 
the  joint." 

Uncomplicated  lesions  of  cartilages  are  of  course  very  rare  in  the 
human  subject,  but  the  examination  of  specimens  such  as  that  above 
referred  to  from  St.  George's  Museum  leads  us  to  believe  that  Dr.  Red- 
fern's  conclusions  are  true  in  the  main  when  applied  to  the  human  sub- 
ject ;  that  is  to  say,  that  cartilage  is  prone  to  repair,  and  that  the  disease 
produced  in  it  b}^  traumatic  injury  rarelj'  extends  far  from  the  part 
injured. 


CHAPTEE   VII. 

INJURIES    OF    THE    HEAD. 

Injuries  of  the  head  are  matters  of  equal  importance  and  interest.  It 
is  an  old  and  good  rule  in  surgery  "  never  to  look  lightly  on  any  injury 
of  the  head,  however  trifling  it  may  appear."  Ver}'^  grave  anatomical 
lesions  may  have  been  produced  by  injuries  which  appear  trivial.  Cases 
are  recorded  in  which  a  weapon  has  passed  deepl}^  into  the  brain,  through 
the  papery  bones  of  the  orbit,  and  has  left  a  fragment  there,  and  the 
man  has  gone  about  his  business  thinking  he  had  only  received  a  scratch 
on  the  eyelid,  till  inflammation  of  the  brain  has  set  in,  and  the  foreign 
body  has  been  found  after  death.'*  So,  again,  a  slight  tap  on  the  skull 
may  possibly  cause  ruptui-e  of  a  large  vessel  or  laceration  of  the  brain, 
followed  by  fatal  luiemorrliage  or  inflammation.  And  again,  lesions  really 
very  slight  in  themselves  may  be  followed  by  the  most  alarming  and  even 
fatal  consequences.  I  once  saw  a  man  who  was  in  hospital  for  a  small 
sebaceous  tumor  of  the  scalp.  The  surgeon  under  whose  care  he  was 
had  forgotten  the  case  and  overlooked  the  man  for  some  days.  One  day 
he  happened  to  come  into  the  ward  where  tlie  man  was  sitting,  who  got 
up  and  reminded  him  of  his  inadvertence.  The  surgeon  apologized, 
took  out  his  pocket-case,  made  a  little  incision,  and  squeezed  out  the 

1  Redfern.     Anormal  nutrition  of  cartilage,  pp.  67  et  seq. 

^  Several  such  cases  have  been  piiblistiod  ;  in  one  case  it  was  the  end  of  a  walking- 
cane  with  which  a  soldier  was  f(Mu;iiig  witli  his  comrade;;  in  another  tlie  ferule  of  an 
umbrella  whicli  a  testy  old  gentleman  poked  into  the  eye  of  a  man  who  ran  against 
him  in  the  street. 


CONTUSION    OF    THE    HEAD.  157 

tumor  in  an  instant.  Tlie  patient  thanked  him  and  went  to  his  seat 
again.  But  in  ten  days  lie  was  dead  of  iwjcmia.  And  every  one  must 
have  seen,  both  in  public  and  private  practice,  cases  in  which  very  slight 
injuries  of  the  head  have  set  up  frightful  attacks  of  erysipelas,  or  have 
been  followed  by  brain-symptoms  (piite  disproportionate  to  their  api)arent 
gravity.  Though,  therefore,  these  unfortunate  cases  are  comparatively 
rare,  they  must  be  borne  in  mind  as  an  argument  for  caution  in  the  treat- 
ment and  some  reserve  in  the  prognosis. 

Clai^i^ification. — Injuries  of  the  head  may  be  thus  divided:  I.  Simple 
contusion  of  the  soft  parts.  II.  Scalp-wound,  (a)  without  exposure,  and 
(6)  with  exposure  of  bone.  III.  Extravasation  of  blood  beneath  the 
skull-cap.  IV.  Fracture  of  the  skull,  simple  or  compound,  and  either 
of  them  with  or  without  depression  of  the  fractured  bone.  Y.  Injury, 
i.  e.,  contusion  or  laceration,  of  the  brain  and  its  membranes.  VI.  In- 
juries to  the  nerves. 

Complications. — The  inflammatory  complications  of  such  injuries  are 
ei'ysipelas  and  diffuse  inflammation  of  the  soft  parts,  suppuration  within 
the  skull,  inflammation  of  the  brain  and  its  membranes,  and  Hernia 
cerebri. 

Surgical  Anatomy  of  the  Scalp. — It  may  be  well,  in  commencing  this 
subject,  to  recall  the  reader's  attention  to  the  main  peculiarities  in  the 
surgical  anatom}^  of  the  scalp.     They  are  as  follows : 

1.  The  skin  is  ultimately  connected  to  the  tendon  of  the  occipito-fron- 
talis  (which  here  represents  what  in  other  regions  of  the  body  is  the 
muscular  fascia),  instead  of  being  separated  from  it  by  cellular  tissue. 

2.  The  large  vessels  lie  immediately  beneath  the  skin,  i.  e.  between  it 
and  the  tendon,  instead  of  under  the  fascia,  as  in  other  parts. 

3.  The  tendon  of  the  occipito-frontalis  is  loosely  united  to  the  peri- 
cranium by  very  extensive  cellular  tissue,  and  is  perforated  by  small 
arteries,  which  run  from  the  larger  vessels,  through  the  cellular  tissue,  to 
nourish  the  pericranium. 

Consequently  (1)  wounds  of  the  skin  almost  always  involve  the  tendon 
also  ;  (2)  bleeding  from  the  large  arteries  is  generally  easily  commanded, 
in  consequence  of  their  superficial  position ;  (3)  in  diffuse  inflammation 
of  the  scalp  the  thickness  of  the  part  is  often  enormously  increased  by 
extravasated  lymph,  and  such  extravasation  will  very  probably  strangu- 
late the  vessels  nourishing  the  pericranium. 

I.  Contusion  of  the  scalp  gives  rise  usually  to  a  little  "bump"  of  extrav- 
asated blood;  but  in  children  it  is  not  uncommon  to  find  huge  extrava- 
sations which  may  sometimes  extend  over  the  whole,  or  over  one  side,  of 
the  head,  and  which  I  have  known  mistaken  for  abscess  the  result  of 
disease  of  the  bones.  But  the  uninflamed  condition  of  the  scalp  and  the 
histor}^  (if  this  can  be  obtained)  will  sufficiently  guard  against  such  a 
mistake.  These  collections  of  blood  and  fluid  are  bounded  by  a  ridge  or 
border  formed  of  condensed  tissue  and  blood-clot.  In  smaller  contusions 
this  ridge  is  very  often  confounded  with  a  fracture ;  and  it  must  be 
allowed  that,  in  some  cases,  the  diagnosis  is  not  an  easy  one.  But  gen- 
erally the  contusion  may  be  recognized  as  such  by  the  following  charac- 
ters :  the  ridge  is  elevated  above  the  level  of  the  neighboring  sound  skull, 
its  edge  is  somewhat  rounded,  its  outline  regular  and  usually  crescentic, 
and,  by  pressing  the  finger-nail  upon  it,  an  impression  ma}^  perhaps  be 
made.  The  apparent  depression  within  the  ridge  will  probably  yield 
suflSciently  to  the  pressure  of  the  finger  to  allow  the  surgeon  to  feel  the 
sound  skull  below  it.     In  fracture  with  depression,  on  the  other  hand, 


158  INJURIES    OF    THE     HEAD. 

the  ridge  which  appears  elevated  is  really  on  the  same  level  as  the  rest 
of  the  skull;  its  margin  is  sharp  and  irregular,  and  its  direction  very 
variable.  If  in  the  depressed  part  any  bone  can  be  felt  it  will  be  loose. 
The  only  question  of  treatment  wliich  occurs  is  in  the  large  extravasa- 
tions of  childhood.  In  these  cases  the  extravasation  is  situated  between 
the  pericranium  and  occipito-frontalis  tendon — not  beneath  the  peri- 
cranium, as  in  cephaliTeniatoma,'  and  therefore  it  may  increase  to  any 
size;  and  I  have  heard  of  (but  not  seen)  a  case  in  which  pulsation  was 
present  in  it,  communicated  from  the  temporal  arter}'-.  If  haemorrhage 
is  going  on  actively  it  may  be  justifiable  to  cut  down  and  look  for  the 
wounded  vessel,  but  I  never  saw  a  case  in  which  there  was  the  slightest 
justification  for  such  a  measure.  In  the  instance  in  which  the  temporal 
artery  was  injured  it  was  tied  at  a  healthy  part  successfully.  And  in  a 
case  where  no  perceptible  improvement  followed  from  prolonged  expectant 
treatment  I  once  drew  off  the  blood  through  a  small  trocar  with  success. 
The  aspirator  would  now  be  used.  But  generally,  with  patience  and  the 
use  of  a  slightly  stimulating  lotion  or  embrocation  (such  as  Lot.  Amnion. 
Hydrochlor.  gr.  x  :  5j ;  or  Tinct.  Arnicte,  pt.  i,  Aqufe  ptes.  iv-vi ;  or 
Liniment  AmmoniiTe),  the  fluid  is  gradually  absorbed,  and  the  part  returns 
to  its  natural  size  and  appearance.  If  the  surgeon  has  been  tempted  to 
puncture  such  a  collection  he  should  close  the  puncture  at  once  and  apply 
pressure,  being  ready,  on  any  appearance  of  suppuration,  to  open  it 
freel^'. 

11.  Scalp-ivoimds  are  generally  contused,  and  in  severe  cases  heavy 
flaps  hang  down,  which  are  very  difficult  to  keep  in  place.  Sometimes 
the  scalp  is  ground  to  pieces  by  the  passage  of  a  wheel;  and  very  often 
in  scalp  wounds  foreign  bodies  (dii't,  stones,  hair,  straw,  etc.),  are 
imbedded.  The  bone  is  very  often  exposed,  and  not  exposed  merely, 
but  is  usually  also  cut,  bruised,  or  rasped  to  a  greater  or  less  extent,  and 
foreign  bodies  may  even  be  imbedded  in  it.  A  case  occurred  many  years 
ago  at  St.  George's  Hospital  in  which  a  man  was  sent  up  from  a  distance 
with  a  scalp-wound  neatly  united  over  a  portion  of  brick  which  had  been 
driven  into  the  skull.  This  being  broken  off  on  tlie  exact  level  of  the 
skull  was  mistaken  for  a  piece  of  exposed  bone. 

There  is  not  very  often  formidable  bleeding  in  scalp-wounds,  for  the 
reason  above  stated.  At  least,  though  active  at  first,  it  generally  soon 
subsides;  nor  is  there  much  difficulty  in  commanding  it  if  it  should  not. 
If  the  arteries  are  too  much  contused  to  be  tied  or  twisted  they  can  easily 
be  compressed,  or,  in  the  last  resort,  be  commanded  between  an  acupres- 
sure-needle thrust  in  below  them  and  a  ligature  aljove.  Bleeding  having 
been  stopped,  and  all  dirt  and  foreign  bodies  carefully  and  gently  removed, 
the  wound  must  be  united.  There  is  an  old  traditional  horror  of  sutures 
in  scalp-wounds  which  seems  to  me,  to  say  the  least,  exaggerated;  and  I 
never  hesitate  to  use  silver  sutures  \vhen  there  is  any  difficult}'  in  keep- 
ing the  wound  in  apposition.  There  is  no  necessity  for  putting  them  in 
deepl}',  so  as  to  wound  the  tendon,  and  therefore  no  justification  for 
doing  so.  The  wound  should  then  l)e  so  dressed  as  in  the  opinion  of  the 
surgeon  is  best  calculated  to  produce  its  rapid  union  (see  Dressing  of 
Wounds);  for  in  every  scalp-wound,  whetliei-  bone  be  exposed  or  not,  and 
whether  that  bone  be  fractured  or  not,  rapid  union  is  the  main  point  by 

^  Cephalaematoma  is  the  name  given  to  a  blood-tumor  produced  on  the  skull  of  the 
inffint  during  birth  by  the  pressure  of  the  uterine  walls.  It  is  treated  of  in  works  on 
obstetrics. 


ERYSIPELAS    OF    SCALP.  159 

which  the  patient's  safety  is  insured.  But  closing  a  wound  wliich  must 
be  reopened  afterwards  for  tlie  discharge  of  sloughs,  or  grit,  or  retained 
•matter,  tends  to  retard  instead  of  hastening  its  ultimate  union;  so  that 
in  such  cases  it  is  better  to  leave  the  wound  open  under  poultice  or  water 
dressing.  Often,  when  the  lips  of  the  wound  are  healthily  granulating, 
but  the  bone  is  exposed  below,  great  advantage  may  be  obtained  by 
bringing  the  granulations  in  gentle  apposition  with  straps  or  sutures,  and 
sometimes  entire '"  secondary  adhesion  "  will  thus  be  obtained.  I  have 
often  watched  large  exposed  bony  surfaces  to  see  how  much  of  them 
would  die,  and  have  frequently  been  both  pleased  and  surprised  to  see 
that  no  necrosis  at  all  has  taken  place,  but  the  whole  exposed  bone  has 
been  covered  in  by  granulations;  at  other  times  only  a  minute  scale  of 
bone  has  exfoliated.  Things,  however,  do  not  always  go  on  thus  kindl3% 
and  the  scalp-wound  may  easily  prove  the  starting-point  of  caries  or 
necrosis  of  the  bone. 

Complications. — The  usual  complications  of  scalp-wounds  are  erysipelas, 
either  of  the  common  or  of  tlie  cellular  variety,  and  suppuration  within 
the  cranium.  Cutaneous  erysipelas  is  comparatively  rare.  It  extends  to 
the  face  and  requires  only  the  ordinary  treatment.  The  cellular  form  is 
more  common,  and  its  treatment  is  a  more  serious  problem.  The  inflam- 
mation originates  in  lesion  of  the  cellular  tissue  between  the  tendon  and 
the  pericranium,  and  extends  often  with  great  rapidity  over  the  whole 
head,  causing  immense  oedema,  and  leading  ultimately  to  sloughing  both 
of  the  scalp  and  pericranium.^  It  begins  with  pnffiness  and  slight  red- 
ness around  the  wound,  but  as  the  inflammation  is  almost  confined  to  the 
cellular  tissue  the  redness  is  not  usually  at  all  vivid.  The  oedema  extends 
from  the  wound,  accompanied  with  pain  in  the  head  and  general  fever, 
ushered  in  usually  with  rigors,  which  may  recur  more  or  less  frequently; 
the  pulse  is  rapid,  and  often  weak;  the  tongue  white,  with  glazed  edge. 
Matter  forms  after  a  day  or  two,  and  the  bone  is  often  exposed  in  places 
by  the  destruction  of  the  pericranium. 

Patients  attacked  with  this  disease  generally,  or  at  any  rate  frequently, 
are  those  whose  constitution  is  broken  down  by  intemperance,  privation, 
or  disease,  and  such  a  case  is  therefore  to  be  looked  upon  always  with 
anxiety.  They  seldom  bear  depletion,  or  even  deprivation  of  nourish- 
ment or  stimulants,  so  that  anything  like  copious  loss  of  blood  is  to  be 
deprecated.  Still,  if  the  parts  are  tense  and  the  oidema  is  rapidl}-  ad- 
vancing, it  is  absolutely  necessary  that  incisions  should  be  made,  and 
that  boldly  and  decisively.  For  the  patient  will  ultimately  save  blood 
by  having  to  submit  to  the  incisions  only  once,  rather  than  be  obliged  to 
bear  a  repetition  of  what  is  a  very  painful  and  depressing  operation. 
Excluding,  then,  the  general  treatment  of  the  case,  which  must  be  con- 
ducted on  the  principles  laid  down  in  the  section  on  Erysipelas  (i^age 
73),  and  which  in  our  hospitals  always  tends  strongly  to  the  supporting 
and  stimulant  method,  we  will  consider  only  the  local  treatment,  and 
mainly  the  question  of  incising  the  scalp.  I  have  seen  cases,  somewhat 
threatening  at  first,  brought  to  a  successful  issue  without  any  incisions  ; 
so  that  unless  the  oedema  is  unusuall}^  acute  I  should  dissuade  any  hurry 
at  first.  In  the  first  place,  the  whole  scalp,  or  at  any  rate  all  the  puffy 
part  of  it,  must  be  cleanly  shaven.  The  original  scalp-wound  must  be 
laid  open  freely,  which  is  done  with  the  least  pain  by  passing  the  finger 

1  In  one  case  where  no  incisions  were  made  I  saw  the  whole  vertex  of  the  skulL 
exposed  by  sloughing  as  cleanly  as  if  the  man  had  been  scalped  by  a  red  Indian. 


160  INJURIES    OF    THE    HEAD. 

into  it  down  to  the  bottom  and  from  end  to  end,  find  then  a  warm  ponltice 
shonld  be  applied  to  encourage  discharge  and  relax  the  parts,  or  the  head 
should  be  fomented  witli  warm  lead  and  opium  lotion  or  decoction  of  pop-- 
pies.  If  this  fails  to  check  the  axlema,  which  is  nevertheless  not  very 
great,  or  accompanied  with  much  tension,  a  crop  of  lancet  punctures  may 
be  made.  When  incisions  are  manifestly  necessary  they  must  be  made 
boldly  down  to  the  bone,  and  to  a  sufticient  extent  to  insure  the  relaxa- 
tion of  all  the  tense  tissues.  But  no  one  incision  should  be  of  any  great 
length,  since  otherwise  some  large  vessel  must  necessarily  be  injured — 
about  H  to  2  inches  is  the  limit  for  each  incision.  They  should  run 
directly  from  before  backwards,  and  any  large  vein  which  is  seen  under 
the  skin  should  be  avoided.  If  much  arterial  htemorrhage  occurs  it  must 
be  checked  before  the  patient  is  left.  Sometimes  the  bleeding  vessel  is 
easily  twisted  or  tied,  and  occasionally  it  is  found  that  an  artery  has  been 
partially  divided  at  one  end  of  the  incision,  whicli  will  cease  bleeding 
when  the  incision  is  so  far  extended  as  to  complete  its  division.  But  if 
the  arteries  continue  to  bleed,  yet  the  surgeon  cannot  find  them  in  the 
mass  of  inflammator}^  exudation,  the  wound  should  be  stuffed  with  lint, 
on  which  pressure  may  be  made  till  all  tendency  to  ha3morrhage  has  ceased. 
The  lint  may  be  removed  in  a  few  hours,  and  the  incision  will  answer  its 
purpose  as  well  as  if  it  had  been  left  open  from  the  first.  A  poultice 
afterwards  is  the  best  dressing. 

Intracranial  Siqjpuration. — A  still  more  formidable  complication  of 
scalp-wounds  and  other  injuries  of  the  head  is  the  formation  of  pus  in  the 
interior  of  the  skull.  Left  to  itself  such  suppuration  is  necessarily  fatal, 
and  unfortunatel}^  we  possess  only  very  imperfect  means  of  treating  it. 
The  cause  of  intracranial  suppuration  is  more  commonly  a  scalp  wound 
with  exposure  of  the  bone  than  any  other  injury,  though  any  other  injury 
may  be  followed  by  this  complication.  As  ordinarily  occurring  the 
sequence  of  events  is  this  :  the  skull-cap  is  exposed,  and  its  external 
table  more  or  less  contused  or  rasped.  This  is  followed  by  inflammation 
of  the  bone,  effusion  between  it  and  the  neighboring  uninjured  periosteum, 
forming  a  "puffy  tumor"  around  the  injured  part;  inflammation  of  the 
diploic  tissue  and  of  the  internal  table,  and  inflammatory  effusion  followed 
by  suppuration  between  the  bone  and  the  dura  mater.  Inflammation  may 
also  be  propagated  to  the  arachnoid  cavity,  to  the  subarachnoid  space, 
between  the  hemispheres  and  the  falx  cerebri,  to  the  tissue  of  the  brain 
or  to  its  ventricles.  Finally,  the  inflammation  of  the  diploe,  and  of  the 
large  venous  sinuses  whicli  it  contains,  ma}^  prove  the  starting-point  of 
general  pyaemia.  It  is  obvious  that  some  of  those  conditions  are  incura- 
ble, and  others  can  only  be  cured  in  the  rarest  cases.  Abscesses  in  tiie 
brain  have  been  successfully  opened,'  and  they  are  usually,  at  least,  if 
not  always  limited.  Suppuration  spreading  along  the  meshes  of  the  pia 
mater  or  down  the  falx  cerebri  is  generally  too  much  diffused  to  allow  of 
any  adequate  exit  being  given  to  it.  Abscess  in  the  arachnoid  cavity 
has  been  found  limited,  and  has  been  successfully  opened.'-  But  when 
the  surgeon  diagnoses  and  attempts  to  open  an  intracranial  abscess  his 
hope  is  to  find  a  limited  collection  of  matter  between  the  bone  and  the 
dura  mater.     It  was  to  the  occurrence  of  these  limited  abscesses  imme- 

1  The  latest  published  case  which  I  have  met  with  is  Mr.  Holden's  (St.  Bartholo- 
mew's Hi).«pital  Reports,  vol.  ix).  Others  will  bo  found  referred  to  in  Mr.  Hewett's 
essay  on  Injuries  of  the  Head,  in  the  second  volume  of  the  Syst.  of  Surgery. 

2  Dumville,  Brit.  Med.  Journ.,  1858,  vol.  ii,  p.  743.  lioux,  Archives  Generales, 
vol.  xxiv,  p.  268. 


INTRACRANIAL    SUPPURATION.  161 

diately  beneath  the  cranium  that  Mr.  Pott^  drew  th^e  attention  of  the 
surgeons  of  his  day,  and  he  dwelt  strongly  on  the  "  pufly  tumor"  (since 
commonly  called  after  his  name)  as  a  valuable  indication  of  the  subjacent 
suppuration.  Mr.  Pott  was  so  fortunate  as  to  meet  with  eight  cases 
suitable  for  the  application  of  trephine,  of  which  five  recovered.  Modern 
surgeons  have  been  far  less  fortunate — in  fact,  the  cases  of  recovery  after 
trephining  for  pus  in  this  country  are  very  few  indeed  within  living 
memory.  Some  years  ago  I  published  the  experience  of  St.  G-eorge's 
Hospital  in  this  particular  for  seventeen  years — 1841  to  1851  inclusive.' 
Eight  cases  occurred  in  which  the  trephine  was  applied  for  pus.  The 
pus  was  found  in  every  case,  but  all  tlie  patients  died.  Seven  were  ex- 
amined after  death,  and  in  six  of  these  unmistakable  evidence  of  phle- 
bitis in  tlie  sinuses  of  the  brain  and  veins  of  the  skull  and  of  general 
pyjemia  was  discovered.  In  the  seventh  case  the  abscess  reached  the 
ventricles  of  the  brain.  There  were  eight  other  cases  in  which  the  trephine 
was  not  used,  and  where  matter  was  found  above  the  dura  mater ;  but  it 
was  not  limited  to  tliis  situation  in  any  of  these  cases,  nor  could  adequate 
exit  liave  been  procured  for  it  by  the  trephine.  In  nine  other  cases  there 
had  been  intracranial  suppuration,  but  the  matter  was  diffused  among 
the  membranes  or  in  the  substance  of  the  brain,  and  lay  entirely  below 
the  dura  mater. 

Taking  this  as  a  fair  specimen  of  what  the  surgeon  is  likely  to  meet 
witli,  it  goes  far  to  explain  the  hesitation  which  is  usually  displayed  in 
recommending  an  operation  for  intracranial  suppuration.  Yet,  as  the 
operation  is  really  the  only  chance  for  the  patient's  life,  it  is  certainly  the 
duty  of  the  surgeon  to  give  him  that  chance  whenever  there  are  clear 
indications  of  limited  suppuration.  We  must,  therefore,  study  carefully 
tlie  symptoms  of  this  condition. 

Suppuration  beneath  the  cranium  commences  usually  a  considerable 
time  after  the  injury — about  a  fortnight  may  be  taken  as  an  average — 
with  pain  in  the  head,  possibly  an  unhealth}'  appearance  of  the  wound, 
feverishness,  vomiting,  rigors,  delirium,  muscular  spasms,  and  finally 
coma,  terminating  in  paralysis.  Tlie  presence  of  the  puff\'  tumor  is  a 
valuable  indication,  but  it  is  by  no  means  common  to  find  it,  probabl}^ 
from  tlie  free  laceration  or  destruction  of  the  pericranium  which  accom- 
panies tliese  injuries. 

'J'he  treatment  at  first  must  be  antiphlogistic.  A  free  discharge  must 
be  promoted  from  the  wound,  which  should  be  laid  completely  open  for 
that  purpose,  and  which  sliould  of  eourse  be  then  very  carefully  exam- 
ined, and  the  state  of  the  bone  ascertained  as  far  as  maA'^  be.  Leeches  to 
the  shaven  scalp  or  to  the  temples  should  be  applied,  if  the  heat  of  the 
head  and  the  beating  of  the  arteries  of  the  scalp  seem  to  call  for  them. 
Mercury  in  small  and  frequent  doses  may  be  useful  at  the  commencement 
of  the  inflammatory  s^nnptoms,  though  its  administration  cannot  be 
recommended  when  the  symptoms  clearly  indicate  that  suppuration  is 
established,  which  may  always  be  safely  concluded  when  the  symptoms 
of  traumatic  inflammation  have  lasted  over  forty-eight  hours,  accom- 
panied with  rigors  and  sweats.  In  cases  where  the  pulse  is  weak,  stimu- 
lants must  be  combined  with  the  local  antij^hlogistics.  Ice  to  the  head 
and  perfect  quiet  in  a  darkened  room  are  essentials  in  the  treatment  of 
traumatic  inflammation   after  injury  to  the  head.     When  the  symptoms 

^  Injuries  of  the  head,  Chirurgical  Works,  vol.  i,  pp.  38  et  seq. 
2  Brit.  Med.  Journ.,  Oct.  16tli,  1858. 

11 


162  INJURIES    OF    THE    HEAD. 

of  suppuration  are  followed  by  those  of  compression  of  the  brain,  and 
espec'iall}'  when  paralysis  is  clearly  marked,  tlie  question  of  trephining 
occurs.  And  now  it  becomes  essential  to  distinguish,  if  possible,  be- 
tween the  symptoms  of  local  pressure  on  the  surface  of  the  brain,  as  from 
a  limited  collection  of  pus  above  the  dura  mater,  or  an  abscess  encysted 
in  the  arachnoid  cavity,  and  the  symptoms  of  general  pressure  on  the 
brain  produced  bv  an  extensive  accumulation  of  pus  in  the  subarachnoid 
space,  or  running  along  the  falx  down  to  the  corpus  callosum,  or  in  the 
substance  or  ventricles  of  the  brain.  This  is  nnluckily  a  very  hard  prol)- 
lem.  Those  cases  are  the  most  appropriate  for  trephining  in  which  with 
exposure  of  a  portion  of  the  skull-cap  there  is  paralysis  definitely  limited 
to  the  opposite  side  of  the  body,  and  no  suspicion  of  general  pyasmic  in- 
fection. In  such  cases  the  denuded  bone  should  be  fully  exposed  by  in- 
cision ;  and  if  one  part  of  it  looks  more  gray  in  color  than  another  the 
trephine  should  be  applied  there  ;  or  if  the  puffy  tumor  exists  it  must  be 
cut  into  and  the  trephine  applied  on  that  spot ;  otherwise  it  must  be  placed 
on  any  part  which  the  surgeon  chooses.  If  (as  is  often  the  case)  matter 
wells  up  while  the  diploe  is  being  sawn  through  it  is  a  bad  sign,  for  in 
such  cases  the  pus  is  hardly  ever  confined  to  a  single  locality.  In  some 
rare  cases  the  sequence  of  events  described  bj^  Pott  takes  place,  i.  e.,  a 
circumscribed  collection  of  pus  is  opened  by  the  removal  of  the  crown  of 
the  trephine,  and  the  paralysis  is  at  once  relieved.  Or  the  dura  mater 
may  bulge  into  the  trephine  hole,  destitute  of  pulsation,  and  possibl}^ 
showing  the  matter  below  it.  A  puncture  should  in  such  a  case  be  made 
into  the  dura  mater.  In  other  cases,  again,  after  the  dura  mater  has  been 
incised  no  matter  escapes,  but  the  surface  of  the  cerebrum  is  driven  up 
into  the  hole;  and  then  it  is  justifiable  to  make  a  small  exploratory  in- 
cision into  the  brain,  and  if  pus  is  found  to  give  it  an  adequate  exit.^ 

1  ought  to  add  that  the  symptoms  of  pressure  following  on  inflamma- 
tion of  the  brain  after  injurj'  have  in  two  recent  cases  led  the  surgeon  to 
apply  the  trephine  where  no  matter  was  discovered,  and  in  both  cases  re- 
covery ensued.  I  was  myself  the  surgeon  in  the  one  case,  and  Mr.  Joseph 
Bell  in  the  other.^  The  symptoms  in  my  own  case  were  certainly  very 
definite,  and  must  have  been  due,  I  conclude,  to  effusion  of  lymph  be- 
neath the  dura  mater,  which  was  relieved  by  the  removal  of  the  skull-cap. 

III.  Exlravanalion  of  blood  as  the  result  of  injuries  to  the  head  may 
occur  in  one  or  more  of  the  following   situations:  (1)  External  to  the 

'  In  an  interesting  paper  recently  published  on  the  diagnosis  and  operative  treat- 
ment of  compression  of  the  brain  (Am.  Jour.  Med.  Sci  ,  Julj',  1873),  Dr.  Gross  at- 
tempts to  distinguish  between  the  symptom.^  of  suppuration — 1,  above  the  dura  mater  ; 
2,  amongst  the  mombranes  ;  and  3,  in  the  substance  of  the  brain — premising,  how- 
ever, that  there  are  many  cases  in  which  suppuration  occurs  in  several  different  parts 
at  the  same  time.  The  first  is  marked  by  its  comparatively  early  occurrence,  6th-16th 
day  ;  by  the  presence  of  the  ])ufly  tumor,  and  by  the  less  marked  character  of  the 
spasms  and  paralysis  ;  the  second  by  a  somewhat  later  occurrence,  8th-21st  day  ;  the 
puffy  tumor  is  only  present  when  the  supjiuration  is  limited  within  the  sac  of  the 
arachnoid;  the  muscular  spasms  and  unihit<'ral  hemi])legia  are  strongly  marked;  the 
third  takes  place  later,  13lh-27lh  day,  sometimes  (!vcn  months  after  the  injury  ;  there 
are  no  changes  about  IIk;  wound,  and  thecoma  and  paralysis  are  much  less  complete. 
Further  experience  is  necessary  to  show  what  trust  is  to  be  reposed  in  these  diagnostic 
differences;  but  I  ijuite  believe  that  as  a  rule  suppuration  within  the  brain  comes  on 
at  a  later  period  and  with  less  definite  symptoms  than  does  suppuration  limited  to 
the- membranes.  See  the  abstract  of  this  paper  in  the  London  Med.  Record,  for  Oct. 
15,  1873. 

2  My  case  is  alluded  to  in  St.  George's  Hospital  Keports,  vol.  vii,  p.  278.  Mr.  Jos. 
Bell's  case  is  somewhat  more  fully  reported  in  the  Edin.  Med.  Jour.,  August,  1873. 


EXTRAVASATION    BENEATH    THE    SKULL. 


163 


cranium;  (2)  between  the  bone  and   dura  mater;  (3)  in   the  arachnoid 
cavity  ;  (4)  in  the  substance  of  the  brain. 

1.  Extravasation  in  the  scalp  has  been  treated  of  already'  (p.  151). 

2.  Extravasation  between  the  bone  and  tlie  dura  mater  depends  either 
on  laceration  of  the  middle  meningeal  artery,  of  the  lateral  or  possibly 
some  other  sinus,  or  of  smaller  vessels  passing  between  the  bone  and 
dura  mater.  The  symptoms  of  compression  from  this  cause  (when  they 
are  sutliciently  definite  to  permit  of  diagnosis)  come  on  after  an  interval 
of  complete  or  incomplete  consciousness.  This  interval,  in  a  well-marked 
case  which  occurred  many  years  ago  at  St.  George's  Hospital,  was  about 
an  hour;  but  it  has  been  known  to  be  as  much  as  four  hours  or  more,  the 
period  varying  of  course  with  the  circumstances  of  the  patient,  whether 
he  is  at  rest  or  in  motion,  quiet  or  agitated,  sober  or  drinking,  etc.  The 
symptoms  of  compression  usually  advance  rapidlj',  and  in  well-marked 
cases  soon  culminate  in  hemiplegia.  When  this  is  the  case  it  is  an  indi- 
cation, even  in  the  absence  of  any  history  or  mark  of  injury,  which  justi- 
fies the  surgeon  in  cutting  down  (on  the  side  opposite  to  that  paralyzed) 
on  the  large  branch  of  the  middle  meningeal  artery  which  crosses  the  an- 
terior inferior  angle  of  the  parietal  bone,  since  this  is  the  vessel  most  fre- 
quently lacerated.  This  point  is  easily  found  by  making  a  horizontal 
incision  i-unning  through  the  temporal  muscle,  about  an  inch  above  the 
Z3'goma,  and  commencing  about  half  an  iucii  from  the  external  angular 
process  of  the  frontal  bone.  The  fibres  of  the  muscle  are  to  be  turned 
oflf  from  the  bone,  and  the  surgeon  is  to  look  for  the  line  of  fracture.  If 
this  is  found  a  crown  of  trephine  is  to  be  removed,  and  the  blood-clot 
will,  it  is  hoped,  be  brought  in  sight.  The  clot  is  to  he  picked  away  and 
the  vessel  sought  for ;  in 
doing  which  it  may  be  nec- 
essary to  remove  more  of  the 
skull.  When  the  wounded 
artery  is  exposed  it  ma}' 
cease  to  bleed,  otherwise  it 
is  easy  to  secure  it,  either  b_y 
torsion  or  by  a  minute  silk 
ligature ;  or,  if  it  is  found 
to  lie  in  a  canal  in  the  bone, 
by  stuffing  the  hole  with  wax 
or  lint.  But  the  haemorrhage 
may  proceed  from  other 
sources.  Thus,  in  the  case 
referred  to,  at  St.  George's 
Hospital,  it  was  not  the  mid- 
dle meningeal  artery  but 
the  lateral  sinus  which  was 
wounded.  The  surgeon  cut 
down  on  the  situation  of  the 
artery;  but  the  incision  not 
having  extended  backward 
quite  far  enough  to  expose 
the  fracture,  the  source  of 
the  bleeding  was  only  dis- 
covered after  death.  Re- 
membering this  case,  then,  the  surgeon  should  be  prepared,  if  neces- 
sary, to  expose  the  posterior  inferior  angle  of  the  parietal  bone  also. 


Fig.  37. 


The  parietal  bone  of  a  child  set.  5,  showing  a  gaping  fissure 
which  crosses  the  groove  for  the  middle  meningeal  artery, 
producing  considerable  extravasation  inside  the  skull  (the 
traces  of  which  are  still  visible)  and  still  more  haemorrhage 
externally.  The  child  was  admitted  a  weelc  after  tlie  accident 
with  a  large  blood-swelling  above  the  ear,  but  without  any 
cerebral  symptoms.  On  the  fourth  day  after  admission  symp- 
toms of  meningitis  commenced,  and  he  died  comatose  four 
days  afterwards.  The  subarachnoid  cellular  tissue  was  found 
infiltrated  with  purulent  fluid.— St.  George's  Hospital  Mu- 
seum, Ser.  i.  No.  4. 


164 


INJURIES    OF    THE    HEAD. 


Again,  a  case  is  recordecV  in  which  the  trunk  of  the  middle  meningeal 
artery  was  lacerated  in  the  foramen  spinosum.  And  there  are  cases  in 
which  the  symptoms  are  due,  not  to  the  laceration  of  any  known  vessel, 
but  of  several  unnamed  branches  passing  from  the  dura  mater  to  the 
bone.  Here,  however,  the  known  situation  of  the  injury  must  be  the 
surgeon's  guide  in  applying  the  trephine.  But  the  greatest  difficulty  in 
the  treatment  of  these  cases  is  that  very  similar  symptoms  may  follow 
on  rupture  of  vessels  in  the  interior  of  the  brain  from  laceration  of  the 
cerebral  substance.  Nevertheless,  as  the  symptoms  of  unilateral  com- 
pression of  the  brain  coming  on  after  an  interval  from  the  injur}^  do  un- 


FiG.  38.— The  inner  surface  of  the  dura  mater,  showing  a  large  quantity  of  blood  extravasated  and 
adhering  to  its  arachnoid  lining.  This  has  become  decolorized  to  a  great  extent,  and  begun  to  assume 
a  membranous  form.  The  dura  mater  itself  and  the  longitudinal  sinus  are  natural.  There  was  some 
blood  extravasated  also  on  the  external  surface  of  the  dura  mater. 

The  preparation  was  removed  from  the  body  of  a  patient  who  had  labored  for  some  days  under  symp- 
toms of  compression  of  the  brain,  the  result  of  disease.  The  remains  of  the  extravasated  blood  have 
been  peeled  off  from  tlie  surface  of  the  arachnoid  at  the  upper  part.— St.  George's  Hospital  Museum, 
Ser.  vili,  No.  G4. 

Fig.  39. — Drawing  (half  the  size  of  life)  of  a  cyst  removed  from  the  cavity  of  the  arachnoid,  which 
originated  in  ha;morrhagic  eflusion  consequent  on  an  injury  received  more  than  three  years  before. 
The  drawing  is  from  the  Path.  Trans.,  vol.  vi,  plate  2.— The  preparation  is  in  St.  George's  Hospital 
Museum,  Ser.  viii.  No.  81. 

doubtedly  often  depend  on  the  lesion  of  an  accessible  vessel,  the  tre- 
phine should  unquestionably  be  applied  in  such  cases,  and  all  the  more 
if  any  fracture  is  perceptible  externally.     But  the  operation  is  not  by 


1  Gross,  Am.  Jour.  Med.  Sci.,  July,  187:3. 


EXTRAVASATION    IN     ARACHNOID.  165 

any  means  a  successful  one.  Dr.  Gross,  speaking  only  of  the  injuries 
received  in  warfare,  has  collected  seven  cases  in  whicli  the  anterior 
brancli  of  the  middle  meningeal  was  tlie  wounded  vessel,  of  which  one 
recovered,  and  seven  in  which  the  hiiemorrliage  proceeded  from  the  small 
vessels  of  the  dura  mater.  Five  of  tliese  recovered  ;  but,  in  the  absence 
of  tlie  histories,  it  may  be  permissible  to  doubt  whether  the  operation  is 
absolutely  necessary  in  such  lesions  as  those  in  tlie  latter  class.  The 
only  successful  case  that  I  can  myself  remember  to  have  seen  was  one 
in  which  the  vessel  was  injured  by  a  spike-wound,  and  where,  the  haem- 
orrhage having  some  exit  externally,  the  usual  symptoms  of  compres- 
sion were  absent.  So  in  Fig.  37,  the  fracture  l)eing  widel3'  open,  the 
blood  passed  freely  into  the  tissues  of  the  scalp,  and  no  symptoms  of 
compression  occurred. 

3.  Extravasation  into  the  arachnoid  cavity  is  a  very  common  result  of 
injury.  It  forms  a  layer  of  blood-clot,  which  soon  becomes  decolorized, 
and  is  ultimately  replaced  by  a  thin  membrane,  looking  liice  a  doubling 
of  the  arachnoid,  or  consisting  in  some  cases  of  numerous  layers.  These 
layers  may  be  continuous,  forming  a  closed  sac  full  of  fluid,  as  in  the 
case  which  furnished  the  accompanying  illustration  (Fig.  39). 

In  this  case  there  liad  been  an  injury  to  the  head  by  falling  out  of  a 
cart  in  a  state  of  intoxication  three  years  before  death.  The  patient  was 
said  to  have  been  insensible  for  half  an  hour,  but  then  recovered  consci- 
ousness, and  was  removed  to  his  house,  a  distance  of  five  miles.  He 
complained  much  after  this  of  pain  in  the  head  and  neck,  was  irritable 
and  depressed,  and  his  memory  was  not  so  clear  as  before.  But  he  dis- 
played no  very  distinct  symptoms  till  a  year  after  the  injury,  when  he 
had  a  fit  of  insensibility,  without  convulsions,  followed  by  some  numb- 
ness of  the  left  side,  and  a  discolored  appearance  of  the  left  arm  and  leg. 
Such  seizures  became  afterwards  common  with  him  ;  but  his  death  was 
due,  not  to  cerebral  causes,  but  to  disease  of  the  heart.  The  cyst  was 
found  lying  quite  loose  on  the  surface  of  the  right  hemisphere,  and  rolled 
out  as  soon  as  the  skull-cap  was  divided.  It  consisted  of  fibrous  tissue 
without  any  obvious  bloodvessels,  and  contained  a  grumous  fluid,  the  re- 
mains of  extravasated  blood. 

In  these  cases  tlie  origin  of  the  false  membranes  has  been  the  subject 
of  much  discussion.  John  Hunter  and  the  patliologists  who  followed 
him  believed  firmly  in  the  organizable  properties  of  blood  ;  others  believe 
that  extravasated  blood  is  never  organized,  but  tliat  such  extravasation 
provokes  the  eff"usion  of  organizable  lymph  from  the  vessels  of  the  neigh- 
borhood, and  that  during  the  process  of  organization  of  such  lymph  the 
blood  itself  is  absorbed.' 

Both  processes  really  seem  to  exist.  The  first  step  in  the  formation, 
both  of  the  cysts  and  false  membranes,  is  that  tlie  blood-clot  is  covered 
on  its  free  surface  with  a  semi-transparent,  soft,  jelly-like  false  mem- 
brane, which  speedily  takes  the  form  of  the  serous  surface  ;  but  tlie  whole 
clot  and  false  membrane  can  at  this  period  be  easily  stripped  off  the  true 
serous  membrane  below.  A  similar  false  membrane  can  sometimes  be 
traced  uniting  the  clot  to  the  parietal  serous  surface.  These  membranes 
appear  to  be  really  inflammatory  products  from  the  vessels,  though  unac- 
companied by  any  general  symptoms  of  inflammation.  But  that  organi- 
zation does  go  on  in  the  extravasated  blood  itself  is  the  opinion  of  many 
of  the  most  eminent  pathologists,  among  whom  Rindfleisch  may  be  re- 

1  On  the  whole  of  this  subject  see  Mr.  Hewctt's  paper,  Med.-Cbir.  Trans.,  vol. 
xxviii,  p.  45. 


166 


INJURIES    OF    THE    HEAD. 


Fii;.4n. 


ferred  to  as  having,  as  he  believes,  demonstrated  how  the  red  corpnscles 
of  the  effused  blood  are  either  converted  into  or  replaced  by  the  "  wan- 
dering leucocytes,"  which  are  afterwards  to  form  the  librillar  base  of  the 
new  tissue.' 

Symptoms. — The  symptoms  of  these  extravasations  ai'e  not  clearly 
made  out,  nor  does  it  seem  at  all  certain  that  they  produce  any  symptoms 
of  tlieir  own,  if  the  effused  blood  is  not  in  large  quantity.  In  some  cases 
(as  in  the  one  above  quoted)  there  have  been  anomalous  symptoms  of 
slight  pressure  or  slight  irritation  of  the  convolutions,  such  as  persistent 
pain,  loss  of  mental  power,  alteration  of  temper,  fits.  When  A'ery  thick 
such  effusions  may  cause  more  decided  symptoms  of  compression,  for 
which  sometimes  the  trephine  has  been  applied  ;  the  dura  mater  having 
bulged  into  the  opening  has  been  incised,  and  the  blood  having  been 
evacuated  the  patient  has  done  well.'^ 

Trauinatic  extravasations  of  blood,  whether  in  the  arachnoid  cavity,  in 

the  meshes  of  the  pia  mater,  or  in 
the  brain,  when  sufficiently  large 
to  produce  s^Miiptoms  of  their  own, 
lead  to  symptoms  so  exactly  like 
those  of  apoplexy,  that  if  the  his- 
tory is  unknown  or  concealed,  and 
there  are  no  visible  traces  of  in- 
jury, I  am  not  aware  that  the  diag- 
nosis can  be  securely  established. 
As  this  is  a  matter  of  ver}'  great 
medico-legal  interest  I  must  refer 
the  student  for  a  confirmation  of 
this  statement  to  our  best  authors 
on  Medical  Jurisprudence.^ 

The  accompanying  illustrations 
(Figs.  38,  40),  taken  from  cases  of 
spontaneous  extravasation  of  blood 
in  the  arachnoid  cavity,  show  that 
such  extravasations  possess  ex- 
actly the  same  anatomical  charac- 
ters, and  become  organized  in  ex- 
actly the  same  way  as  the  traumatic 
extravasations.  In  fact,  their  symp- 
toms, as  well  as  their  anatomy,  are 
identical,  nnd  when  no  marks  of 
A'iolence  are  found  the  cases  are 
indistinguishable.  And  it  is  by  no 
means  rare  for  extensive  lesions 
inside  the  skull  to  be  caused  by 
traumatic  injuries,  which  leave  no 
trace  on  the  scalp  or  the  skull.  I 
remember  a  remarkable  instance 
which  occurred  while  I  was  Cura- 

Bloofl-cyst  in  the  urachnoltl  cavity,  thn  result  of  tor  of  tllC  Museum  at  St.  George's 

disease.    This  case  is  referred  to  in  Mr.  llewetfs  ■  ][ospital.     A  WOman  WaS  admitted, 

paper,  Med.-Chir.  Trans.,  vol.  xxviii,  p.  (il. — From  .            j    i.        !•    i           ..               i    i     • 

8t  George's  Hospital  Museum,  Sor.  viil,  No.  79.  '^  «  ^tate  Ot  almOSt  Complete  IHSen- 

>  Rindfleisch,  PhUi.  Hist  ,  vol.  ii,  p.  822.     New  Syd.  Soc.'s  Trans. 
^  Howott,  in  tlie  Syst.  of  Siirj^.,  vol.  ii,  p.  202 

3  "  The  symptoms  of  traumatic  compression,  when  well  marked  and  uncomplicated, 
arc  those  of  apoplexy."     Lo  Gros  Clark,  Diagnosis  of  Visceral  Lesions,  p.  121. 


FRACTURES    OF    THE    SKULL.  167 

sibility,  from  apoplexy,  as  was  supposed,  under  the  care  of  one  of  the 
ph3'sicians.  She  was  said  to  have  had  a  fit  two  or  three  days  before.  She 
died  on  tiie  following  day.  The  head  was  carefully  examined,  and  espe- 
cially with  a  A'iew  to  the  detection  of  any  mark  of  violence.  No  trace  of 
injur}'  was  found,  no  bruise,  no  fracture,  no  laceration  of  any  part  of  the 
brain.  The  whole  of  one  hernisi)here  was  covered  with  an  enormous 
quantity  of  blood,  external  to  the  brain,  and  chiefly  in  the  meshes  of  the 
pia  mater.  Microscopical  examination  of  the  vessels  did  not  enable  me 
to  detect  any  disease  of  their  coats.  The  case  was,  in  the  absence  of  any 
further  information,  classed  as  one  of  meningeal  apoplexy,  and  the  woman 
had  been  buried,  when  the  medical  man  who  had  attended  her  before  her 
admission  informed  us  that  her  death  was  attributed  to  violence  on  the 
part  of  her  husband.  It  turned  out  that  both  of  them  were  ver}'  drunken 
people,  and  that  finding  her  drunk  on  his  return  home  he  had  beaten 
her,  and  then  left  her  locked  up  in  his  room  for  the  greater  part  of  a  da}'. 
The  body  was  exhumed,  and  the  man  put  on  his  trial  for  murder;  but, 
though  the  circumstances  were  suspicious,  it  was  found  impossible  to 
come  to  any  certain  conclusion,  and  he  was  acquitted.  For,  notwith- 
standing the  apparently  healthy  condition  of  those  vessels  which  were 
examined,  it  was  impossible  to  affirm  that  constant  intoxication  might 
not  have  given  rise  to  apoplexy  in  this  case ;  especially  since  cases  of 
meningeal  apoplexy  have  been  put  on  record  where  no  suspicion  of  vio- 
lence could  be  entertained,  and  where  no  disease  of  the  vessels  was 
detected. 

4.  So  it  is  with  extravasation  of  blood  in  the  substance  of  the  brain. 
It  is,  to  sa}'  the  least,  excessively  difficult  in  many  cases  to  say  with  any 
approach  to  certainty  whether  it  depends  on  injury  or  on  disease,  or  on 
a  mixture  of  the  two,  i.  e.,  on  slight  injury  acting  upon  tissues  degenerated 
b}'  disease. 

lY.  Fractures  of  the  Skull. — We  come  now  to  fractures  of  the  skull — 
divided  into  those  of  the  vault  and  those  of  the  base.  The  chief  varieties 
of  fracture  of  the  vault  are  simple  fissures,  starred  and  comminuted  frac- 
tures, fractures  with  depression  of  the  entire  thickness  of  the  skull,  frac- 
tures with  depression  of  the  outer  or  of  the  inner  table  only,  and  fractures 
with  elevation  of  the  fractured  portion.  In  young  subjects  it  is  said  that 
the  skull  may  be  indented  or  driven  in  (as  any  soft  substance  might) 
without  any  fracture,  but  this  is  doubtful.^ 

Any  of  these  forms  of  fracture  may  be  either  simple  or  compound.'  In 
the  injuries  which  we  usually  meet  with  in  civil  practice  fissured  fractures 
frequently  spread  from  the  vertex  far  into  tiie  base  of  the  skull,  and  some- 
times travel  vertically  round  the  whole  cranium,  so  as  to  separate  the  an- 
terior completely  from  the  posterior  part.  Compound  fractures  may  be 
said  as  a  rule  to  be  more  often  of  limited  extent  than  simple. 

Fi'aetures  with  depression  of  one  table  only,  and  elevated  fractures,  are 
rare.     The  other  varieties  of  fracture  of  the  skull  are  of  constant  occur- 

1  I  mean  that  it  is  doubtful  whether  the  indentations  which  are  occasionally  found 
in  the  skulls  of  children  are  not  always  accompanied  by  some  amount  of  fracture. 
The  occurrence  of  such  indentations  and  their  gradual  disappearance  is  indubitable. 
See  in  Mr.  Le  Gros  Clark's  work,  p.  94,  a  very  characteristic  case  in  a  baby  six 
months  old,  caused  by  fallinc:  on  a  stone.  "  The  indentation  was  oval,  about  three- 
quarters  of  an  inch  deep  in  the  centre ;  the  end  of  the  thumb  might  easily  have  been 
buried  in  it:  it  presented  no  sharp  edge  to  the  touch."  There  were  no  head  symp- 
toms. Mr.  Clark  saw  the  child  several  years  afterwards,  and  there  remained  no  trace 
of  the  injury. 


168 


INJURIES    OF    THE     HEAD. 


rence,  FKactures  N\-ith  depression  of  the  outer  table  only  are  best  exem- 
plified b}'  those  which  occur  in  the  frontal  sinus,  where  a  great  depression 
ma}'  exist  in  the  outer  wall  of  the  sinus  without  its  inner  wall  having  been 
in  any  respect  interfered  with.     Such  cases  are  easily  known  by  the  free 


Fl(}.  41. 


A  fracture  passin-g  vertically  round  the  skull,  so  as  to  divide  it  into  two  portions,  anterior  and  pos- 
terior. The  line  of  fracture  can  be  traced  from  the  vertex,  where  it  follows  pretty  nearly  the  course  of 
the  coronal  suture  to  the  base,  where  it  becomes  comminuted,  the  chief  branch  passing  through  the 
body  of  the  sphenoid  bone  and  extending  into  the  sphenoidal  fissure  on  the  left  side,  while  another 
large  branch  traverses  the  basilar  portion  of  the  occipital  bone,  just  in  front  of  the  foramen  magnum. 
The  petrous  portion  of  the  left  temporal  bone  is  quite  isolated,  a.  The  foramen  magnum.  6.  The 
basilar  portion  of  the  occipital  Ixine.  c.  The  foramen  ovale,  d.  The  sella  turcica. — St.  George's  Hos- 
pital Museum,  Ser.  i.  No.  6. 

escape  of  air  out  of  the  sinus,  leading  to  considerable  emphysema,  and  by 
the  absence  of  brain  symptoms,  in  spite  of  the  extensive  depression.' 
Fractures  with  depression  of  the  internal  table  only  are  rare,  and  their 
diagnosis  very  obscure.  The  Museum  of  St.  George's  Hospital  contains 
two-very  well-marked  specimens  ;-  and  there  is  another  specimen  showing 
the  skull-cup,  from  which  a  portion  of  the  depressed  inner  table  had  been 
removed  a  year  after  the  accident,  but  the  patient  died  of  arachnitis. 
This  injury  may  be  suspected,  though  it  cannot  be  exactly  diagnosed, 
from  the  continuance  of  constant  pain  in  the  part,  accompanied  with 
S3'mptoms  of  imperfect  compres-sion  of  the  brain,  or  followed  by  low  in- 
flammation of  the  membranes  ;  and  in  such  cases  the  trei)hine  may  be 
applied  over  the  seat  of  injury,  if  the  symptoms  are  grave  enough  in  the 
jiulgment  of  the  surgeon  to  warrant  so  serious  a  measure.  The  accidents 
which  usually  give  rise  to  tiiis  injury  are  blows  or  cuts  with  a  moderately 
sharp  substance,  a  sabre  cut,  a  fall  on  a  stone,  the  blow  of  a  piece  of  slate, 
brick,  shovel,  etc.     In  almost  all  cases  there  is  a  fissure  in  the  external 


'  A  very  woU-markod  case  of  fracture  of  the  out(;r  lal)le  only,  from  the  blow  of  a 
bludgeon,  in  which  the  fractured  portion  ultimatelv  separated,  is  related  by  Mr.  Le 
Gros  Clark,  p.  91. 

^  Series  I,  Nos.  7  and  8.  One  of  these  is  figured  in  Mr.  Hewett's  article  on  In- 
juries of  the  Head,  Syst.  of  Surg.,  vol)  ii,  p.  2GG. 


DEPRESSED     FRACTURE.  169 

table,  but  the  internal  table  is  said  to  have  been  fractured  alone.  Frac- 
tures with  elevation  of  the  fractured  part  can  only  be  produced  by  direct 
wound,  and  are  at  once  obvious.'  The  importance  of  the  injury  depends 
generally  on  the  lesion  of  the  brain  or  its  membranes  by  the  wound.  The 
portion  of  bone  turned  up  will  be  easily  bent  down  again  if  it  interferes  with 
the  union  of  the  wound,  or  if  it  breaks  in  the  attempt  it  may  be  removed. 

Fracture  by  '-'Contre-cnuj).'''' — We  frequently  hear  of  fracture  of  the 
skull  by  "  contre-coup,"  but  it  seems  undeniable  that,  as  Mr.  Le  Gros 
Clark  has  pointed  out  [op.  cit.^  p.  102),  this  expression  is  generally  em- 
ployed in  quite  an  erroneous  sense.  Strictl}',  it  ought  to  mean  that,  the 
skull  being  struck  at  a  given  point,  fracture  occurs  at  the  point  diametri- 
cally opposite,  while  no  force  is  applied  to  the  skull  in  the  latter  situation. 
This  appears  to  be  quite  unproved.  If  the  vertex  be  struck,  fracture  often 
takes  place  at  the  base,  and  not  at  the  vertex  ;  or  if  one  side  of  the  head  be 
struck  fracture  often  takes  place  at  the  other;  but  in  the  former  case  the 
injury  to  the  base  is  due  to  the  skull  having  been  made  to  impinge  forcibly 
on  the  occipital  condyles  ;  and  in  the  latter,  as  far  as  I  have  been  able  to 
discover,  it  has  always  been  the  case  that  the  opposite  side  of  the  skull  has 
been  driven  against  an  obstacle  ;  so  that  both  are  instances  really  of  direct 
force.  Again,  when  a  blow  is  struck  on  one  side  of  the  vertex  of  the 
skull,  the  opposite  side  of  the  base  of  the  brain  is  often  lacerated,  but  this 
is  obviousl}^  caused  by  the  brain  having  been  driven  down  on  to  the  rough 
base  of  the  skull.  The  term  is,  therefore,  speaking  accurately,  quite  in- 
correct, but  it  may  be  retained  as  having  now  come  into  general  use  to 
express  the  fact  that  a  blow  at  one  part  of  the  skull  often  produces  its 
main  result  at  the  other  end  of  the  axis  of  the  cranium,  a  fact  which  is  of 
considerable  practical  importance. 

Diagnosis  of  Fracture. — The  only  diagnostic  sign  of  a  simple  fracture 
of  the  skull  is  the  depression  by  which  it  may  be  accompanied.  If  no 
such  depression  exists  there  is  no  means  of  knowing,  in  any  case  of  con- 
cussion or  other  injury,  whether  the  bone  is  or  is  not  also  broken.  Nor 
does  it  much  matter,  for  though,  in  popular  language,  a  fracture  of  the 
skull  is  represented  as  a  very  grave  injury — and  rightly  so,  because  frac- 
tures of  the  skull  are  usually  accompanied  by  injury  to  the  cranial  con- 
tents— it  should  be  remembered  that  it  is  this  concomitant  injury  which 
alone  gives  them  their  gravit}',  and  that  in  themselves  fractures  of  the 
skull  are  hardly  more  serious  than  fractures  of  any  other  bone.  The 
skull  is  richly  supplied  with  blood,  and  simple  fractures  of  the  vertex, 
unaccompanied  by  any  other  lesion,  unite  very  kindly. 

In  examining  the  skull  for  depression  care  must  be  taken  not  to  con- 
found the  depression  so  often  found  in  the  centre  of  a  lump  of  extrava- 
sated  blood  with  the  depression  of  a  fracture.  There  are  also  some  rare 
cases  in  which  an  injury  lias  been  received  over  a  portion  of  the  skull  in 
which  either  the  whole  cranium  or  the  external  table  only  has  been  de- 
ficient from  congenital  malformation  or  from  atrophy,  and  the  edge  of 
the  deficient  part  has  been  mistaken  for  that  of  a  fracture.  The  diag- 
nosis of  compound  fracture  is  generally  obvious  ;  care  must,  however,  be 
taken  not  to  mistake  a  suture  for  a  fissure  ;  this  may  easily  be  done  when 
the  sutures  are  irregular,  as  in  the  instance  of  numerous  Wormian  bones. 

Treatment. — The  treatment  of  an  undepressed  fracture,  whether  simple 
or  compound,  consists  merely  in  precautionary  measures.  In  compound 
fracture  everything  should  be  done  to  promote  the  immediate  union  of 

1  A  good  illustration  of  this  rare  form  of  fracture,  also  from  St.  George's  Museum, 
will  be  found  in  Mr.  Hewett's  essay,  p.  265. 


170 


INJURIES    OF    THE     HEAD. 


tlic  woiiiul,  and  very  often  the  fracture  will  heal  as  uninterrupted!}'  as  a 
simple  fissure.  The  rest  of  the  treatment  consists  merely  in  watching  for 
and  treating  any  cerebral  symptoms  which  may  arise. 

Simple  depressed  fractures  ought  to  be  elevated  by  operation  when  ac- 
companied by  symptoms  of  compression  or  of  irritation  of  the  brain,  but 
not  otiierwise,  and  in  practice  cases  will  often  be  met  with  where  the 
surgeon  will  require  all  his  acumen  to  determine  whether  the  symptoms 
of  cerebral  irritation  which  exist  do  or  do  not  depend  on  the  depression 
of  bone.  When  this  depression,  however,  is  considerable  and  there  are 
cerebral  symptoms,  the  operation  is  indicated. 

Fig.  42. 


An  old  depressed  fracture  of  the  skull  souudly  and  perfectly  cured  without  trephining.  The  frac- 
ture is  seen  to  he  chiefly  of  the  frontal  hone,  extending  slightly  into  the  parietal.  Its  depth  is  equal 
to  that  of  the  whole  thickness  of  the  skull,  and  the  length  of  the  fissure  is  at  least  four  inches.  On  the 
inside  of  the  skull  the  angle  of  the  depressed  portion  projects  as  a  spike  or  thorn  of  bone  which  had 
penetrated  the  dura  mater,  and  was  lodged  in  a  little  pit  or  depression  in  the  surface  of  the  brain. 

Notliing  is  known  about  the  original  injury,  except  that  the  man  was  in  the  Middlesex  Hospital  in 
the  year  18.53,  fourteen  years  before  his  death,  on  account  of  some  injury  to  his  head;  and  that  he  had 
been  subject  ever  since  to  violent  paroxysmal  attacks  of  pain  in  the  head.  The  records  of  the  ISIiddle- 
sex  Hospital,  however,  contain  no  notice  of  the  case. — Museum  of  St.  George's  Hospital,  Ser.  i,  No.  244  a. 

In  compound  depressed  fractures  most  surgeons  are  in  favor  of  ex- 
tending the  province  of  operation  so  far  as  to  say  that  they  ought  always 
to  be  elevated,  whether  symptoms  are  present  at  the  moment  or  not.  But 
this  is  a  rule  which  is  by  no  means  universally  adopted.  Cases  of  de- 
pressed fracture,  both  simple  and  compound,  often  unite,  and  the  patient 
recovers  without  operation.  This  is  illustrated  by  the  accompanying 
figure  (42)  and  by  some  striking  preparations  of  sabre-wounds  of  the 
skull  in  the  Museum  of  the  College  of  Surgeons.  For  my  own  part,  if 
the  depth  of  the  depression  is  slight,  and  especially  if  its  extent  is  also 
considerable,  I  have  no  doubt  that  in  the  absence  of  symptoms  it  is  best 
left  alone,  whilst  under  opposite  circumstances  (i.  e.,  the  deep  depression 
of  a  small  piece  of  bone)  it  might  be  better  to  elevate  it ;  but  then  such 
a  depression  will  almost  certainly  produce  cerebral  symptoms.  And 
depressed  compound  fractures  with  symptoms  should  no  doubt  always  be 
elevated.  On  the  whole,  therefore,  the  treatment  of  compound  and  sim- 
ple fractures  would  not  vary  so  much  as  used  to  be  the  rule.  There  is, 
no  doubt,  somewhat  less  hesitation  in  applying  the  trephine  when  the 
fracture  is  already  exposed  in  a  wound,  but  the  depth  and  the  extent  of 
the  depression  are  far  more  iini)ortant  considerations.  The  more  a  frac- 
ture approaches  the  "punctured"  form  the  more  is  trephining  indicated. 

Fractures  of  the  base  of  the  skull  are  in  the  great  majority  of  cases 
caused  by  indirect  force,  and  are  extensions  downwards  of  fractures  of 
the  vault.  Sometimes,  however,  they  are  caused  by  direct  violence. 
This  occurs  most  commonly  in  wounds  of  the  orbit.  Here  it  has  fre- 
quently happened  that  a  slight  injury,  such  as  the  thrust  of  a  foil  or  a 


FRACTURES    OF    RASE. 


171 


parasol  or  some  weapon,  has  inflicted  an  apparent!}^  trivial  injury  on  or 
below  the  eyelid  (generally  the  upper),  and  that  the  accident  has  been 
taken  little  notice  of,  until  some  days  afterwards  symptoms  of  cerebral 
inflammation   have  appeared  and  have  proved  rapidly  fatal.     On  post- 


A  fracture  of  the  skull  in  which  some  of  the  large  branches  of  the  middle  meningeal  artery  were  cut 
across,  causing  extravasation  of  blood  between  the  bone  and  dura  mater.  A  portion  of  the  vault  of  the 
skull  has  been  left  on,  in  order  to  show  that  this  fracture,  contrary  to  what  is  usual  in  such  cases,  does 
not  affect  the  vertex.  It  is  of  a  trilateral  shape,  with  a  horizontal  and  two  vertical  branches,  c,  c,  c. 
Some  of  the  large  grooves  for  the  meningeal  artery,  d,  are  cut  across,  but  not  in  the  usual  position. 
The  main  trunk  of  the  middle  meningeal  artery  was  divided,  and  there  was  extensive  extravasation 
of  blood  between  the  bone  and  dura  mater,  as  well  as  laceration  of  the  cerebral  substance.  Yet  there 
was  no  paralysis  as  far  as  could  be  made  out,  though  the  patient  was  completely  insensible  and  fre- 
quently convulsed,  a,  a  refer  to  sections  of  the  outer  wall  of  the  orbit,  separated  by  the  spheno-max- 
illary  fissure ;  6,  to  the  styloid  process. — St.  George's  Hospital  Museum,  Ser.  i,  No.  260. 

mortem  examination  the  weapon  has  been  found  to  have  passed  through 
the  papery  inner  wall  of  the  orbit  into  the  brain,  and  a  fragment  has  not 
unfrequently  been  found  lodged  in  the  cerebral  substance.  In  other 
cases,  though  the  brain  has  not  been  wounded,  the  cavernous  sinus  has 
been  laid  open,  giving  rise  to  fatal  haemorrhage,  or  to  lesions  of  the 
orbital  nerves,  or  to  orbital  aneurism.^  All  such  cases,  therefore,  should 
be  very  carefully  examined  at  first,  and  sedulously  watched  afterwards. 
Other  and  rarer  instances  of  direct  fractures  of  the  base  of  the  skull 
are  found,  as,  for  example,  in  the  preparation  from  St.  George's 
Museum,  figured  in  Mr.  Hewett's  essay,  where  the  condyle  of  the  lower 
jaw  is  driven  through  the  base  of  the  skull ;  but  the  vast  majority  are 
indirect  fractures,  sometimes  of  the  form  of  simple  fissures,  at  other  times 
branching  in  various  directions.  They  are  either  confined  to  a  single 
zone  or  fossa  of  the  base,  or  the}^  implicate  two  or  three  fossoe  at  the 
same  time.^     The  great  majority  of  these  fractures  pass  through  the  mid- 

1  See  Lancet,  1873,  vol.  ii,  p.  143,  for  a  reference  to  some  of  these  cases. 
^  Mr.  Hewett  refers  to  the  records  of  St.  George's  Hospital  for  ten  years,  compris- 
ing 64  cases  of  fracture  of  the  base.     Out  of  these  there  were  25  in  which  the  line  of 


172 


INJURIES    OF    THE    HEAD. 


die  fossa.  As  stated  above  the  fracture  iisuall}'  extends  into  the  vertex, 
being  sometimes  a  branch  of  a  fracture  originating  in  tlie  vault ;  some- 
times but  more  rarely  it  originates  in  a  shock  transmitted  through  the 


Fig.  44. 


A,  the  external  and  b,  internal,  view  of  a  preparation  in  which  hernia  cerebri  took  place  into  the 
external  auditory  meatus  eight  days  after  a  gunshot  wound.  The  case  is  related  by  Mr.  Caesar  Haw- 
kins, Contributions  to  Surgery  and  Pathology,  vol.  i,  p.  318. — St.  George's  Hospital  Museum,  Ser.  viii, 
No.  13. 


spine  to  the  base  of  the  skull,  and  spreading  up  into  the  vertex.  In  some 
cases,  as  in  tliat  which  furnished  Fig.  43,  the  fracture,  though  of  con- 
siderable extent,  nia^^  be  confined  to  the  base,  but  this  is  decidedly  un- 
usual in  indirect  injuries. 

Si/mpfom.'i. — These  fractures  occurring  as  they  do  in  severe  injuries  of 
the  head,  are  therefore  usuall}^  accompanied  by  the  ordinaiy  cerebral 
S3'mptoms.  Irrespective  of  these  the  only  symptoms  of  fracture  of  the 
base  are  the  escape  of  the  contents  of  the  cranial  cavity,  or  injury  of  the 
nerves  which  pass  through  the  foramina  at  the  base  of  the  skull.  Now, 
the  contents  of  the  cranial  cavity  are  blood,  subarachnoid  fluid,  and  brain- 
fracture  was  confined  to  a  single  fossa;  the  anterior  in  5  cases;  the  middle  in  14; 
the  posterior  in  G.  There  were  29  cases  where  2  fossas  were  implicated,  viz.,  the  an- 
terior and  middle  in  14;  the  middle  and  posterior  in  15.  In  the  remaining  10  the 
fracture  traversed  all  3  fossaj.  Thus  the  middle  fossa  was  implicated  alone  or  with 
the  others  in  53  out  of  the  G4  cases. — Syst.  of  Surg.,  vol.  ii,  p.  281. 


FRACTURES    OF    BASE. 


173 


matter.  The  brain-matter  very  rarely,  indeed,  exudes  from  a  fracture  of 
the  base.  I  have  seen,  however,  a  case  in  vvliich  liernia  cerebri  took  place 
into  the  meatus  auditorius,  and  a  preparation  showing  a  hernia  cerebri 
in  the  meatus  is  figured  on  the  previous  page.  Wiien  present  this  symp- 
tom is  of  course  decisive  of  the  existence  of  fracture.  But  tlie  usual 
symptoms  are  either  extravasation  of  l)lood  or  escape  of  watery  fluid. 

In  fractures  of  tlie  anterior  fossa  the  blood  is  extravasated  at  first  in 
the  deep  cellular  tissue  of  the  orbit,  and  makes  its  way  forward  till  it 
appears  under  the  ocular  conjunctiva  and  the  lids.  This  extravasation 
is  distinguished  from  that  of  ordinary  black  eye  by  its  l>eing  less  in  the 
lids,  considerable  in  the  ocular  conjunctiva,  and  increasing  as  it  passes 
backwards  out  of  sight.  The  reverse  is  the  case  in  a  simple  bruise. 
Blood  may  also  pass  through  the  body  of  the  sphenoid  bone  into  the  nose, 
as  it  may  also  in  fracture  of  the  middle  fossa.  Persistent  epistaxis, 
therefore,  is  sometimes  met  with  in  fractures  of  the  base,  or  liiiemateraesis 
occurs  from  the  blood  having  been  swallowed  and  rejected  by  the  stomach. 


Part  of  the  base  of  the  skull,  showing  a  line  of  fracture  which  traverses  the  internal  auditory  meatus. 
The  principal  fracture  formed  the  upper  boundary  of  the  piece  of  skull  here  depicted.  At  the  point  a 
a  branch  ran  down  through  the  internal  auditory  meatus  into  the  jugular  foramen.  The  patient  had 
fallen  down  stairs,  striking  one  side  of  his  head.  He  was  admitted  in  a  state  of  partial  insensibility, 
bleeding  from  the  opposite  ear  and  from  the  nose.  Next  day  a  copious  watery  discharge  commenced 
from  the  ear  and  continued  till  his  death,  which  took  place  three  days  after  the  accident  from  suppu- 
rative inflammation  of  the  cerebral  membranes.  Small  extravasations  of  blood  were  found  in  the 
anterior  pillars  of  the  fornix,  and  on  the  under  surface  of  both  middle  lobes  of  the  brain. — St.  George's 
Hospital  Museum,  Ser.  i,  No.  243. 


The  more  common  haemorrhage,  however,  in  fractures  of  the  middle 
fossa  is  from  the  ear,  the  membrana  tympani  being  usually  lacerated  in 
such  injuries,  whereby  a  way  is  afforded  for  the  blood  to  pass  out  from 
the  lateral  sinus,  or  any  other  large  vessel  in  its  neighborhood  which  may 
have  been  wounded  in  the  fracture.  Bleeding  from  the  ears  is  accord- 
ingly a  valuable  sign  of  fracture  of  the  middle  fossa  of  the  base  of  the 
skull,  when  copious  and  long  continued  ;  though  it  cannot  be  said  to  be 
absolutely  diagnostic  of  the  injury,  since  considerable  bleeding  has  been 
known  to  occur  in  injuries  involving  only  the  ear  itself.  Blood  may  also 
pass  into  the  pharynx  and  nose,  causing  hrematemesis  and  epistaxis, 
which,  however,  may  have  so  many  other  sources  that  they  can  only  very 
rarely  assist  much  in  the  diagnosis.  In  some  rare  cases  extravasation 
of  blood  behind  the  wall  of  the  pharynx  is  found. 

In  fractures  of  the  posterior  fossa  blood  may  be  extravasated  in  the 
neighborhood  of  the  mastoid  process,  in  the  occipital  region,  or  at  the 


174 


INJURIES    OF    THE    HEAD. 


side  of  the  neck,  and  such  extravasation  may  become  a  valuable  sign  of 
fracture  in  cases  where  the  soft  parts  are  known  not  to  have  been  bruised. 
Tenderness  to  pressure  over  the  mastoid  process  is  sometimes  observed 
in  such  cases. 

Se7'ouf!  DiftcJiarye. — But  the  most  striking  symptom  of  fracture  of  the 
base  of  the  skull,  and  one  which  under  certain  circumstances  is  really 
decisive  of  the  nature  of  the  injury,  is  the  discharge  of  serous  fluid.  This 
occurs,  though  very  rarely,  also  in  fractures  of  the  vertex,  and  it  has  been 


Fig.  4G. 


Fig.  47. 


Fig.  46. — Fractuio  of  tlie  anterior  fossa  of  the  .skull,  united.  The  patient  died  of  erysipelas  two 
montlis  after  the  injury.  The  fracture  traversed  the  anterior  and  middle  fossie  of  the  skull.  At  a  is 
seen  the  line  of  the  fracture  traver.sing  the  anterior  fossa.  The  union  uere  is  very  perfect.  In  other 
parts  a  considerable  deposit  of  vascular  porous  new  hone  is  found  around  and  between  the  edges  of  the 
fracture,  b  shows  a  mass  of  partly  decolorized  blood-clot,  mixed  with  organized  fibrin  on  the  outer 
surface  of  the  dura  mater,  corresponding  to  the  fracture.— From  the  Museum  of  St.  George's  Hospital, 
Ser.  i,  No.  .'}4. 

Fig.  47.— Union  of  an  old  fracture  of  the  posterior  fossa  of  the  base  of  the  skull.  The  accident  had 
occurred  three  years  before  death.  On  post-mortem  examination  the  line  of  fracture  was  found  to 
commence  at  the  upper  part  of  the  occipital  bone,  and  its  upper  half  has  lieon  completely  united,  and 
is  seen  on  the  outside  of  the  skull  as  a  mere  groove  in  the  solid  bone.  On  the  inner  surface  the  bone 
was  found  thickened  and  vascular  at  this  part,  from  deposit  on  its  internal  surface.  The  lower  half  of 
the  line  of  fracture  i.s  not  united,  but  a  distinct  fissure  is  left  which  (as  seen  in  the  engraving)  is  per- 
fectly open  in  the  macerated  bone,  the  margins  being  thinned  and  rounded  oil'  by  absorption.  In  the 
recent  state  ibis  fissure  was  coni])letely  tilled  by  filjrous  tissue.  Ciiinplcd'  bony  anchylosis  had  taken 
place  in  the  joint  between  the  atlas  and  occiput,  and  the  lateral  sinus  was  obliterated  at  its  termination 
(Path.  Soc.  Trans.,  vol.  vii,  p.  282).— St.  George's  Hospital  Museum,  Ser.  i,  No.  30. 

known  to  take  place  tiirough  the  nose,  but  in  all  ordinary  cases  the  dis- 
charge is  from  the  eai's.  When,  immediately  alter  the  iiijiuy,  a  copious 
discharge  of  watery  saline  fluid — /.  c,  fluid  containing  only  the  faintest 


FRACTURES    OF    BASE. 


175 


Fig.  48. 


trace  of  albumen^ — is  found  issuing  from  tlie  ear,  there  can  be  no  ques- 
tion tliat  there  is  a  fracture  of  the  base  of  the  skull  cutting  the  meatus 
auditorius  internus  across,  and  thus  laying  open  that  prolongation  of  the 
arachnoid  membrane  which  accompanies  the  seventh  pair  of  nerves  down 
the  meatus,  where!)}'  the  subarachnoid  space  is  laid  open.  For  no  other 
cavity  exists  in  which  there  is  any  collection  of  such  fluid. ^  But  when 
after  an  injury  to  the  head,  followed  b}'  bleeding  from  the  ear  which  has 
lasted  more  than  a  day,  a  watery  (or  rather  colorless)  discharge  follows, 
which  contains  more  or  less  of  inflammatory  products,  the  inference  is 
not  so  clear,  for  such  discharges  ma}'  be  furnished  by  the  lining  mem- 
brane of  the  external  meatus  only,  or  by  that  of  the  tympanum,  and 
have  been  known  to  occur  in  cases  in  which  it  has  been  proved  by  dissec- 
tion that  there  was  no  fracture  of  the  skull  whatever.''  Such  discharges, 
however,  are  far  less  vvatery  than  those  which  consist  of  the  cerebro- 
spinal fluid,  and  they  can  never  occur  immediately  after  the  injury,  though 
they  may  commence  after  a 
short  interval. 

Lesions  of  the  nerves  which 
issue  fi'om  the  base  of  the 
brain  are  tolerably  often  pres- 
ent in  fractures  of  the  base  ; 
and  the  paralysis  of  the 
nerves,  especiall}^  those  of  the 
seventh  pair,  is  a  symptom 
strongl}'  confirmatory  of  the 
diagnosis,  though,  as  will  be 
seen  in  the  sequel,  paralysis 
of  these  nerves  may  also  re- 
sult from  ecchymosis  into 
their  substance,  and  prob- 
ably from  inflammation  fol- 
lowing an  injury  of  any 
kind ;  so  that  the  symptom 
is  liot  in  itself  unequivocal. 

Union  of  Fractures  of  the 
Base. — Fracture  of  the  base 
of  the  skull  is  by  no  means 
necessarily  fatal.  Excluding 
very  many  cases  in  which 
all  the  symptoms  have  ex- 
isted, but  the  patient  has 
recovered,  we  have  ample 
anatomical  proof  that  such 
fractures  do  get  well,  and 
that  they  are  not  insuscepti- 
ble of  union,  though  in  the 


Fracture  of  the  left  temporal  bone  extpiiding  into  the  base 
of  the  skull  The  patient  died  two  months  afterwards,  from 
a  different  cause.  The  part  of  the  bone  here  represented  is 
the  squamous  portion.  "The  edges  of  the  fissure  have  been 
so  thinned  away  by  absorption  that  an  opening  in  the  bone 
is  formed  13*^  in.  in  length,  tapering  to  its  extremities,  and 
}/g  in.  in  breadth  at  its  centre.  At  the  points  where  the  edges 
of  the  fissure  are  in  contact  (between  a  and  6)  no  bony  union 
has  taken  place,  as  ascertained  by  Mr.  Tomes  on  endeavoring 
to  make  a  section  for  the  microscope."     See  Mr.  Gregory 


parts  of  the    base    where    the    Forbes  in  Lancet,  vol.  i,  p.  SSO,  18-19. 

'  "The  absence,  except  in  small  quantity,  of  albumen,  and  the  presence  of  an  ex- 
cess of  chloride  of  sodium  in  the  cerebro-spinal  fluid,  has  been  repeatedly  shown  by 
analysis." — Le  Gros  Clark. 

'■^  There  seems  some  possibility  that  the  descending  horn  of  the  lateral  ventricle 
may  in  some  cases  have  been  broken  into;  at  least  such  is  Dr.  Moxon's  idea;  and 
cases  which  support  this  belief  mav  be  found  quoted  in  Mr.  Hewett's  essay,  pp.  292, 
293. 

3  See  in  the  Path.  Soc.  Trans.,  vol.  vi,  p.  22,  a  case  reported  by  Mr.  Gray,  in  which 
serous  discharge  followed  upon  injury  to  the  tympanum,  and  inflammation  of  the 


176  INJURIES    OF    THE    HEAD. 

bone  is  very  thin  and  the  foramina  large  the  union  is  apt  to  be  irregular, 
and  the  edges  may  often  be  found  somewhat  absorbed,  forming  a  chink 
or  fissure.  I  apiiend  illustrations  of  united  fracture  in  each  of  the  fossfe 
of  the  skull  from  the  Museum  of  St.  George's  Hospital. 

No  treatment  is  required  for  the  fracture  of  the  base  beyond  that 
which  the  concomitant  injury  of  the  brain  demands. 

Y.  Lesions  of  the  Brain. — We  must  now  pass  on  to  those  symptoms 
which  accompany  injuries  of  the  brain  itself. 

These  are  usuall}^  classed  under  two  heads, — Concussion  and  Compres- 
sion of  the  brain.  Such  a  classification,  however,  is  far  from  complete; 
for  many  cases  are  met  with  in  practice  which  it  is  very  difficult  to  in- 
clude under  the  term  Concussion,  and  3'et  which  do  not  exhibit  any  de- 
cisive evidence  of  compression.  The  only  way  to  include  all  cases  under 
these  two  heads  is  to  regard  all  those  as  instances  of  concussion  in  which 
there  is  insensibility  after  injury  (to  a  greater  or  less  extent),  unaccom- 
panied by  paralysis  ;  and  all  those  in  which  there  is  paralysis,  as  cases  of 
compression.  But  such  a  definition  departs  very  far  from  the  original 
meaning  of  the  term  Concussion.  In  fact,  when  this  term  was  introduced 
it  was  believed  that  in  cases  where  insensibility  follows  injury,  without 
paralysis,  the  brain  was  often  free  fi'om  an}'  visible  lesion — very  much  in 
the  condition  of  a  jelly  when  shaken  up — and  that,  if  examined,  no  lacer- 
ation of  its  substance  or  its  vessels  would  be  found.  This  opinion  was 
supported  b}'  some  histories  of  patients  who  had  died  immediately'  after 
blows  on  the  head,  whose  death  was  attributed  to  concussion,  and  in  whom 
the  brain  was  found  free  from  any  trace  of  injury,  as  in  the  case  recorded 
by  Littre'  of  a  prisoner  whose  arms  were  bound  behind  him,  and  who 
rushed  with  his  head  against  the  wall  of  his  cell,  falling  dead  on  the  floor. 
The  brain  alone  was  examined,  and  no  trace  of  injur}'  found  in  it;  and 
this  case  was  put  down  as  one  of  concussion  without  visible  lesion  of  the 
brain.  But  in  this,  as  in  other  cases  of  supposed  death  from  concussion, 
the  upper  part  of  the  spine  was  never  examined,  nor  the  viscera;  and  Mr. 
Hewett  has  pointed  out  that  without  such  examination  the  fact  that  death 
was  really  caused  by  concussion  is  quite  unproved;  in  fact,  it  is  most 
probable  that  in  the  case  mentioned  above  the  man  died  from  injury  to 
the  upper  part  of  the  spinal  cord.  Mr.  Hewett  gives  a  remarkable  case 
where  the  death  was  attributed  to  concussion  ;  the  head  was  alone  ex- 
amined, and  the  case  would  have  been  recorded  as  one  analogous  to 
Littre's,  had  it  not  occurred  afterwards  to  another  surgeon  to  reopen  the 
examination  and  investigate  the  condition  of  the  medulla  oblongata  and 
spinal  cord,  when  doatli  was  found  to  be  due  to  injury  of  the  upper  part 
of  the  spine.  In  other  cases  death  may  have  been  caused  by  rupture  of 
the  heart  or  some  of  the  great  viscera.  There  is,  therefore,  at  present  no 
evidence  that  an}'  case  of  concussion  ever  occurs  without  anatomical 
lesion  of  the  brain  or  its  vessels  to  some  extent.  We  may  nevertheless 
concede  that,  as  Mr.  Savory  argues,'^  even  if  it  be  true  that  no  case  of 
concussion  occurs  without  some  lesion,  yet  this  does  not  prove  absolutely 
that  such  lesion  is  the  cause  of  the  insensibility,  since  that  insensibility 
will  pass  away  suddenly,  while  the  lesion  must,  of  course,  still  be  present; 


lining  membrane  of  the  tympanum  and  mastoid  cells,  but  without  any  fracture  of 
the  ti-mporiil  bone.  And  in  the  same  series  (vol.  xii,  p  159)  a  case  by  myself,  where 
serous  discharge  was  produced  by  a  fracture  of  the  neck  of  the  condyle  of  the  lower 
jaw  perforating  the  meatus,  but  without  any  injury  to  the  sUull  whatever. 

>  Mem.  de  I'Acad.  des  Sc,  1705,  p.  54. 

2  St.  Barth.  Husp.  Reports,  vol.  v,  p.  72. 


CONCUSSION    OF    THE    ERAIN. 


177 


and  besifles,  such  lesions  have  been  known  to  lie  present  without  any 
symptoms  of  concussion.  Therefore,  though  it  is  not  proved  that  con- 
cussion occurs  without  anatomical  lesion,  it  is  certainly  not  disproved — 
nay,  there  is  a  pi'iori  reason  for  thinking  that  it  may  do  so. 

It  would  be  far  more  satisfactory,  and  more  in  accordance  with  the 
practice  of  surgical  literature  in  its  other  departments,  if  we  could  classify 
the  injuries  of  the  brain,  not  accordingto  their  symptoms,  as  Concussion, 
Compression,  etc.,  but  according  to  the  anatomical  lesion,  as  cases  of  ex- 
travasation in  the  membranes  or  in  the  substance  of  the  brain,  of  contu- 
sion, and  of  laceration  of  the  cerebral  substance.  But  our  knowledge  of 
the  symptoms  which  depend  on  each  of  these  injuries  is  so  very  iuiperfect 
that  this  anatomical  division  is  as  yet  impossible.  No  distinct  symptoms 
exist  from  which  it  can  be  affirmed  that  in  one  case  there  is  extravasation 
of  blood  in  the  cavity  of  the  arachnoid  ;  in  another,  punctiform  extrava- 
sation in  the  substance  of  the  brain  ;  in  another,  laceration  of  the  surface  ; 
in  another,  of  the  central  parts  of  the  encephalon  ;  and  still  less  can  we 
localize  the  lesion  which  we  may  suspect.  All  that  can  be  said  as  yet  is, 
that  in  cases  of  slight  concussion  small  extravasations  probably  exist 
either  on  the  surface  of  the  brain  or  scattered  about  in  its  substance,  or 
the  brain  is  bruised  here  and  there,  and  that  in  all  cases  vvhere  the  symp- 
toms of  head  injury  are  very  severe  (as  where  there  is  severe  spasm  or 
profound  coma,  with  general  paralysis)  the  brain  will  be  found  lacerated. 
I  exclude,  of  course,  cases  of  external  pressure  in  which  the  compressing 
agent  and  the  part  compresed  can  be  diagnosed  with  more  or  less  ap- 
proach to  certainty. 

TJie  symptoms  of  concusf^ion  are  as  follows:  The  patient  is  stunned, 
and  lies  insensible,  with  pale  face  and  cold  skin  ;  the  pulse  is  weak,  pos- 
sibly imperceptible,  and  often  very  irregular ;  the  state  of  the  pupils  is 
variable,  but  usually  they  respond  to  light ;  the  breathing  is  feeble  and 


Fig.  50. 


Fig.  49. — Depression  of  the  brain,  from  a  case  in  which  the  patient  had  suffered  from  severe  concus- 
sion twenty  years  before  his  deatli. 

The  case  is  related  in  Mr.  Hewett's  essay,  Syst.  of  Surg.,  vol.  ii,  p.  321,  from  which  the  woodcut  is 
taken. 

In  this  case  the  mechanical  lesion  which  accompanied  the  symptoms  of  concussion  must  have  been 
superficial  laceration  of  the  brain,  followed  by  extravasation  of  blood  into  the  lacerated  part.  In  other 
cases  punctiform  extravasations  have  been  found  in  various  parts  of  the  brain,  and  probably  the  ex- 
travasations of  blood  in  the  membranes  of  the  brain  uncomplicated  with  laceration  or  bruising  of  its 
substance,  which  are  spoken  of  on  p.  166,  are  sometimes  accompanied  by  symptoms  of  concussion. 

Fig.  50. — Thermograph  of  concussion. 

shallow ;  the  urine  and  faeces  ma}'  be  passed  involuntarily,  but  there  is 
no  paralysis  of  the  sphincters,  nor  any  other  s3mptom  of  paralysis. 
This  is  the  first  stage,  that  of  insensibility  or  collapse. 


178  INJURIES    OF    THE     HEAD. 

Temperature. — I  append  a  thermograph  of  an  ordinary  case  of  severe 
concussion,  which  passed  over  in  about  the  average  time,  and  have  also 
noted  the  rate  of  the  pulse  and  respiration. 

On  the  subject  of  temperature  in  head  injuries  I  cannot  do  better  than 
ao-ain  quote  from  Mr.  Le  CJros  Clark's  valuable  lectures:  "Tlie  tempera- 
ture in  cases  of  severe  liead  injury  seems  to  be  no  measure  of  the  amount 
of  lesion  sustained  by  tlie  brain.  Thus,  in  two  instances  of  simple  con- 
cussion, in  which  the  temperature  was  taken  half  an  hour  and  an  hour 
respectively  after  the  accident,  it  was  found  to  be  93.5°  and  9(i.3°  ;  yet 
both  these  patients  recovered  without  any  reaction  beyond  tlie  normal 
standard.  In  another  case  of  haemorrhage  into  the  brain,  with  total  un- 
consciousness, the  temperature  was  noted  as  being  95.2^  half  an  hour 
after  the  injury,  and  never  sank  below  94.9°.  In  another  remaikable 
instance,  however,  of  fractured  base,  with  laceration  of  brain,  tiie  tem-  . 
perature  fell  as  low  as  87.4°  in  an  hour  and  a  half  after  the  accident.  I 
am  not  aware  of  any  lower  recorded  temperature.  This  patient  survived 
about  nine  hours,  but  the  temperature  scarcely  attained  90°  just  before 
death"  (oj).  cit.,  pp.  122,  123). 

The  second  stage  is  that  of  reaction.  The  patient  can  now  be  roused, 
though  sometimes  not  without  difficulty.  He  usually  vomits.  The  pulse 
rises  and  becomes  more  regular,  and  the  natural  temperature  returns ; 
headache  generally  is  complained  of  for  some  time,  and  after  this  the  pa- 
tient may  entirely  recover,  or  the  third  stage  may  ensue,  which  is  that  of 
traumatic  inflammation  of  the  brain  or  its  membranes — to  be  afterwards 
described. 

Treatment. — No  treatment  is  necessary  in  the  early  stage  of  concussion. 
If  the  collapse  is  very  alarming  it  may  be  thought  right  to  give  some 
stimulant,  but  this  is  hardly  ever  necessary  in  cases  of  average  severity. 
Warmth  and  sinapisms  may  be  applied  to  the  extremities  and  epigastrium. 
When  reaction  sets  in  it  should  be  watched.  If  moderate,  nothing  will 
be  rerpiired  beyond  quiet,  cold  to  the  head,  and  low  diet,  with  occasional 
purgatives.  If  the  pulse  rises  ver}^  rapidly  in  volume  and  rate  it  is  right 
to  take  blood  from  the  arm.  But  tiie  question  of  venesection  and  of  the 
administration  of  mercury'  rather  belongs  to  the  treatment  of  traumatic 
inflammation,  wliich  will  be  considered  further  on. 

It  must  be  remembered  tliat  the  tendency  to  death  in  pure  concussion 
is  from  syncope  or  shock — failure  of  the  heart's  action  ;  so  that  the  only 
treatment  which  can  be  efficacious  in  the  early  stage  is  such  an  adminis- 
tration of  stimulants  as  in  the  judgment  of  the  surgeon  will  not  involve 
the  risk  of  provoking  inflammation. 

I  would  repeat  that  in  this,  as  in  all  other  forms  of  injury  to  the  head, 
perfect  quiet,  in  a  darkened  chamber,  seems  of  great  importance  as  a 
precaution  against  too  severe  reaction. 

(Jomprci^niini  of  the  tjrain  is  the  term  used  to  describe  cases  in  which 
there  is  definite  evidence  of  paralysis — a  condition  marked  by  stertorous, 
oppressed,  and  slow  breathing;  dilatation  of  the  pupils,  perlia|)s  with 
insensibility  to  light;  slow,  labored  pulse  ;  relaxation  of  the  sphincters; 
coma;  and  paralysis  of  tiie  liml)s  on  one  or  both  sides. 

Compression  seems  to  me  to  depend  generally  on  the  extravasation  of 
blood  into  the  interior  of  the  bi'ain  from  laceration.  It  usuall,v  proves 
rapidly  fatal  when  that  lacei'ation  involves  the  central  parts,  giving  rise 
to  rapid  extravasation  into  the  ventricles,  the  pons  Varolii,  or  the  medulla 
oblongata ;  and  such  cases  are  quite  beyond  the  reach  of  surgical  treat- 


COMPRESSION    OF    THE    BRAIN. 


179 


Fio.  51. 


ment.  It  is  onl}'  when  the  paralysis  affects  one  side  (that  opposite  to  the 
injury),  and  appears  to  be 
due  to  one  of  the  well- 
known  causes — viz.,  depres- 
sion of  a  fracture,  lodgment 
of  a  foreign  bod}'  on  the  sur- 
face of  the  brain,  extravasa- 
tion of  blood  between  tlie 
bone  and  dura  mater,  or 
superficial  effusion  of  pus — 
that  the  operation  of  tre- 
phining is  justifiable.  In 
such  circumstances  I  think 
it  is  so,  though  in  none  of 
them  is  it  often  successful. 
The  paralj'sis  which  accom- 
panies depressed  fracture  or 
the  lodgment  of  a  foreign 
body  often  depends  reall}-  on 
extravasation  of  blood  with- 
in the  brain  from  laceration. 
Extravasation  of  blood  above 
the  dura  mater  very  rarel}^  is 
limited  to  the  precise  point 
which  can  be  reached  by  the 
trephine,  and  it  also  is  often 
accoraj)anied  by  central  or 
by  meningeal  extravasation. 
And  the  numerous  causes  of 
failure  in  trephining  for  pus 
have  already  been  fully  de- 
tailed. Therefore,  though  in 
desperate  cases  any  opera- 
tion is  justifiable  wliich  holds  out  a  reasonable  hope  of  success,  it  is  not 
to  be  wondered  at  that  trephining  is  very  rarely  successful,  or  that  some 
surgeons  appear  to  have  almost  altogether  renounced  it. 

These  views  about  the  justifiability  and  tlie  causes  of  failure  of  trephin- 
ing may  be  illustrated  by  the  Figs.  51  and  52,  taken  from  two  cases  of 
depressed  fracture,  in  one  of  which  trephining  was  performed,  and  in  the 
other  not.  In  Fig.  51,  although  the  operation  seems  to  have  been  per- 
formed most  thoroughly'  and  most  successfully,  as  far  as  the  elevation  of 
the  depressed  bone  goes,  it  proved  useless  in  consequence  of  the  sulija- 
cent  mischief.  And  I  may  take  occasion  to  remark  that  in  many  instances 
'  the  immediate  object  of  the  operation — viz.,  the  replacement  of  the  de- 
pressed bone — is  not  effected  by  any  means  so  fully  as  in  the  case  before 
us.  The  examination  of  a  large  number  of  Museum  specimens  has  shown 
me  that  often,  although  the  greater  part  of  the  bone  has  been  lifted  up, 
and  the  operation  must  have  appeared  to  the  surgeon  to  have  been  com- 
pleted (and  no  blame  can  attach  to  him  for  thinking  so,  and  for  abstain- 
ing on  that  account  from  any  further  interference),  yet  examination  from 
the  inside  would  show  spicnla  or  depressed  edges  still  irritating  the 
membranes  or  the  brain. 

In  Fig.  52  is  seen  one  of  the  ordinary  injuries  in  which  the  practice 
of  different  surgeons  varies.     There  was  no  positive  compression  ;  the 


An  extensive  depressed  fracture  of  the  vertex  of  the  skull 
which  has  been  elevated  by  trephining.  The  mark  of  the 
trephine  is  seen  at  the  corner  of  the  .sound  bone,  and  it  has 
also  just  touched  the  end  of  the  depressed  bone;  and  the 
traces  of  Hey's  saw,  which  has  been  used  to  take  off  the 
overhanging  edges  of  the  sound  bone,  are  very  distinctly 
marked.  The  depressed  bone  has  all  been  very  fairly  ele- 
vated, and  the  operation  did  temporarily  relieve  the  symp- 
toms of  compression,  as  the  patient  became  a  little  more 
sensible  and  was  able  to  speak ;  but  lie  only  lived  a  few 
hours.  Death  was  caused  mainly,  as  it  seems,  by  hsemor- 
rhage  between  the  bone  and  dura  mater,  the  source  of 
which  was  not  precisely  ascertained.  Tlie  fracture  passed 
across  one  of  the  main  grooves  for  the  middle  meningeal 
artery,  but  the  vessel  itself  appeared  uninjured.  The  dura 
mater  was  not  torn,  but  the  lower  part  of  the  middle  lobe  of 
the  brain  was  contused  on  each  side.  The  depression  seen 
at  the  back  of  this  preparation  appears  to  be  due  to  some 
old  injury;  but  nothing  is  known  about  it.— St.  George's 
Hospital  Museum,  Ser.  i.  No.  16. 


180 


INJURIES    OF. THE    HEAD. 


bnvin  was  deeply  injured,  and  the  surgeon  thought  it  useless  to  interfere. 
Yet  it  is  perfeftly  fair  to  argue  that  in  a  case  where  it  would  have  been 
so  easy  to  remove  sharp  edges  of  hone  sticking  into  the  wound  of  the 
membranes  and  irritating  tlie  lacerated  surface  of  the  brain,  it  ought  to 
have  been  done,  as  affording  a  patient  the  last  chance,  however  feeble  it 
might  be  ;  and  such  is  unquestionably  my  own  opinion. 


Fic.  ")•?. 


A,  OUTER  VIEW. 


B,   INNER  VIEW. 


Compound  depressed  fracture  of  the  parietal  bone.  The  brain  in  this  case  was  lacerated,  and  the 
escape  of  brain-matter  from  the  wound  relieved  the  symptoms  of  compression,  so  that  the  patient  (a 
boy  £et.  16)  was  sufficiently  sensible  to  give  an  account  of  the  accident.  He  had  no  head-symptoms  for 
three  days.  Then  pain  in  the  head  came  on,  with  suppuration  and  increased  discharge  of  brain-matter 
from  the  wound.  A  fortnight  after  the  accident  he  became  suddenly  unconscious,  with  stertor  and 
dilated  pupils.  Next  day  he  died.  At  the  post-mortem  examination  a  large  abscess  was  found,  occu- 
pying all  the  outer  part  of  the  middle  lobe  on  that  side.  The  injury  was  caused  by  a  fall  through  a 
skylight. 

The  drawing  shows  the  exact  limitation  of  the  fracture,  and  the  ease  with  which  the  whole  of  the 
depressfd  bone  might  have  been  removed.  Fig.  a  presents  the  external  aspect.  At  one  angle  is  dotted 
the  circle  of  an  imaginary  trephine  hole.  If  this  portion  of  bone  had  been  removed,  the  whole  fracture 
might  have  been  elevated  at  once,  for  the  large  fragment  at  the  opposite  side  of  the  fracture  was  per- 
fectly loose  (and  has  fallen  out  in  the  preparation),  and  by  lifting  up  the  upper  of  the  two  other  frag- 
ments which  were  interlocked  they  might  both  have  been  most  easily  removed.  Thus  all  the  rough, 
jagged  edges,  which  are  seen  in  Fig.  b  sticking  into  the  brain,  would  have  been  taken  away. — St. 
George's  Hospital  Museum,  Ser.  i,  No.  248. 

Cases  7iof  Claasifiahlc. — Besides  the  cases  which  correspond  to  the 
topical  descriptions  of  concussion  and  compression  cases  are  met  with 
(and  not  rarely)  in  which  tlie  insensibility  is  by  no  means  complete,  and 
where  it  is  dillicult  to  see  whether  tiiere  is  not  some  iini)erfecL  paralysis, 
but  where  other  sym})toms  are  far  more  prominent.  In  some  of  these 
cases  there  is  delirium,  sometimes  (piicL,  sometimes  furious  and  maniacal, 
spasms  or  convulsions,  constant  screaming,  excessive  irregidarity  of  the 
jjulse,  and  in  many  cases  great  irritability  when  I'oused.  Such  symptoms 
may  be  connected  witii  laceration  of  various  ])arts  of  the  brain  in  which 
the  haemorrhage  lias  iu)t  l)ecn  suflicient  to  produce  complete  compression  ; 
but  it  must  be  admitted  that  we  know  little  of  the  real  anatomy  of  them 
beyond  this,  that  in  those  cases  which  prove  fatal  (for  many  recover) 
some  laceration  of  the  l)rain,  or  extravasation  into  tiie  meinbranes,  ap- 
pears to  have  l)een  always  found.  But  as  such  laceration  and  extravasa- 
tion have  existed  in  cases  presenting  no  such  symptoms,  it  is  clear  that 


TRAUMATIC    INFLAMMATION.  181 

the  real  cause  of  the  difference  in  different  cases  between  the  sequelae  of 
injuries  which  seem  nearly  identical  in  tlieir  anatomy  is  still  to  seek. 

In  all  such  cases  it  seems  to  he  tlie  chief  object  of  treatment  to  avoid 
and  soothe  excitement,  for  wliich  purpose  strict  quiet,  in  a  darkened  room, 
is  most  essential.  Tlie  head  should  be  shaved,  and  cold  lotion  or  an  ice- 
bag  applied,  if  the  patient  is  not  too  restless  ;  otherwise  it  should  be  con- 
stantly wetted,  so  as  to  cool  it  by  evaporation.  Low  diet  should  be  in- 
sisted on,  unless  contraindicated  by  the  state  of  the  pulse;  and  the  cau- 
tious but,  if  necessary,  free  use  of  morphia  has  in  some  striking  cases 
appeared  to  me  to  be  of  the  most  signal  service  in  calming  tl»e  spasms  or 
fits,  and  so  saving  the  patient  from  death  by  exhaustion. 

Traumatic  Inflammation. — Compression  tends  to  death  by  coma,  i.  e., 
by  gradually  increasing  insensiliility  and  paralysis,  which,  when  it  ex- 
tends to  the  functions  of  deglutition  and  respiration,  necessarily  proves 
fatal.  And  such  paralysis  is  due  to  one  or  both  of  two  causes,  viz.,  pres- 
sure by  extravasated  blood  or  pus  or  by  foreign  bodies,  or  softening  from 
inflammation  of  the  substance  of  the  brain.  Such  inflammation  is  the 
most  formidable  accident  in  head  injuries,  and  the  chief  object  of  our 
treatment  is  to  obviate  or  to  combat  it.  In  old  times  bleeding  was  used 
unsparingly  with  this  view — no  doubt  too  indiscriminately;  but  I  have 
met  with  no  hospital  surgeon  who  does  not  think  that  the  reaction  against 
this  "antiphlogistic"  treatment  lias  also  been  too  indiscriminate,  and 
who  could  not  recall  striking  instances  of  the  benefit  of  judicious  vene- 
section in  cases  of  apprehended  or  incipient  inflammation  after  injury  to 
the  brain.  The  great  point  is  to  be  aware  of  the  symptoms  which  mark 
the  onset  of  this  inflammation,  so  as  not,  on  the  one  hand,  to  depress  the 
patient,  and  possibly  favor  the  occurrence  of  diffuse  suppuration  by  inju- 
dicious and  unnecessary  loss  of  blood,  or,  on  the  other,  to  allow  the  in- 
flammation to  get  ahead,  when  bleeding  will  probably  prove  useless. 

Traumatic  inflammation  affects  either  the  membranes  (meningitis)  or 
the  substance  of  tlie  brain  (enceplialitis).  The  membranes  may  be  in- 
volved in  injury  of  the  bone,  the  inflammation  spreading  from  the  dura 
mater  inwards,  leading  to  effusion  in  the  arachnoid  cavity,  where  it  is 
almost  always  diffused,  and  to  inflammatory  cellulitis  of  the  pia  mater; 
or  the  inflammation  may  spread  outwards  from  the  injured  brain,  and 
then  it  is  often  limited  to  the  pia  mater.  Traumatic  encephalitis  may  be 
caused  by  the  spread  of  meningitis  inwards,  or  it  may  be  the  result  of 
lesion  of  the  substance  of  the  brain,  and  so  follow  on  a  case  which  has 
commenced  as  one  of  "simple  concussion."  Its  common  results  are, 
softening,  usually  of  the  surf\ice,  sometimes  also  of  the  central  parts,  of 
the  brain,  effusion  into  the  ventricles,  or  abscess  of  the  brain. 

The  symptoms  of  meningitis  and  encephalitis  have  not  been  found  as 
yet  to  admit  of  diagnosis  from  each  other  beyond  such  a  conjectural  opin- 
ion as  is  derived  from  the  exciting  cause.  The  early  symptoms  are,  pain 
in  the  head,  feverishness,  hot  skin,  quick  pulse,  contraction  of  the  pupils, 
intolerance  of  light  and  sound.  Then  sickness  ensues,  with  restlessness. 
Convulsions  succeed — at  least  this  is  the  usual  order  of  appearance  of 
this  symptom,  though  there  are  cases  in  which  they  come  on  very  early, 
and  are  almost  the  first  alarming  symptom  noticed.  They  are  followed, 
or  sometimes  preceded,  by  delirium.  Coma  ensues,  and  then  paralysis. 
The  first  onset  of  inflammation  may  be  heralded  by  rigors ;  but  rigors 
occur  usually  in  the  later  stage  of  inflammation,  and  may  be  taken  as 
indicative  of  suppuration. 

Whenever  traumatic  meningitis  or  encephalitis  is  diagnosed,  or  even 


182 


INJURIES    OF    THE    HEAD. 


DAY 

1 

^ 

3 

OIID 

UNCONSCIOUS 
RESTLESS        J 

DROWSY 

CONSCIOUS 
DELIRIOUS 

yenp 
!l04- 

1 

/■/ 

,103 

/ 

lOZ 

/■' 

101 

'■■ 

100 
99 
98 
97 

f- 

brain ;  but  inflainniation  and  suppura- 
tion of  the  injured  anterior  lobe  rapidly 
supervened. 


Avlien  there  is  reasonable  cause  for  aiiprelieiidino;  such  an  event,  the  first 

indication  is  certainly  to  shave  the  head,  and 
!""■   •'■''  ^Wh'  ^^^'^  to  it,  to  purge  the  patient  very 

freely  by  a  large  dose  of  calomel,  followed 
by  a  saline  purgative,  and  to  keep  him  very 
quiet  in  a  darkened  room.  If  the  pulse 
rises  decidedl}'  in  rate,  and  if  its  volume 
and  hardness  also  increase,  1  never  saw  a 
case  in  which  any  harm  resulted  from  a  mod- 
erate bleeding  (say  10  to  12  ozs.),  and  many 
in  which  it  did  great  good.  At  the  same 
time  mercur}^  should  be  given  in  powder, 
calomel  being  the  salt  usually  selected,  in 
doses  of  about  2  grs.  four  or  six  times  a  day. 
A  (bcnuograph  showing  the  rapid   The  powdcr  cau   be  placed  OH  the  back  of 

rise  oltemperature  which  sometimes  is    ^j^^    patient's    tOUgue  with    a    little    SUgar,  if 
noted  in  cases  of  head  injurv  as  intlani-     ,       .   '  ,,  mi-  j_  h  xtti 

niation  comes  on  and   passes   into  sup-    he  IS  Unable  Or  UUVVllling  tO  SWalloW.      When 

puration.   The  patient  was  admitted   there  is  nuicli  excitement,  and  especially  if 
^Tith  compound  fracture  of  the  frontal   eonvulsious  are  present  and  are  severe,  mor- 

sinus,  involviuK  also  the  internal  table,        i  •      •  i  /•    •    i       -ii  i  •         i       -,.1 

a  porHon  of  wh.ch  w«s  driven  into  the   P^ia  IS  Very  beneficial,  either  combined  with 

brain.  The  depressed  bone  was  perfectly     the    Calomcl    Or  introduced    UUdcr  the    skiu, 

loose,  and  was  easily  removed  froin  the  or  both.    We  have  the  high  authority  of  Mr. 

Hewett  for  saying  that  ''opium,  or  better 
still,  morphia  is  doubtless  of  great  value  in 
mau}^  cases  presenting  some  of  the  most 
characteristic  symptoms  of  inflammation."  ^  The  main  questions  in  the 
subsequent  treatment  are  whether  to  repeat  the  venesection,  and  whether 
the  trephine  is  indicated.  The  first  is  a  matter  which  will  tax  the  sur- 
geon's judgment  and  tact.  There  can  be  no  doubt  that  manj'  cases  have 
terminated  unfavorably  from  overbleeding,  of  which  Mr.  Hewett  records  a 
remarkable  example,  where,  however,  the  diagnosis  was  also  at  fault,  for, 
after  death,  no  anatomical  proof  of  inflammation  was  found.  But  this 
ought  not  to  discoui'age  the  surgeon  when  the  indications  are  clear,  1  e.,  if 
the  same  symptoms  which  first  led  him  to  bleed  still  continue,  or  even 
increase.  A  very  valuable  contraindication  to  repeated  venesection  is 
pointed  out  by  Mr.  Hewett  in  the  watery  condition  of  the  blood,  which 
sometimes  is  noticed  after  one  or  two  bleedings.  In  cases  where  the 
indications  of  cerebral  congestion  and  excitement  persist  (heat  of  head, 
excessive  pulsation  of  carotids  and  temporals,  violent  delirium),  but  the 
general  circulation  hardly  warrants  bleeding,  leeches  may  be  applied  to 
the  scalp  and  temples.  As  to  the  indications  of  the  formation  of  pus 
beneath  the  cranium,  and  the  symptoms  which  justify  trephining,  refer- 
ence must  be  made  to  p.  102. 

Hernia  rerobri  is  a  consequence  of  local  or  limited  inflammation  of  a 
portion  of  the  bi-ain,  coexisting  with  wound  or  sloughing  of  exposed  dura 
mater,  whereby  the  inflamed  brain  is  forced  through  the  skull.  It  is  not 
every  wound  of  the. brain,  even  when  it  involves  loss  of  substance,  which 
necessarily  produces  hernia  cerebri.  I  have  seen  a  portion  of  the  brain 
sliced  off  (in  a  case  of  encephalocele  mistaken  for  encysted  tumor),  and 
no  harm  result.  And  there  are  plenty  of  instances  on  record  in  which 
large  portions  of  the  brain  have  been  torn  away  in  injuries  of  the  head, 
and  the  wound  has  healed  kindly.     But  very  commonly  after  a  compound 


Op.  cit.,  p.  350. 


HERNIA     CEREBRI.  183 

fracture,  in  which  the  dnra  mater  has  also  been  lacerated,  in  a  few  days 
an  offensive  ichorous  discharge  is  noticed  from  tlie  wound,  and  a  fungous 
mass  begins  to  sprout  out  of  it.  This  sloughs  and  drops  off  in  fragments, 
which,  if  examined  in  the  microscope,  are  found  to  consist  in  great  part 
of  the  products  of  inflammation.  Sometimes,  indeed,  they  consist  en- 
tirely of  such  products,  and  to  these  protrusions  the  name  of  "  false 
hernia  cerebri"  is  sometimes  given,  reserving  the  name  of  "true"  for 
those  in  which  the  characteristic  structure  of  the  cerebral  substance  can 
be  found. 

Hernia  cerebri  is  generally  fatal,  though  by  no  means  universally  so. 
It  commonly  occurs  in  compound  fracture  of  the  vertex;  but  I  have 
figured  above  an  instance  in  which  it  took  place  in  the  middle  fossa  of 
the  base  of  the  skull ;  and  Mr.  Holden  has  referred  to  a  remarkable  in- 
stance in  the  anterior  fossa,  where  the  patient,  a  boy,  lost  a  large  quan- 
tity of  brain-matter  through  the  nose,  but  ultimately  recovered.  1  once 
watched  a  case  in  which  the  greater  part  of  one  anterior  lobe  of  the  cere- 
brum was  discharged  through  a  compound  fracture  of  the  orbit,  in  which 
the  whole  roof  of  the  orbit  had  been  removed.  There  were  remarkably 
few  symptoms,  and  the  boj'^  seemed  so  have  a  fair  chance  of  recovery, 
when  symptoms  of  general  pyaemia  developed  themselves,  and  he  died 
eighteen  days  after  the  injury.  It  is  often  remarkable  how  little  the 
functions  of  the  brain  suffer  even  when,  as  in  this  case,  the  actual  loss  of 
substance  is  great.  Often,  however,  the  real  loss  is  but  small,  since  a 
great  proportion  of  the  fungus  consists  of  inflammatory  products. 

No  treatment  is  either  necessary  or  indeed  admissible  in  hernia  cerebri, 
beyond  such  applications  as  may  correct  the  fetor  of  the  discharge  as  far 
as  possible.  AH  attempts  to  repress  the  protrusion  are  dangerous,  and 
probably  inefficient,  and  the  practice  of  shaving  it  off  is  quite  exploded. 

I  can  say  but  little  on  the  subject  of  direct  lesion  of  the  nerves  at  the 
base  of  the  brain.  Those  of  the  seventh  pair  are  the  most  common,  and 
in  fracture  of  the  base  loss  of  hearing  and  facial  paralysis  are  not  un- 
frequently  noticed.  Extravasation  of  blood  in  the  sheath  of  the  optic 
nerve  has  been  found  after  death, 
and  blindness  may  be  so  caused,  and  „ 

may  pass  away,  though  in  other 
cases  it  has  resulted  from  absolute 
laceration  of  the  nerve,  and  is  then 
probabl^^  permanent.  But  all  the 
nerves  of  the  base  (with  the  excep- 
tion, I  believe,  of  the  little  fourth 
nerve)  have  presented  distinct  evi- 
dence of  traumatic  lesion,  as  indi- 
cated by  the  loss  of  their  function, 

and   proved    by  post-mortem    exami-  Extravasation  of  blood  in  the  sheath  of  the 

.  sj  .  1  optic  nerve  after  injury  to  the  head.     Prom  Mr. 

nation.         JNo       treatment       can       be       Hewett-s  essay,  Syst.  of  Surg.,  2d  ed.,  vol.  ii,  p. 

adopted ;  but  the  symptom  is  often     332. 
valuable   in   a   diagnostic    point   of 

view.  It  is  important  to  remember  the  fact  on  which  Mr.  Le  Gros  Clark 
has  laid  some  stress,  that  the  symptoms  of  paralysis,  indicating  lesion  of 
the  nerves  at  the  base  of  the  skull,  often  do  not  present  themselves  till 
three  or  four  days  after  the  receipt  of  the  injury,  showing  that  they  are 
due  to  inflammatory  reaction.  This  fact,  however,  by  no  means  nega- 
tives the  diagnosis  of  fracture,  since  a  fracture  is  one  of  the  most  prob- 
able causes  of  such  inflammation. 


184 


INJURIES    OF    THE    HEAD. 


Trephining  the  Skull. — The  operation  of  trephining  the  skull,  although 
it  is  always  called  by  that  name,  is  not  alwa^'s  performed  with  the  circn- 
lar  saw  called  Trephine.  The  elevated  edge  of  an  injured  bone  is  often 
more  easily  and  expeditiously  removed  by  the  saw  which  bears  Hey's 
name;  tiiough,  as  Mr.  Hey  points  out,  it  was  originally  figured  in  Scul- 
tetus's  Armamenfarium    Chirurgicum,  and  was  either  revived  or  rein- 

FlG.  55. 


^♦'"♦vMv^*^ 


Hey's  saw  (from  Hey's  Stcrgei-y). 

vented  by  Dr.  Corbell  of  Pontefract,  who  showed  it  to  Mr.  Hey.  The 
straight  edge  enables  the  surgeon  to  remove  any  length  of  bone  at  one 
stroke.  When  a  curvilinear  direction  has  to  be  given  to  the  section  the 
round  edge  must  be  used. 

Trephining  is  an  operation  which  is  neither  very  easy  in  all  cases  nor 
destitute  of  dangers  of  its  ovvn  in  any.  The  soft  parts  are  first  to  be 
cleaned  carefully  from  the  part  of  the  bone  on  which  the  trephine  is  to 
be  applied,  which  in  cases  of  fracture  should  be  the  sound  bone  on  the 
edge  of  tl)e  depressed  portion,  and,  if  there  are  two  depressed  and 
interlocking  pieces,  the  trephine-hole  should  hit  the  edge  between  them 
(sec  Fig.  52).     The  pin  of  the  trephine  being  run  out  and  firml}^  fixed,  is 


Fig.  50. 


^S^^^^¥%ti%if1^"^ 


'rilfri'Tfi--''Mi 


The  "  elevator."    Mem.  In  tripliitiiiiK  it  is  well  to  liiive  a  few  elevators  of  different  shapes  and  curves 
at  hand.    The  one  here  represented  is,  however,  one  of  the  most  useful. 

a[)plied  at  such  a  point  as  will  secure  this  object,  and  then  by  a  screwing 
motion  the  section  of  the  bone  is  commenced.  Wlien  the  groove  is  deep 
enough  to  avoid  all  risk  of  tiie  trephine  slipping,  its  pin  is  withdrawn, 
and  as  soon  as  tlie  surgeon  believes  that  he  has  got  through  the  external 
table  he  begins  to  proceed  witii  caution,  and  witli  a  very  ligiit  liand,  often 
feeling  the  groove  with  a  fine  i)robe,  or,  as  is  more  usual,  a  common  quill 
toothpick.  When  tiie  internal  table  is  perforated  at  any  part  of  the  circle 
the  elevator  is  introduced  here,  and  the  crown  of  l)one  will  generally 
come  away.  If  it  does  not  do  so,  the  internal  table  must  be  sawn  in 
some  other  part;    but  the  trephine   must  not  be  pressed   on  the   part 


TREPHINING. 


185 


already  sawn  through,  for  fear  of  womiding  the  dura  mater.  When  the 
first  crown  of  trepliine  has  been  removed  it  may  be  necessary  to  take 
away  a  second  or  a  third,  or  to  saw  off  the  projecting  edges  of  the  sound 
bone  with  Hey's  saw  (as  in  Fig.  51);  or  perhaps  the  whole  operation 


Fig.  57. 


Fig.  57. — Trephine.  The  central  pin  is  seen  projecting  slightly  beyond  the  te«th  of  the  saw.  It  can 
be  withdrawn  altogether  within  the  crown  of  the  instrument  by  the  screw  which  is  seen  in  the  cleft 
of  the  stalk. 

Fig.  58. — The  vertex  of  the  skull,  with  a  portion  of  bone  removed  in  trephining  for  supposed  de- 
pression of  the  inner  table,  ten  months  after  the  injury.  The  skull  had  been  much  thicktiied,  espe- 
cially at  its  back  part,  by  inflammation,  so  that  the  thickness  of  the  bone  removed  is  twice  as  great 
behind  as  in  front.  In  consequence  of  this  irregularity  in  thickness  the  dura  mater  was  wounded  in 
the  operation  —St.  George's  Hospital  Museum,  Ser.  ii,  Ko.  24. 

may  be  accomplished  with  the  saw,  in  using  which  the  same  precautions 
are  to  be  taken  as  in  sawing  with  the  trepliine ;  but  there  is  less  risk  of 
wounding  the  dura  mater  with  Hey's  saw,  since  it  is  only  applied  on  the 
sound  edge  close  to  the  fracture,  and  here  the  dura  mater  has  of  course 
been  driven  down  by  the  depression.  The  greatest  danger  to  the  dura 
mater  is  in  cases  like  the  one  from  which  Fig.  58  was  taken,  where  the 
skull  is  of  different  thicknesses  at  diff'erent  parts  of  the  circle. 


CHAPTER   VIII. 

INJURIES    OF    THE    BACK. 


Sprains  of  the  back  are  amongst  the  commonest  of  all  accidents.  They 
are  the  effects  of  wrenches  or  contusions,  either  of  which  produce  violent 
flexion  of  the  whole  column,  and  which,  therefore,  sprain  it  at  the  part 
where  such  flexion  is  arrested,  viz.,  near  the  sacrum. 

The  injury  consists  in  stretching,  and  in  the  severer  cases  probabl}^ 
more  or  less  rupture,  of  the  muscles,  fascia,  and  ligaments  on  the  pos- 
terior aspect  of  the  spine,  while  the  parts  in  front  may  be  more  or  less 
crushed ;  and,  in  particular,  the  kidney  is  sometimes  contused  or  lacerated. 


186  INJURIES    OF    THE    BACK. 

The  latter  injury  will,  however,  be  treated  of  by  itself  in  a  subsequent 
section.  When  there  are  s>Mnptonis  of  injury  to  the  spinal  cord  itself 
('•concussion  of  the  spine,"  as  it  is  termed),  those  symptoms  constitute 
the  main  feature  of  the  casi;,  and  will  be  spoken  of  presently.  In  this 
place  I  shall  t»peak  merely  of  tlie  uncomplicated  sprains. 

Si/mplomK. — There  is  swelling  at  the  injured  part,  with  subsequent 
inflammation  ;  but  oenei'ally  no  visible  ecchymosis,  since  the  blood  which 
must  have  been  poured  out  is  beneath  the  deep  aponeurosis.  There  is 
great  pain  in  moving,  and  especially  in  extending  the  spine.  The  prog- 
nosis-is  very  favorable,  though  recovery  is  often  slow. 

Treatment. — If,  from  the  severity  of  tiie  injury,  the  patient  is  at  all 
collapsed,  the  first  indication  is  to  revive  him  from  that  condition.  Then 
at  first  moderate  general  and  local  antiphlogistics  will  be  indicated,  with 
opiates,  mercurial  purges,  Dover's  powder  at  night,  salines,  spoon-diet, 
and  leeches.  Afterwards  fomentation  with  poppy-heads,  warm  Goulard 
lotion,  with  laudanum,  or  compresses  of  tincture  of  arnica  (.^j  to  Oj). 
When  the  patient  is  able  to  move  in  bed  and  sit  up,  friction  and  stimula- 
ting embrocations  (liniment.  lodi,  Terebinthinse,  Sinapis),  or  blistering 
or  painting  with  iodine  will  probably  relieve  any  remaining  pain.  In 
obstinate  cases  an  occasional  light  touch  with  the  actual  cautery  is  very 
beneficial. 

Fractu7^e  or  dislocation  of  the  sjnne  is  one  of  the  most  surely  fatal  of 
all  accidents.  Fracture  sometimes  affects  onl}'  some  of  the  processes  of 
the  vertebrae — most  commonly  the  spinous — and  the  mobility  of  the  frac- 
tured process  is  the  only  symptom  necessarily  connected  with  the  injury. 
No  treatment  is  required  be^'ond  rest  and  a  bandage.  But  when  ''frac- 
ture of  the  spine"  is  spoken  of,  it  is  understood  that  the  continuity  of 
the  whole  vertebral  column  is  severed.  The  gravity  of  the  injury  does 
not,  howevei',  depend  on  the  fracture  itself;  for  although  no  doubt  the 
spinal  column  is  the  centre  for  almost  all  the  movements  of  the  body,  and 
its  integrity  is,  therefore,  necessary  for  any  active  motion,  yet  this  integ- 
rity would  be  restored  after  fracture,  by  bony  union,  as  in  any  other  bone, 
and  the  solidity  of  the  column  would  probably  not  be  materially'  impaired. 
Fig.  59  is  an  example  of  the  repair  of  a  fracture  of  the  spine  by  bony  union 
in  a  patient  who  happened  to  survive  long  enough  for  the  completion  of 
the  process.  But  tlie  history  of  the  same  preparation  also  illustrates  the 
reason  why  this  injury  is  so  fatal,  for  the  cord  in  that  case  was  crushed 
by  the  fracture  as  it  almost  always  is  ;  so  that,  although  the  bones  united, 
the  spinal  symptoms  were  unrelieved,  and  pursued  their  usual  course  to 
a  fatal  termination. 

In  describing,  therefore,  the  symptoms  of  fracture  (or  dislocation)  of 
the  spine,  I  must  premise  that  most  of  these  symptoms  are  what  are 
called  (on  p.  1.S9)  merely  the  rational  symptoms  of  fracture,  i.  e.,  lesions 
for  which  we  can  find  no  other  cause  ;  and  that  some  cases  occur  in  which 
similar  symptoms  (or  symptoms  very  nearly  similar)  appear  to  be  pro- 
duced by  contusion  of  tiie  cord  without  fracture;  while  on  the  other  hand, 
there  are  cases  on  record  in  which  fracture  of  the  spine  has  l)een  proved 
by  post-mortem  examination  to  have  occurred,  yet  in  which  there  have 
been  no  such  symptoms,  in  consequence  of  the  cord  having  escaped  in- 
jury. 

The  symptoms,  then,  of  fracture  of  the  spine  are  as  follows:  pain  in 
the  part,  aggravated  by  passive  motion,  more  or  less  incapability  of 
moving  the  spine  at  that  i)art  and  deformity  of  tlie  spinal  column.  All 
tliese  are  no  doubt  direct  symptoms  of  tlie  injury  ;  but  they  are  not 
decisive,  with  the  exception  of  the  last,  which,  if  present  in  a  marked 


FRACTURE    OF    THE    SPINE. 


187 


Fio.  59. 


degree,  leaves  no  doubt;  but  it  is  frequently  absent.  Tiiere  is  usually 
considerable  collapse  from  the  severity  of  the  injury.  The  usual  sequehie, 
and  those  by  which  we  infer  the  existence  of  fracture,  are  complete  par- 
alvsis  of  motion  and  sensation  in  all  the  j^arts 
supplied  with  nerves  from  below  the  seat  of  the 
lesion.  Thus  in  fracture  above  the  origins  of 
the  phrenic  nerve  (?'.  ^.,  above  the  fourth  cervi- 
cal vertebra),  that  nerve,  as  well  as  all  the  others 
which  supply  the  respiratory  muscles,  will  prob- 
ably be  ])aralyzed,  and  death  will  be  instantane- 
ous.' With  fracture  lower  down  in  the  neck,  the 
patient  will  retain  the  power  of  diai)hragmatic 
breathing,  but  not  the  motion  of  the  intercostals 
or  of  any  other  muscle  of  respiration,  or  of  any 
of  the  muscles  of  the  trunk  or  limbs.  Sensation 
will  also  be  completel}'  absent  in  all  parts  below 
the  neck  (except  that  in  some  cases  perception 
of  impressions  may  still  be  noted  in  the  parts 
supplied  I)}'  the  superficial  descending  branches 
of  the  plexus) ;  the  sphincters  are  paralyzed,  so 
tiiat  the  urine  is  at  first  entirely  retained,  and 
then  dribbles  over,  and  there  is  no  power  of  re- 
taining the  faeces  ;  the  passage  of  the  catheter, 
thougli    nnfelt,   usually    excites    priapism ;    and 

tickling    or    pinching    the    limbs,  though    equally    dorsal  vertebra  is  crushed;  some 

nnfelt,  also  very  often  i)roduces  reflex  motions.   °''  i'«  fragments  are  driven  for- 

mi        •     .     11       ,     •  n-     \     ^  1   ii  J.-       J.  wards,  forming  an  irregular  ring 

The  intellect  is  unaffected,  and  the  patient  usu-  of  bone  which  lies  in  front  of  the 
ally  free  from  pain.  The  temperature  of  the  bodyof  the  firstiumbar,  to  which 
paralyzed  part  varies.     Sometimes  it  is  higher   it  is  soldered  by  bony  union.  An- 

7i  liij?i.i       1       1        \      ,.  J.I  •     •  4.1  ii        other  large  fragment  is   driven 

than  that  of  the  body;  but  this  is  not  always  the    i.^.^wards  into  the  canal.    The 

case.  solidity  of  the  column  is  restored, 

In   fractures  so  high  up  as  this  the   patient  b"t  with  slight  angular  eurva- 
usually  dies  in  two  or  three  days,  and  often  much   Z^:^;^^^^^^'-, 
sooner.     Death    is   produced    generally  by  the   no.  49. 
accumulation  of  fluid  in  the  lungs,  which  the 

patient  is  unable  to  cough  up,  and  which  chokes  him.  But  when  death 
follows  more  rapidly  it  is  probal>ly  from  luiemorrhage  into  the  substance 
of  the  cord  or  into  its  theca,  which  produces  pressure  on  or  disintegration 
of  the  spinal  marrow  above  the  seat  of  fracture. 

The  lower  down  in  the  column  the  fracture  is  situated,  the  less  is  the 
extent  of  the  paralysis.  At  the  lowest  part  of  the  lumbar  region,  where 
there  is  no  spinal  cord,  but  only  the  leash  of  nerves  of  the  cauda  equina, 


Fracture  of  the  spine  united, 
the  patient  having  survived  five 
months.    The    body   of   the  last 


1  A  very  interesting  case  is  related  by  Mr.  Shaw,  in  the  Syst.  of  Surg.,  vol.  ii,  p. 
396,  in  which  a  fracture  with  disphicoment  of  the  first  and  second  vertebrae  was  ac- 
companied by  no  serious  symptoms,  the  fragments  being  displaced  forwards,  towards 
the  pharynx  instead  of  backwards  on  to  the  cord.  The  patient  died  from  dropsy  a 
year  afterwards,  and  the  preparation  is  in  the  Museum  of  Middlesex  Hospital.  The 
same  author  (ibid.  p.  393)  relates  a  case  in  which  the  patient  survived  fifteen  months 
after  a  fracture  of  the  fourth  or  fifth  cervical  vertebra,  though  the  cord  was  entirely 
disorganized  at  the  seat  of  fracture,  and  there  was  therefore  paralysis  of  all  the  parts 
below  the  head. 

2  On  the  temperature  after  injuries  to  the  cervical  portion  of  the  cord  see  Wunder- 
lich's  Manual  of  Medical  Thermometry,  translated  by  Dr.  Woodman  for  the  New 
Syd  Soc,  p.  423.  If  we  can  trust  the  observations  there  recorded,  the  temperature 
has  been  fuund  as  high  as  111°  F.  and  as  low  as  86°.  In  Clin.  Soc.  Trans.,  vol.  vi,  p. 
75,  may  be  found  acase  of  laceration  of  the  cord  opposite  the  first  dorsal  vertebra, 
where  the  temperature  in  the  axilla  is  said  to  have  fallen  as  low  as  80.6°  F. 


188  INJURIES    OF    THE    BACK. 

some  of  these  nerves  may  escape  injnry  while  the  rest  are  torn,  and  so  the 
resnltino;  paralysis  of  the  lower  limbs  may  be  imperfect.  Usually,  how- 
ever, in  fractures  of  the  liiml)ar  spine  the  lower  limbs  and  tlie  sphincters 
are  totally  jiaralyzed.  In  the  dorsal  region  there  is  also  paralysis  of  the 
abdominal  muscles  and  loss  of  sensation  to  an  extent  corresponding  to 
the  seat  of  the  injury,  while  in  the  fracture  of  the  upper  part  of  the  dorsal 
spine  symptoms  of  ditficulty  of  breathing  occur  which  api)roach  more  and 
more  to  those  produced  by  fracture  in  the  cervical  region. 

The  later  symptoms  of  fracture  of  the  spine  are  due  to  low  inflamma- 
tion of  the  urinary  mucous  membrane,  and  to  sloughing  of  the  skin.  The 
nrine  which  dribbles  over,  or  which  is  withdrawn  from  the  bladder,  is  at 
first  natural;  but  it  soon  becomes  very  offensive,  phosphatic  and  alkaline. 
For  a  while  it  may  be  secreted  acid,  and  only  becomes  alkaline  from  de- 
composition in  the  bladder,  but  after  a  time  it  is  secreted  alkaline  in  the 
kidney,  the  inflammation  having  extended  to  that  organ.  This  inflam- 
mation is  partly  due  no  doubt  to  the  retention  of  the  urine  in  the  l>lad- 
der,  but  not  entirely  so  ;  nor  can  it  1)e  entirely  obviated  by  withdrawing 
the  urine  frequently  and  washing  out  the  l)ladder  with  acidulated  lotion, 
although  these  measures  will  diminish  it.  In  fact,  there  is  a  tendency  to 
low  inflammation  of  all  the  mucous  membranes  as  well  as  of  the  skin  as  a 
consequence  of  the  deprivation  of  their  nervous  influence.  This  is  shown 
sometimes  in  the  intestines  by  the  tarry  condition  of  the  fieces,  and  the 
congestion  found  after  death;  and  probably  the  low  bronchitis  which  is 
so  constant  in  fractures  high  up  is  not  caused  by  hypostatic  congestion 
alone.  So  also  the"  gangrene  of  the  skin,  though  greatly  accelerated  by 
pressure,  is  not  due  entirely  to  that  cause,  as  will  be  stated  below. 

Apart,  then,  from  complications,  the  tendency  to  death  in  fractures 
high  up  is  from  the  pulmonary  congestion  ;  in  those  low  down  from  urinary 
inflammation  or  from  sloughing. 

Didocalion  of  the  Spine. — The  symptoms  of  dislocation  are  the  same 
as  those  of  fracture  at  the  same  level,  and  the  cause  of  death  is  the  same. 
Thus  in  the  specimen  from  which  Fig.  fiO  was  taken,  and  which  is  one  of 
pure  dislocation  at  the  level  at  which  this  injury  is  most  common  {i.  e.,  at 
the  root  of  the  neck),  the  upper  vertebra  was  brought  forward  and  the 
lower  backward,  and  the  cord  crushed  between  them.  Death  took  place 
at  the  usual  period,  viz.,  two  days  after  the  accident.  And  some  amount 
of  dislocation  is  a  usual  concomitant  of  fracture,  so  that  the  two  are 
always  treated  of  as  being  jjractically  the  same  injury.'  There  is,  how- 
ever, one  point  of  practical  importance  in  connection  with  the  subject, 
viz.,  the  possil)ility  of  diagnosing  and  reducing  dislocation,  and  the  pros- 
pect of  benefit  from  such  reduction.  Most  dislocations  occur  at  the  lower 
part  of  the  cervical  region,  though  a  few  examples  are  recorded  in  the 
dorsal;  and  I  have  pul)lisl)ed  an  instance  of  one  (of  which  the  })repara- 
tion  is  in  the  Museum  of  St.  George's  Hospital)  between  the  last  dorsal 
and  first  lumbar  vertebra,  in  which  the  dislocation  was  actually  reduced.'"' 
But  the  reduction  had  no  effect  in  relieving  the  symptoms  of  paralysis, 
and  it  is  even  possible  that  the  force  employed  may  have  been  the  cause 
of  suppuration  which  took  place  around  the  seat  of  injury,  and  which 

'  In  Mr.  Le  Groa  Clark's  Lectures  on  the  Principles  of  Surgical  Dingnosis,  p. 
142,  will  bo  found  the  account  and  drawing  of  a  case  in  which,  along  with  fracture  of 
the  spine,  the  tiftli  kiiubHr  vertebra  was  dislocated  from  all  its  connections,  and 
thrown  entirely  hehind  the  spinal  column 

■'  See  Path.  Soc.  Trans.,  vol.  x,  p.  219.  The  patient  was  under  Mr.  Caosar  Haw- 
kins's care.  Sir  Charles  Bell  seems  to  have  possessed  a  somewhat  similar  preparation, 
but  I  do  not  know  whether  it  is  still  in  existence. 


FRACTURE    OF    THE    SPINE. 


189 


proved  the  starting-point  of  general  pyjBmia.  Nor  do  I  see  by  what  signs 
it  is  possilile  to  recognize  the  existence  of  dislocation  apart  from  fracture. 
Yet,  though  the  diagnosis  may  be  uncertain,  and  though  it  is  certainly 
possible  that  harm  may  be  done  by  the  manipulation,  I  still  tiiink  that 
when  the  displaced  parts  can  be  returned  with  tolerable  ease  into  their 
natural  position,  it  is  justifiable  to  try  thus  to  liberate  the  cord  from  pres- 
sure, whether  we  believe  the  injury  to  be  dislocation  or  fracture.  And 
there  are  doubtless  histories  of  cases  in  which  the  surgeon  has  found  an 
amount  of  displacement  of  the  spinous  or  transverse  cervical  processes 
which  has  been  evidence  to  his  mind  of  dislocation,  or  at  any  rate  dis- 
placement of  the  bodies  of  the  vertebrae,  and  which  has  been  remedied  by 
extension,  the  patient  regaining  perfect  health.     But  it  must  be  allowed 


Fig.  60. — Dislocation  of  the  spine  in  the  cervical  region.  The  fifth  and  sixth  cervical  vertebrse  are 
completely  separated  from  each  other,  the  ligamenta  subflava  are  torn  through,  and  the  ariiciilating 
processes  dislocated  from  each  other.  The  intervertebral  substance  was  lacerated,  and  the  anterior 
and  posterior  common  ligaments  completely  torn  through.— St.  George's  Hospital  Museum,  Ser.  i,  No.  42. 

Fig.  fil.— Fracture  of  the  spine — to  show  the  displacement  which  very  coTnmonly  takes  pliice  of  a  por- 
tion (or,  as  in  this  case,  almost  the  whole)  of  the  body  of  the  vertebra  into  the  spinal  canal.  T)ie  frac- 
tured and  displaced  vertebra  is  the  seventh  cervical.  The  intervertebral  substance  between  the  sixth 
and  seventh  cervical  vertebrae  was  ruptured,  and  their  laminiie  separated  from  each  other  by  rupture  of 
theligamenta  subflava,  i.  e.,  the  fracture  was  complicated  with  dislocation,  as  so  commonly  occurs.  The 
cord  in  this  case  was  entirely  disintegrated  from  a  point  opposite  the  fifth  cervical  to  the  tliird  dorsal 
vertebra. — St.  George's  Hospital  Museum,  Ser.  i.  No.  56. 


that  these  cases  are  in  man}'^  respects  of  doubtful  value,  and  we  have  yet 
to  seek  for  one  in  which  immediate  paralysis  after  an  injury  accompanied 
with  visible  displacement  of  the  spine  has  l)een  remedied  by  reduction  of 
the  projecting  portions.  In  any  case  in  which  the  surgeon  thinks  it  right 
to  attempt  reduction,  all  possible  gentleness  and  caution  sboidd  be  used, 
and  if  moderate  force  is  unsuccessfid  the  attempt  should  be  abandoned. 
Trejjhiniiig  the  Spine.- — This  leads  us  to  the  consideration  of  the  treat- 
ment of  fractured  spine.  In  the  first  place,  if  the  displacement  cannot  be 
remedied  by  extension  and  counterextension,  can  it  be  b}'  surgical  opera- 
tion ?  The  proposal  to  "trephine  the  spine" — i.e.  to  attempt  in  one 
way  or  another  to  elevate  the  portions  which  have  been  depressed  on  to 
the  spinal  marrow — has  been  sustained  by  the  supposed  analogy  of  de- 
pressed fractures  of  the  skull,  and  has  received  the  support  of  many 
famous  surgeons.     It  is  not  becoming,  therefore,  to  speak  of  it  with  dis- 


190  INJURIES    OF    THE    BACK. 

respect.  But  the  assumed  analogy  is  obviously  a  very  deceptive  one, 
and  I  can  lind  no  evidence  that  the  operation  has  ever  been  really  in  any 
degree  successful ;  while,  if  unsuccessful  in  its  object,  it  must  tend  to 
hasten  death,  for  it  is  undeniably  a  very  severe  proceeding,  requiring  a 
long  and  deep  incision  through  a  large  mass  of  muscle,  and  thus  exhaust- 
ing the  patient  by  hi^morrhage  when  the  rational  indication  of  treatment 
is  to  spare  his  strength  in  ever3'  possible  way.  There  is,  in  fact,  little 
analogy  between  the  indications  which  lead  the  surgeon  to  trephine  the 
cranium  and  the  conditions  present  in  almost  everj'  case  of  fractured 
spine  with  displacement.  The  brain  in  cases  suited  for  the  operation,  is 
compressed  at  a  single  definite  accessible  part  (of  no  great  extent  com- 
pared to  its  volume)  by  a  small  portion  of  depressed  bone  or  by  a  foreign 
body ;  but  its  own  proper  tissue  is  believed  to  be  only  very  slightl_y  or 
not  at  all  injured.  In  f*ractiires  of  the  spine,  on  the  other  hand  (as  may  be 
seen  in  Fig.  Gl ),  the  displacement  is  generally  due  to  projection  of  a  por- 
tion or  the  whole  of  a  bod}^  of  a  vertebra,  and  sometimes  of  more  tlian 
one  vertebra,  into  the  spinal  canal,  at  a  part  utterly  inaccessible,  crush- 
ing and  disorganizing  the  whole  spinal  cord  to  an  extent  v.'hich  cannot 
be  remedied  by  the  removal  of  the  cause  which  produced  it.^  Yer^^  often 
the  cord  is  entirely'  divided  at  the  seat  of  fracture.  No  judicious  sur- 
geon would  think  of  trephining  the  skull  if  he  believed  that  the  brain  was 
hopelessly  lacerated — far  less  if  it  be  thought  that  there  was  in  all  proba- 
bility a  large  mass  of  bone  sticking  into  it  at  the  base  of  the  skull.  Dr. 
Brown-Sequard  tries  to  meet  this  action  by  urging  that  though  the 
laminffi  and  spinous  processes  are  the  only  parts  which  are  accessible  for 
removal,  yet  the  removal  of  these  from  behind  will  liberate  the  cord  from 
the  pressure  of  the  displaced  bone  in  front.  Even  if  this  were  so,  how- 
ever, it  would  leave  a  rugged  fragment  irritating  the  cord,  and  the  pros- 
pect of  benefit  would  not  justify  the  additional  irritation  produced  by  the 
operation.  It  is  quite  true  that  there  are  cases  in  which  the  displace- 
ment of  bone  is  less  than  that  shown  in  the  figure,  and  that  the  cord  is 
not  always  hopelessly  disorganized;  but  it  is  also  true  that  in  such  cases 
the  patient  has  a  good  prospect  of  survival,  and  it  seems  that  under  such 
circumstances  an  operation  is  more  likely  to  prove  the  starting-point  of 
inflammator}'  softening  than  to  cure  the  patient.  Dr.  Gordon's  case,^ 
though  an  interesting  one,  and  though  some  improvement  seems  to  have 

1  The  only  part  of  the  vertebral  column  which  is  completely  accessible  and  which 
can  be  fairlj-  removed,  when  depressed  on  to  the  cord,  is  the  arch  or  lamina.  Now, 
this  is  the  part  which  is  the  most  seldom  affected.  Mr.  Le  Gros  Clark  says  :  "  Of  the 
many  cases  of  fractured  spine  which  I  have  on  record,  and  which  I  have  examined 
post-mortem,  I  cannot  recall  an  instance  in  which  the  depression  of  the  arch  alone 
sufficed  to  account  for  the  symptoms.  I  am  aware  that  such  cases  are  recorded,  but  1 
speaU  only  of  my  own  e.\p(!rience,  and  therefore  I  conclude  that  they  are  rare  "  He 
goes  on  to  show  that  even  when  the  injury  is  a  direct  blow  on  the  back  of  the  spine, 
the  cord  is  in  all  jirt>babiiity  disintegrated  beyond  recovery.  The  whole  discussion  of 
this  topic  in  Mr.  Lc;  Gros  Clark's  Lectures  on  the  Diaj^nosis  of  Visceral  Lesions,  pp. 
187  and  seq.,  is  well  worthy  of  perusal.  The  conclusion  is  as  follows:  "I  fear  we 
must  abandon  this  operation.  .  .  .  To  weaken  still  further  the  remaining  connec- 
tions of  a  broken  spint- ;  to  convert  a  simple  into  a  compound  fracture  ;  to  expose  the 
sheath  of  the  cord,  and  possibly  the  cord  itself;  and  to  entail  the  risks  attending  the 
period  of  repair — cannot  be  regarded  as  circumstances  of  indifference.  Accidentally, 
here  and  there,  an  instance  may  occur  in  which  benefit  does,  or  seems  to,  result  from 
surgical  interference;  and  the  time  may  arrive  when,  perchance,  the  means  of  diag- 
nosis at  our  command  may  enable  us  to  judge  with  more  precision  of  the  nature  and 
extent  of  the  injury  inflicted  ;  but  at  prcssent  I  catniot  regard  trephining  the  spine  ao 
brought  within  the  pale  of  the  justifiable  operations  of  surgery." 

-  Med.-Chir.  Trans.,  vol.  xlix,  p.  21. 


FRACTURE    OF    THE    SPINE.  191 

followed  the  operation,  cannot  be  quoted  as  successful,  since  the  paralysis 
remained  permanent ;  and  although  the  operation  has  been  repeated 
man}'  times  since,  in  no  case  does  it  seem  to  have  been  of  unmistakable 
service.  Exceptional  cases  may  occur  in  which,  from  the  nature  of  the 
accident  or  the  appearance  of  the  part,  the  surgeon  may  think  that  only 
a  small  amount  of  bone  is  implicated  in  the  injur}',  and  where  he  may 
determine  to  give  the  patient  the  poor  prospect  of  relief  which  this  opera- 
tion holds  out ;  but  in  general  it  will  onl}^  hasten  the  end. 

Treatment. — The  treatment  of  fractures  of  the  spine  must  be  directed 
to  combat  the  two  main  dangers  to  life  which  can  be  met  by  surgical  treat- 
ment, viz.,  the  tendency  to  cystitis,  and  that  to  sloughing  ;  the  other  and 
still  more  formidable  danger,  from  loading  of  the  lungs,  is  unfortunately 
irremediable;  but  it  only  occurs  in  fractures  high  \\\^.  The  tendency  to 
cystitis  may  be  partly  obviated  by  the  careful  and  frequent  use  of  the 
catheter,  and  by  gently  washing  out  the  bladder  with  acidulated  water  ; 
but  there  is  a  strong  disposition  to  low  inflammation  of  all  the  mucous 
membranes,  and  especially'  that  of  the  urinary  tract,  in  this  accident,  so 
that  the  relief  afforded  can  only  be  partial.^  As  the  patient  is  not  sensible 
to  the  pain  of  rough  catheterization,  injury  may  easily  be  done  unless 
great  care  is  taken.  But  if  catheterization  be  neglected  the  inflammation 
may  prove  fatal  by  spreading  up  to  the  kidneys,  or  (as  I  saw  in  one  case) 
by  perforation  of  the  bladder.  Sloughing  is  a  very  frequent  cause  of 
death.  Sloughs  form  on  all  parts  exposed  to  pressure,  but  also  on  places 
(as  the  malleoli)  where  no  pressure  seems  to  have  acted  ;  so  that  there 
can  be  no  doubt  that  the  privation  of  nervous  influence  acts  as  a  cause  of 
the  gangrene,  as  well  as  pressure,  though  the  latter  is  a  very  powerful 
agent  in  producing  the  sloughing  ;  and  tlie  tendency  to  this  inflammation 
is  much  increased  by  neglect  in  nursing,  whereby  urine  and  fteces  are 
left  in  the  bed  to  irritate  the  skin.  Scrupulous  cleanliness,  frequent 
slight  changes  of  position,  which  can  be  effected  by  means  of  pillows  in- 
serted here  and  there,  and  by  gently  rolling  the  patient  to  one  side  or 
another,  and  the  use  of  the  water-bed  or  water-pillow,  seem  to  me  all  that 
can  be  done. 

Should  the  patient  survive  he  may  recover  power  to  some  extent,  but  I 
am  not  aware  of  an}^  case  of  complete  recovery  from  paralysis  which  was 
proved  to  be  due  to  fracture  of  the  spine. 

Concui^mon  of  the  spine  is  a  term  which  is  applied  to  cases  in  which 
after  injury  the  functions  of  the  spinal  cord  are  more  or  less  lost,  but 
without  any  evidence  of  fracture.  The  injuries  which  produce  concussion 
of  the  spine  vary  greatly  in  severity,  and  the  symptoms  vary  also  from 
slight  numbness,  pricking  sensations,  or  difficulty  of  motion,  to  an  amount 
of  paralysis  both  of  motion  and  of  sensation  as  great  as  that  of  fracture, 
though  commonly  not  so  persistent.  The  anatomy'  of  concussion  must 
vary  also  to  a  corresponding  extent.  Frequently,  I  have  no  doubt,  the 
lesion  consists  in  haemorrhage  external  to,  or  in  the  substance  of  the  cord, 
sometimes  most  likely  in  laceration  of  the  cord,  and  at  others  possibly  in 
inflammatory  effusion  or  inflammatory  softening.  That  cases  ever  occur 
in  which  the  tissues  of  the  spinal  marrow  and  its  vessels  are  uninjured, 
as  would  be  implied  by  tlie  term  "  concussion,"  if  rigidl}'  interpreted,  is 
as  unproved  in  the  case  of  the  spine  as  of  the  cranium. 

The  symptoms  to  which  the  term  concussion  of  the  spine  is  applied 

^  Those  who  hold  the  germ-theory  of  disease  dwell  on  the  advantage  of  using  ear- 
bolized  oil  for  the  catheter  in  such  cases  as  these,  and  there  can  certainly  be  no  harm 
in  doing  so. 


192  INJURIES    OF    THE    BACK. 

come  on  eithei-  iinuiediately  on  the  injury  or  after  an  interval  of  uncertain 
duration.  I  do  not  liuow  that  I  can  do  better  than  quote  two  of  the  cases 
which  Mr.  Le  Gros  Clarli  gives  as  instances  of  concussion  of  the  spine 
following  in  one  case  immediately,  and  in  the  other  subsequently  to  an  in- 
jury. "A  man  3G  years  of  age,  weighing  IH  stone,  was  tripped  up  in  the 
road,  and  fell  heavily  on  his  left  hip,  and  then  turned  over  on  his  back.- 
On  trying  to  rise  he  failed,  not  having  any  power  of  movement  in  either 
lower' extremity.  He  was  brought  at  once  to  the  hospital.  On  admit- 
tance he  complained  of  pain  in  the  lumbar  region,  and  there  was  slight 
tenderness  in  pressing  the  spinous  ridge  of  this  part  ;  but  careful  exami- 
nation failed  to  detect  any  irregularity  or  other  sign  of  mechanical  injury 
of  the  vertebral  column.  There  was  entire  loss  of  power  in  his  lower 
limbs  ;  he  could  not  even  move  a  toe  ;  sensation  was  impaired ;  he  said 
his  legs  were  numbed.  There  was  slight  priapism,  and  he  was  unable  to 
micturate.  His  pulse  was  60,  but  there  were  no  signs  of  well-marked  col- 
lapse. On  the  third  day  he  was  able  to  move  his  toes  a  little.  On  the  ninth 
day  sensation  was  perfect,  but  he  had  made  very  little  progress  in  regain- 
ing muscular  power.  Nearly  three  weeks  elapsed  before  he  was  able  to 
dispense  with  the  catheter;  and  at  the  expiration  of  five  weeks  he  was 
still  almost  as  helpless  in  moving  any  part  of  his  lower  extremities.  He 
remained  in  the  hospital  for  four  months,  his  health  being  tolerably  good 
throughout.  He  was  tlien  able  to  get  about  very  fairly,  but  with  a  shuf- 
fling, unsteady  gait." 

The  diagnosis  of  a  case  of  this  sort  from  one  of  fracture  will  rest  partly, 
as  Mr.  Clark  observes,  on  the  absence  of  the  local  signs  of  fracture,  and 
on  the  fact  that  the  accident  is  not  one  likely  to  have  produced  fracture, 
and  partly  on  the  partial  extent  of  the  paralysis.  Yet,  as  he  adds,  "in 
some  cases  where  the  symptoms  are  persistent,  doubt  must  remain  as  to 
the  true  nature  of  the  lesion,  and  a  cautious  prognosis  is  therefore  re- 
quired." 

The  case  in  which  symptoms  of  spinal  concussion  followed  after  an  in- 
terval is  as  follows  :  "  A  man  was  injured  in  a  collision  in  the  tunnel  four 
or  five  miles  from  Brighton.  He  walked  this  distance  with  some  difficulty 
into  the  town,  and  within  twenty  hours  became  entirely  paraplegic.  He 
recovered  slowly  ;  and  after  a  lapse  of  two  years  was  able  to  walk  as  well 
as  before  the  accident.  One  spot  in  the  back  was  always  tender,"  and 
continued  so  at  tlie  time  of  the  report,  which  was,  I  believe,  about  five 
years  after  the  injury. 

These  cases  of  spinal  concussion  have  acquired  great  surgical  and  even 
public  interest  of  late,  from  the  frequency  with  whicii  they  really  occur,  and 
from  the  frequency  also  with  which  they  are  alleged  more  or  less  falsely 
to  have  occurred  in  cases  of  railway  injury.  No  part  of  a  surgeon's  duties 
is  more  ditlicult  than  that  of  forming  an  opinion  in  these  cases,  in  which 
the  alleged  symptoms  are  sometimes  entirely  fabricated  ;  at  others  mixed 
with  more  or  less  of  unconscious  exaggeration  or  delusion,  the  result  of 
mental  causes;  at  others  really  existing,  but  iii  so  latent  a  condition  that 
it  is  hardly  possible  at  first  to  l)elieve  in  their  reality.  It  is,  therefore,  no 
wonder  that  the  most  eminent  surgeons  constantly  dilfer  in  their  estimate 
of  such  cases,  and  that  they  constantly  make  opposite  errors,  by  denying 
the  reality  of  symptoms  which  the  after-progress  of  the  case  shows  to 
have  been  perfectly  genuine,  or  by  accepting  others  which  are  fraudulent 
or  imaginary.  No  doubt  as  this  class  of  cases  becomes  more  familiar  such 
diff'erences  of  opinion  will  become  rarer;  and  they  would  even  now  be  far 
less  common  if  the  system  of  our  courts  of  law  would  permit  of  a  delib- 
erate examination  and  report  by  a  medical  commission  authorized  to  avail 


RAILWAY    INJURIES.  193 

themselves  of  all  necessary  opportunities  for  pronouncing  an  unbiassed 
judgment.  As  it  is,  both  sides  in  the  trial  have  an  interest  in  procuring 
medical  testimony  on  hasty  examinations  from  wiiich  one  aspect  of  the 
case  has  been  concealed  as  far  as  possible. 

Railway  injuries  are  not  usually  pure  examples  of  concussion  of  the 
spine,  but  the  spinal  injury  is  mixed  up  with  symptoms  of  general  siiock, 
besides,  as  may  easily  be  the  case,  detinite  lesions  of  other  parts  of  the 
body.  I  will  again  quote  from  Mr.  Le  Gros  Clark,  who  speaks  thus  on 
the  subject  of  railvva}'  injuries  affecting  the  spine:  ''Spinal  concussion 
may  be  immediate  and  well  marked  ;  or  the  indications  of  spinal  mischief 
may  not  supervene  until  after  the  lapse  of  some  time.  General  shock  is 
often,  but  not  always,  in  excess  of  that  which  accompanies  simple  con- 
cussion ;  in  some  instances  the  collapse  is  great,  accompanied  by  insensi- 
bility, but  without  evidence  of  injury  to  the  head.  Reaction,  under  such 
circumstances,  is  tardy  and  irregular.  Numbness  and  tingling,  some- 
times local,  sometimes  universal,  is  complained  of.  Other  symptoms  are, 
rigor,  continued  sickness,  intermittent  fits  of  numbness,  excito-motor 
spasm  in  the  limbs,  violent  throbbing  sensations,  or  sense  of  heat  or 
cold  in  the  head  or  other  parts,  want  of  sleep  or  continued  drowsiness, 
confusion  of  intellect,  enfeebled  muscular  power,  deafness,  defective  sight, 
accompanied  by  ocular  spectra ;  hyperaesthesia  in  some  parts,  but  espe- 
cially in  the  spine ;  great  emotional  excitability.  Besides  these  I  could 
enumerate  other  more  especial  symptoms;  but  they  have  been  peculiar  to 
isolated  cases.  With  rare  exceptions,  extreme  sensitiveness  of  the  spine 
is  present  in  these  cases,  and  more  frequently  located  at  some  particular 
part  than  distributed  over  the  whole  column.  Again,  this  pain  on  pres- 
sure is  sometimes  referred  to  the  lumbar  muscles,  at  others  to  the  spinous 
ridge.  In  some  of  these  cases  the  patients  entirely  recover  after  a  longer 
or  shorter  interval ;  in  others  the  health  is  permanently  enfeebled,  and  a 
life  of  protracted  discomfort  is  entailed  ;  or  the  sufferer  sinks,  emaciated 
and  exhausted,  into  a  premature  grave ;  or  becomes  the  victim  of  some 
acute  disease,  the  destructive  tendency  of  which  his  defective  organism 
is  incapai)le  of  resisting. 

"It  will  be  perceived  that  many  of  the  foregoing  symptoms  and  signs 
may  be  referred  to  what  we  are  accustomed  to  regard  as  concussion  of 
the  spine  ;  but  many  also  are  due  to  general  rather  than  special  nervous 
shock.  In  some  instances  there  is  probably  meningeal  mischief;  but  the 
indications  in  others  clearly  point  to  organic  change  in  the  cerebro-spinal 
centre. 

"I  have  already  shown,  in  a  preceding  lecture,  how  powerful  an  influ- 
ence emotional  shock  or  physical  concussion  may  exercise  on  organic 
vitality  ;  and  I  think  it  not  inconsistent  with  acknowledged  facts  to  affirm 
that  protracted  functional  disturbance,  or  even  fatal  disease,  may  be  the 
consequence  of  a  rude  shock  simultaneously  to  the  nerve-centres  of  the 
emotions,  of  organic  and  of  animal  life.  I  am,  therefore,  disposed  to 
regard  these  cases  of  so-called  railway  spinal  concussion  as,  generally, 
instances  of  universal  nervous  shock,  rather  than  of  special  injury  to  the 
spinal  cord.  At  the  same  time  I  admit  that  in  this  class  of  cases  we 
meet  with  instances  of  simple  concussion,  but  I  see  no  reason  for  taking 
them  out  of  the  category  of  concussion  of  the  spine  from  other  causes."^ 

Mr.  Clark  gives  also  an  account  of  the  post-mortem  appearances  of  the 
spinal  cord  in  two  cases,  one,  under  his  own  care,  in  a  child  who  had 
sustained  an  injury  to  tlie  spine  without  fracture,  and   not  producing 

1  Op.  cit.,  p.  f50. 
13 


194  INJURIES    OF    THE    BACK. 

paralysis  at  first,  though  this  soon  afterwards  supervened.  The  child 
died  three  niontlis  afterwards  with  inflammation  of  the  whole  cord  below 
the  eighth  dorsal  vertebra.  There  was  no  trace  of  hi^^morrhage  or  of  dis- 
ease of  the  membranes,  but  the  spinal  cord  was  replaced  by  a  mere  "  string 
of  soft  atrophied  nerve-matter."  In  the  other  case,  which  was  under  the 
observation  of  Dr.  Lockhart  Clarke,  and  is  published  by  him  in  the 
Path.  Soc.  Tranx..  vol.  xvii,  the  case  was  one  of  ordinar\^  railway  injury, 
the  patient  having  survived  three  and  a  half  years.  His  gait  had  been 
"unsteady,  somewhat  like  partial  intoxication,  but  without  jerking  or 
twitching;"  and  latterly  his  speech  had  become  thick  and  hesitating. 
The  spinal  cord  was  wasted  and  shrunken,  and  its  white  matter  showed 
evident  traces  of  inflammator}'  degeneration.^  The  brain  was  also  pallid 
and  soft,  particularly  on  the  under  surface  of  both  anterior  lobes. 

Diagncsis  of  Spinal  Goncuaaion. — It  would  be  impossible  in  a  work  like 
this  to  go  fully  into  the  ver}'^  difficult  problem  of  the  diagnosis  of  cases  of 
railway  injury.  The  subject  is  treated  of  with  conspicuous  ability  in 
Mr.  Erichsen's  well-known  work  on  Eaihvay  Injuries,  to  which  I  would 
refer  the  reader  for  a  more  adequate  view  of  the  symptoms,  pathology, 
and  treatment  of  these  difficult  cases  than  my  limits  allow.  I  w-ould  only 
sa}'  here,  that  when  there  is  any  doubt  of  the  patient's  veracity  or  of  the 
reality  of  the  symptoms  in  all  cases  of  alleged  inability  to  perform  cer- 
tain movements,  it  is  most  satisfactory  to  have  physical  evidence  of  the 
wasting  of  the  muscles  concerned  in  those  movements,  or  other  tangible 
proof  of  the  effect  of  the  loss  of  function.  The  effects  of  the  galvanic 
current  applied  to  the  muscles  alleged  to  be  affected  must  be  carefully 
watched  and  compared  with  its  effects  when  applied  to  those  of  the  other 
side.  When  loss  of  sensation  is  alleged,  it  is  desirable  to  examine  the 
patient  in  many  ways,  and  with  his  attention  distracted  from  the  part  in 
which  sensation  is  said  to  be  deficient.  Unsteadiness  of  gait  may  easily 
be  simulated,  and  the  fraud  may  be  detected  when  the  patient  is  cleverly 
thrown  off"  his  guard.  Alleged  loss  of  power  over  the  bladder  ought  to 
produce  certain  symptoms  and  appearances  in  the  urine,  and  a  urinous 
smell  about  the  clothes  and  bed  ;  and  finally,  all  the  more  serious  cases 
of  injury  are  accompanied  with  a  disturbance  of  the  general  health  which 
is  often  "conspicuous  from  its  absence"  in  persons  who  prosecute  claims 
against  railway  companies.  But  besides  the  grosser  and  more  easily 
detected  cases  of  fraud  instances  are  met  with  often  in  practice  in  which 
the  mental  and  bodily  symptoms  are  so  mingled  together  that  it  is  hardly 
possible  to  say  what  is  the  real  injury  and  what  is  the  patient's  prospect 
of  recovery. 

Pi'ofjnosis. — The  prognosis  of  these  injuries  is  also  a  very  difficult 
question.  Those  which  come  on  at  once,  and  with  syn)ptoms  of  active 
liaMiiorrliage,  seem  to  me  on  the  whole  more  encouraging  tlian  those  in 
which  the  mischief  is  consecutive  on  infiannnation,  probably  accompanied 
by  textural  changes  (softening  in  most  cases,  in  others  imluration)  ;  and 
if,  as  is  sometimes  tiie  case,  the  inflammation  spreads  upwards,  and  symp- 
toms of  cerebral  meningitis  or  softening  begin  to  make  their  appearance, 
the  prospect  of  recovery,  or  even  of  amelioration,  becomes  still  worse. 
Much  also  will  depend  on  the  state  of  the  general  health.  Those  cases 
are  the  worst  in  which  the  patient's  condition  goes  on  deteriorating,  and 
unluckily  they  are  by  no  means  tiie  least  common. 

Tre.aiment. — The  treatment  of  these  cases  at  their  commencement  must 

1  A  drawinpc  from  ii  microscopical  section  of  llio  iifTocted  cord  will  bo  found  in 
Mr.  Le  Gros  ClarK's  work. 


INJURIES    OF    THE    FACE.  195 

be  by  rigid  rest  and  l>y  antiphlogistics — much  as  in  severe  sprain  ;  and 
Mr.  Ericlisen  witli  great  probability  suspects  that  many  of  the  ill  conse- 
quences which  often  follow  on  railwa3'  injuries  depend  on  the  patient 
having  neglected  at  first  to  observe  that  perfect  quiet  which  should  always 
be  enforced  after  such  an  accident.  When  the  first  acute  symptoms  have 
subsided  much  benefit  will  probably  be  produced  b}^  counterirritation 
and  the  actual  cautery,  and  by  the  cautious  administration  of  mercury 
in  ver}'  small  quantities,  the  perchloride  being  the  favorite  preparation. 
When  all  inflammatory  symptoms  have  subsided  the  use  of  strychnia  is 
indicated  ;  and  it  is  possible  that  then  the  patient  may  derive  benefit 
from  gentle  exercise  with  all  possible  caution.  The  general  health  must, 
of  course,  be  carefully  attended  to,  and  when  he  is  able  to  move  the 
patient  may  be  advised  to  try  the  efl'ect  of  change  of  climate. 


CHAPTEK   IX. 

INJURIES    OF    THE    FACE. 

The  free  vascular  supply  which  is  enjoyed  by  all  parts  of  the  face 
renders  the  process  of  union  rapid,  and  the  prognosis  of  all  injuries 
better,  in  this  than  in  an}^  other  part  of  the  body.  It  is  true  that  cutaneous 
erysipelas  is  common,  but  it  seldonn  produces  alarming  symptoms  except 
in  persons  whose  health  is  broken  down  by  intemperance  or  visceral  dis- 
ease. Bruises  are  often  extensive,  since  the  large  vessels  lie  close  under 
the  skin,  surrounded  by  a  loose  cellulo-adipose  structure,  in  which  ex- 
travasation can  go  on  to  an  almost  unlimited  extent ;  but  it  speedily 
subsides  if  the  patient  is  in  good  health.  All  wounds  ought  to  be  imme- 
diately and  accurately  united,  with  sutures  if  the  edges  cannot  be  other- 
wise kept  in  exact  apposition  ;  and  the  sutures  must  be  supported  with 
harelip-pins  when  the  flaps  are  heavy,  or  in  the  lips,  where  powerful 
muscles  are  attached  to  the  skin.  Even  if  the  wounds  be  considerably 
contused  or  lacerated  they  may  nevertheless  be  united.  Perhaps  no 
sloughing  will  ensue,  or  if  the  edges  slough  still  the  resulting  deformity 
will  most  likely  be  less  than  if  the  flap  had  not  been  replaced.  But 
sutures  will  very  likely  leave  a  mark  of  their  own,  so  that  they  should 
not  be  used  unless  absolutely  necessary ;  the}^  should  be  as  delicate  as  is 
consistent  with  security,  and  they  ought  always  to  be  withdrawn  as  early 
as  possible.  Even  in  adults  and  in  the  lips  there  is  no  reason  for  leaving 
the  harelip-pins  in  longer  than  forty-eight  hours. 

Saliva?^  Fistula. — One  of  the  most  disagreeable  complications  of 
wounds  of  the  face  is  salivary  fistula.  This  is  caused  usually  by  a  wound, 
but  sometimes  by  an  abscess,  which  lays  open  Steno's  duct.  The  saliva 
is  constantly  running  out  on  the  cheek,  and  the  flow  is  increased  when 
the  patient  eats  or  when  his  "  mouth  waters."  If  the  division  is  complete 
the  patient  may  be  conscious  of  dryness  of  that  side  of  the  mouth. 


196  INJURIES    OF    THE    FACE. 

The  disease  is  to  he  treated  by  restoring  the  passage  for  the  saliva 
from  the  gland  into  the  mouth.  For  this  purpose  the  proximal  part  of 
the  duct  {i.  e  ,  the  part  of  the  duct  whicli  is  still  in  connection  with  the 
o-land)  should  be  found  by  examination  of  the  wound;  then  the  cheek 
should  be  everted,  and  along  the  natural  opening  of  the  duct,  in  the 
interior  of  the  mouth  (which  is  generally  found  without  difficulty,  oppo- 
site the  second  upper  molar  tooth),  a  probe  or  leaden  string  is  to  be 
passed  across  the  wound  and  along  the  duct  in  the  direction  of  the  gland. 
The  probe  or  string  is  fixed  in  its  position  by  bending  its  extremit}^ 
round  the  commissure  of  the  lips  on  to  the  cheek,  where  it  can  be  secured. 
When  the  saliva  is  thus  guided  into  the  moutli  the  fistula  will  probably 
heal,  either  of  itself  or  on  its  edges  being  refreshed  and  brought  together. 
In  some  cases  the  opening  of  the  duct  in  the  mouth  cannot  be  found, 
and  when  this  is  the  case  the  distal  opening  of  the  duct  as  well  as  the 
proximal  must  be  sought  in  the  wound ;  or  if  that  part  of  the  duct  is 
obliterated,  an  artificial  passage  must  be  made  and  kept  open  ;  but  such 
cases  are  far  less  promising.  And  indeed  many  cases  of  salivary  fistula 
present  very  considerable  "difficulty,  from  the  rottenness  of  the  tissues 
surrounding  the  wounded  duct,  which  renders  them  very  unapt  to  unite 
when  brought  together,  and  favors  the  percolation  of  the  saliva  through 
the  wound  which  it  is  intended  to  unite. 

Foreign  Bodien  in  the  Nose  and  Ear. — Children  very  frequently  pass 
foreign  bodies  into  the  nose  or  ear,  which  they  cannot  withdraw  again, 
and  which  afterwards  may  set  up  grave  mischief.  In  the  nostril  they 
give  rise  to  foul  discharge  from  inflammation  of  the  membrane,  and  may 
even  produce  disease  of  the  bones.  The  case  is  constantly  mistaken  for 
one  of  "  oziBua,"  or  strumous  disease — so  constantly  that  it  has  become 
a  familiar  caution  in  surgery  always  to  put  dowai  a  case  of  foul  discharge 
from  one  nostril  in  a  child  as  being  probably  due  to  a  foreign  body,  and 
to  pronounce  no  opinion  about  it  till  after  a  thorough  examination,  for 
which  purpose  anaesthesia  is  generally  necessary.  The  foreign  substance 
is  always  quite  easy  to  remove,  either  from  the  nostril  or  by  pusliing  it 
through  into  the  throat,  and  then  the  discharge  will  at  once  subside. 

Foreign  bodies  in  the  meatus  auditorius  are  more  dangerous,  for  they 
may  eas'ily  cause  perforation  of  the  membrana  tympani,or  even  cerebral 
mischief,  by  inflammation  spreading  through  the  base  of  the  skull  to  the 
cranial  sinuses.  Sucli  foreign  bodies  may  be  removed  by  constant  syr- 
inging with  warm  water,  or  under  chloroform  with  a  pair  of  forceps,  a 
bent  probe,  a  loop  of  wire,  or  some  special  instrument  of  which  several 
liave  been  devised  for  the  purpose.  But  if  these  means  fail,  as  they 
often  do,  nothing  further  should  be  done,  beyond  perseverance  in  syr- 
inging, since  harm  may  easily  be  produced  by  the  incautious  use  of  in- 
struments, and  in  all  probability  suppuration  will  loosen  the  foreign  sub- 
stance, and  then  it  will  come  away. 

Fractures  of  Facial  Bones. — The  bones  of  the  face  can  onl}-  be  frac- 
tured by  direct  force,  and  these  fractures  are  not  so  frequent  as  might 
be  expected.  One  observation  which  it  is  necessary  to  bear  in  mind  in 
these  injuries  is  that  tlie  distinction  whicli  in  other  regions  is  so  impor- 
tant between  simple  and  compound  fractures  lias  really  hardly  any  im- 
portance as  applied  t(j  the  bones  of  the  face.  Wounds  of  the  face  heal 
so  rapidly,  and  the  thin  facial  bones  are  so  surrounded  by  structures 
rich  in  vessels,  that  compound  fractures  heal  almost  as  readily  as  simple 
fractures  do. 


FRACTURE    OF    LOWER    JAW.  197 

The  ossa  nasi  when  fractured  are  usually  also  depressed,  causino;  a 
flattening  of  the  bridge  of  the  nose  and  a  very  unpleasant  deformity. 
The  accident  is  a  very  easy  one  to  recognize,  but  the  treatment  is  not 
always  satisfactory,  for  these  delicate  bones  are  often  comminuted  as 
well  as  fractured,  and  it  is  very  difllcult  to  adjust  the  fragments  properly. 

All  possible  care,  however,  should  be  bestowed  on  the  restoration  of 
all  the  fragments  to  their  proper  position,  by  means  of  a  curved  staff  or 
a  female  catheter  introduced  up  the  nostril.  If  it  is  otherwise  impos- 
sible to  keep  the  fragments  in  their  place  the  surgeon  may  try  to  support 
them  by  some  substance  introduced  into  the  nostril;  but  Mr.  Holmes 
Coote  justly  says  that  "plugging  of  the  nostril  should  not  be  resorted 
to  except  in  cases  of  severe  displacement,  for  it  causes  the  patient  great 
discomfort,  and  not  uncommonly  fails  to  effect  the  purpose  for  which  it 
is  used."  If  it  is  found  necessary  to  introduce  a  foreign  body,  it  should 
be  removed  after  a  few  days.  The  fracture  unites  very  rapidly,  in  some 
cases  the  cartilages  only  are  broken  or  bent.  The  treatment,  however, 
of  these  cases  must  be  conducted  on  the  same  principles.  The  septum 
is  of  course  usually  involved  in  the  fracture  and  displacement,  and  great 
care  must  be  bestowed  in  order,  if  possible,  to  keep  it  straight  while  the 
process  of  union  is  going  on.  Mr.  W.  Adams^  has  lately  described  a 
screw  steel  apparatus  for  sui)porting  the  fragments  in  these  cases,  which 
is  to  be  worn  for  two  or  three  days,  and  then  replaced  by  an  ivory  plug. 
And,  no  doubt,  in  some  complicated  cases  the  use  of  a  metallic  or  glass 
support  is  necessary ;  though  in  those  where  the  fracture  is  only  single, 
and  the  septum  is  not  much  deviated,  it  may  be  superfluous. 

Fractures  of  the  upper  jaw  are  accidents  of  little  moment  unless  the 
displacement  is  such  as  to  produce  much  change  in  the  features.  I  re- 
member a  case  in  which,  a  carriage-wheel  having  passed  over  the  face, 
most  of  the  bones  seemed  to  be  separated  from  the  skull,  and  on  recov- 
ery a  peculiar  and  most  disagreeable  lengthening  of  the  face  was  left. 
Such  deformities  are  very  difficult  indeed  to  avoid,  for  there  is  little 
means  of  acting  on  the  upper  jaw  from  any  side  so  as  to  replace  its  frag- 
ments when  once  driven  in. 

Fractures  of  the  malar  hone  are  rare,  and  are  usually  caused  by  con- 
siderable violence.  The  only  point  of  interest  in  their  patholog}^  is  one 
illustrated  by  a  case  which  I  published  many  years  ago,''  where  a  gentle- 
man, who  had  fallen  from  his  horse  and  had  sustained  fatal  injury  to  the 
brain,  presented  an  orbital  ecchymosis  exactly  resembling  that  which  at- 
tends on  a  fracture  of  the  base  of  the  skull.  On  post-mortem  examina- 
tion the  bleeding  was  found  to  depend  on  a  fracture  traversing  the  malar 
bone  near  its  junction  with  the  frontal. 

Fracture  of  the  zygoma  is  exceedingly  rare,  and  it  is  said  that  in  some 
cases  displacement  is  produced  by  the  action  of  the  fibres  of  the  masseter 
muscle  implanted  into  the  fractured  part,  but  I  have  no  personal  experi- 
ence of  this  injury.  The  displacement,  when  recognized,  must  be  reme- 
died by  careful  manipulation  under  anaesthesia.  Replacement  by  the 
insertion  of  a  sharp  metallic  point  into  the  displaced  fragment  and  trac- 
tion upon  it  has  been  spoken  of. 

Of  the  Loiver  Jaiv. — By  far  the  most  common  fracture  in  the  face  is 
that  of  the  lower  jaw.  This  is  usually  caused  by  a  very  heavy  blow,  such 
as  the  kick  of  a  horse,  though,  as  curiosities,  cases  are  recorded  in  which 
muscular  action  is  said  to  have  caused  it.     It  is  frequently  in  some  sense 

1  Lancet,  1875,  vol.  i,  p.  649.  2  Brit.  Med.  Journ.,  1855,  p.  907. 


198  INJURIES    OF    THE     FACE. 

compound,  that  is,  the  line  of  fracture  communicates  with  the  air  in  the 
cavity  of  tlie  moutli,  for  the  soft  coverings  of  the  jaw  are  very  commonly 
torn.  But  the  fracture  almost  always  unites  after  the  manner  of  a  simple 
fracture.  In  some  complicated  injuries,  however,  the  comminuted  por- 
tions will  exfoliate.  Any  part  of  the  bone  may  be  broken.  There  are 
cases  in  which  only  the  alveolar  edge  is  broken  off,  but  the  continuity  of 
the  bone  is  not  interrupted,  since  its  base  is  not  broken.  Such  accidents 
are  rare  in  the  present  day,  but  were  said  to  be  common  when  "the  key" 
was  in  ordinary  use  in  extracting  teeth.  Mastication  will  be  painful  or 
impossible  at  first,  but  as  the  parts  consolidate  the  patient  will  completely 
recover,  though  perhaps  with  the  loss  of  some  of  the  teeth.  Another 
rare  fracture  of  the  jaw  is  that  of  its  neck.^  It  is  not  difficult  to  diag- 
nose, by  following  the  ascending  ramus  upwards  with  the  finger  intro- 
duced into  the  mouth.  I  once  dissected  a  specimen  of  this  injury  in 
which  the  broken  ramus  had  protruded  through  the  meatus  auditorius 
externus,  and  had  so  irritated  its  lining  membrane  as  to  give  rise  to  a 
catarrhal  discharge  very  much  i-esembling  that  which  is  seen  in  some 
fractures  of  the  base  of  the  skull.'-  Another  fracture  is  that  through  the 
angle  between  the  body  and  ascending  ramus,  and  in  this  there  is  not 
much  displacement,  since  the  masseter  and  internal  pterj'goid  inserted 
on  either  side  keep  the  parts  in  position.  The  fractures  which  occur  be- 
tween the  angle  and  S3'mphysis  are  generally  much  displaced,  and  especi- 
all}'  when,  as  very  commonly  happens,  there  is  fracture  on  both  sides — 
the  central  piece  being  drawn  down  by  the  hyoid  muscles  in  addition  to 
the  displacement  caused  by  the  force  of  the  blow.  Fracture  often  trav- 
erses the  bone  at  or  close  to  the  symphysis,  and  this  fracture  will  not  be 
much  displaced  unless  the  force  has  been  unusually  severe,  since  the 
muscles  of  the  two  sides  will  balance  each  other. 

Fracture  of  the  coronoid  process  is  a  rare  accident,  but  one  which  is 
illustrated  by  a  preparation  in  the  Museum  of  King's  College  Hospital,  of 
which  Mr.  Heath  gives  a  representation,  copied  from  Sir  W.  Fergusson's 
Practical  Surgery.  The  former  author  thus  speaks  on  the  subject  of  this 
rare  injury:  "The  fragment  would,  no  doubt,  be  drawn  upwards  and 
backwards  by  the  temporal  muscle,  and  might  be  felt  in  its  new  situation, 
thougii  this  displacement  would  probably  be  limited  liy  the  very  tough 
and  tendinous  fibres  which  are  so  closely  connected  with  the  bone,  form- 
ing the  insertion  of  the  temporal  muscle,  and  reaching  down  to  the  last 
molar  tootli.  According  to  Sanson  fractures  of  the  coronoid  process  do 
not  admit  of  union."*  I  venture  to  think  that  the  latter  statement  is  en- 
tirely unsupported,  and  that  the  idea  that  fractures  of  the  coronoid  pro- 
cess of  the  jaw  do  not  unite  by  bone — though  it  has  been  copied  from  one 
author  to  another  till  it  has  become  one  of  the  loci  communes  of  surgery 
— rests  on  no  evidence.  If  the  fragment  were  much  drawn  up  the  frac- 
ture would  unite  by  ligament;  but  there  is  no  proof  that  this  displace- 
ment usuall}'  occurs. 

Fractures  of  the  lower  jaw  are  often  multiple  or  comminuted.  This  is 
the  case,  of  course,  in  gunshot  fractures  almost  always,  but  not  infre- 
quentl^'  in  those  caused  by  the  passage  of  wheels  over  the  face  or  by  other 
unusual  violence.     And  the  nature  of  the  displacement,  as  well  as  the 


'  Mr.  Ilenlh  says  that,  jvidging  from  the  number  of  Museum  specimens  which  exist 
of  it,  this  injury  is  probably  not  so  uncommon  as  it  is  represented.  1  can  onlj-  say 
that  it  seems  rarely  met  with  in  extensive  hospital  practice,  where  other  fractures  of 
the  jaw  are  common. 

2  Path.  Soc.  Trans.,  vol.  xii,  p.  150. 

3  Injuries  and  Diseases  of  the  Jaws,  2d  ed.,p.  14. 


FRACTURE    OF    LOWER    JAW.  199 

amount  of  deformity  resultino-,  is  greatly  influenced  by  tins  circumstance. 
It  is  mainly  in  these  more  complicated  fractures  that  non-union  is  to  be 
apprehended. 

The  state  of  the  teeth  should  always  be  carefully  considered  in  cases  of 
fractured  jaw,  and  an}^  which  are  so  displaced  as  to  interfere  with  union, 
or  so  injured  as  to  be  useless,  had  lietter  be  removed  at  once. 

Diagnoi^ia  and  Treatment. — The  symptoms  of  fractured  jaw  are  usually 
very  plain,  '^i'he  patient  will  feel  very  great  pain  in  trying  to  open  his 
mouth,  the  saliva  will  very  probably  drivel,  the  line  of  the  teeth  will  be 
broken,  and  one  or  more  will  very  likely  be  loose  or  be  knocked  out ; 
there  will  be  displacement  as  descrilied  above,  and  crepitus  will  lie  easily 
felt  on  manipulating  the  parts  into  position.  If  the  fracture  be  com- 
minuted the  diagnosis  will  be  still  more  easy. 

The  treatment  consists  in  replacing  the  parts  by  proper  manipulation, 
whicii  is  seldom  ditticnlt  in  uncomplicated  fracture,  and  then  in  the  sim- 
pler injuries  nothing  further  is  necessary  than  to  ])ut  up  the  parts  in  a  jaw- 
bandage,  i.  e.,  a  four-tailed  bandage,  with  a  hole  cut  in  the  centre  to 
receive  the  chin,  the  tails  crossing  each  other,  one  pair  tied  behind  the 
occiput  (sometin)es  for  more  security  brought  thence  over  the  forehead), 
the  other  over  the  vertex.  Inside  this  may  be  placed  a  gutta-i)ercha  or 
pasteboard  splint  moulded  so  as  to  fit  the  chin.^  The  teeth  of  the  lower 
jaw  are  thus  brought  into  close  apposition  with  those  of  the  upper,  which 
serve  in  some  measure  as  a  splint  for  them,  fixing  in  their  natural  posi- 
tion. For  the  efficiency  of  this  treatment  it  is  clear  that  the  teeth  must 
be  kept  together,  i.  e.,  that  the  patient  must  not  be  allowed  to  open  his 
mouth.  He  must,  therefore,  be  content  with  such  fluid  or  semifluid 
nourishment  as  he  can  suck  in  through  any  gaps  tliere  may  be  in  his 
teeth  or  can  pass  in  through  the  hiatus  tiehind  the  molars.  After  the  first 
fortnight  perhaps  a  little  movement  of  the  jaw  may  become  tolerable.  In 
a  period  of  from  three  to  four  weeks  from  the  accident  the  parts  will  be- 
come sufficiently  united  to  dispense  vvith  the  bandage,  but  the  patient 
may  prudently  wear  a  handkerchief,  in  order  to  prevent  his  opening  his 
mouth  too  far  or  using  the  teeth  too  violently. 

Complicated  fractures  of  the  javv  are  sometimes  ver}'  hard  to  deal  with. 
If  sound  teeth  remain  on  both  sides  of  the  line  of  fracture  a  piece  of  wire 
may  be  passed  round  them  tight  enough  to  draw  the  fragments  together, 
and  this  is  often  a  useful  way  of  fixing  a  comminuted  piece;  but  the  wire 
should  only  be  left  for  a  few  days,  for  it  has  a  great  tendency  to  cut  into 
and  injure  the  teeth.  Mr.  H.  O.  Thomas,  of  Liverpool,  has  dwelt  strongly 
on  the  advantages,  in  cases  of  compound  and  much-displaced  fractures, 
of  wiring  the  fragments  together,  for  which  purpose  he  either  drills  a  hole 
through  the  fragments  and  passes  an  annealed  silver  wire  g^  of  an  inch 
in  diameter  through  both  of  them,  or  passes  the  wire  over  or  through  any 
teeth  which  may  be  left  firm  enough  to  bear  the  strain.  The  wire  is  then 
so  twisted  at  either  end  as  to  allow  of  its  being  tightened  (which  will  be- 
come ne(;essary  in  a  few  days,  from  the  subsidence  of  effusion  between 
the  fragments),  and  also  of  eas}'  removal.  The  advantages  claimed  for 
this  method  are  greater  nicety  of  adaptation  and  more  comfort  to  the  pa- 
tient, who  is  able  to  masticate  easily."    In  the  case  of  non-union  of  frac- 

1  An  oval  piece  of  pasteboard  is  taken  of  appropriate  size,  and  a  cut  is  made  on 
either  side  in  the  long  axis  of  the  oval,  leavins:  a  part  in  the  centre  undivided.  The 
pasteboard  is  softened,  and  this  central  part  is  moulded  on  to  the  chin,  while  the  di- 
vided ends  overlap  each  other  and  hold  the  splint  in  place. 

2  For  further  details  I  must  refer  to  the  original  paper  in  the  Lancet  for  1867,  or 
to  a  tract  entitled  Cases  in  Surgery  illustrative  of  a  new  method  of  applying  the  wire 
ligature  in  compound  fractures  of  the  lower  jaw.    2d  ed.     Liverpool,  1875. 


200  IXJURIES    OF    THE     FACE. 

tures  I  have  already'  spoken  of  the  benefit  which  is  often  derived  from 
pegging  or  drilling  the  fragments  together  (page  151). 

In  eases  where  there  is  mncli  comminution  tliese  simpler  plans  will  not 
succeed,  and  there  is  much  danger  either  that  the  fracture  will  not  unite 
at  all  or  that  great  deformity  will  result.  In  such  cases  a  mouhl  must  be 
constructed  in  vulcanite,  or  better  in  thin  metal,  silver  or  gold.  Such 
moulds  are  made  on  one  of  two  principles,  i.  e.,  they  either  use  the  teeth 
of  the  upper  jaw  as  a  base  on  which  the  mould  is  fixed  above,  while  its 
lower  part  carries  cavities  for  the  reception  of  the  teeth  of  the  lower  jaw, 
and  they  are  confined  in  those  cavities  by  a  splint  and  bandage  exter- 
nally, the  mould  itself  being  attached  to  the  splint  by  an  arm  at  either 
corner  of  the  mouth,  or  else  the  support  of  the  upper  jaw  is  dispensed 
with— a  frame  is  moulded  to  the  chin  ;  an  arm  projects  from  this  frame 
on  either  side  and  carries  a  mould,  in  which  the  teeth  are  received.  In 
the  former  plan  (the  interdental  splint,  as  it  is  called)  it  may  even  be 
possible  to  dispense  with  any  external  support,  and  to  confine  the  appa- 
ratus entirely  within  the  mouth.  The  convenience  of  these  apparatus 
which  are  moulded  on  to  the  teeth  is,  that  the}'  do  not  prevent  the  patient 
from  opening  his  mouth,  and  therefore  they  cause  no  impediment  to 
speaking  or  mastication,  for  the  portions  which  fit  on  to  the  lower  and 
upper  teeth  are  hinged  together  inside  the  month.  But  the}'  require  more 
skill  in  modelling  than  a  surgeon  usually  possesses,  so  that  the  services 
of  a  skilled  dentist  have  to  be  called  in,  and  great  care  must  be  taken  to 
reduce  the  fracture  completely  under  chloroform  before  the  mould  is 
taken.  If  the  bone  is  much  comminuted  it  may  be  necessar}-  to  wire,  or 
peg,  some  of  the  fragments  together  inside  the  mould.  The  treatment 
of  these  complicated  cases  must  extend  over  a  much  longer  period  than 
that  of  simple  fracture,  especially  when  some  of  the  fragments  become 
necrosed.  In  the  celebrated  case  of  Mr.  Seward,  the  American  states- 
man, who  suffered  from  a  fracture  of  the  lower  jaw  complicated  b}^  a  sub- 
sequent gunshot  wound  of  the  same  part,  the  interdental  splint  was  worn 
for  more  than  a  year.  The  reader  will  find  all  the  details,  which  space 
forbids  me  from  inserting  here,  carefull}'  and  clearly  described  in  a  paper 
by  Mr.  Bei'keley  Hill,  in  the  B^nf.  Med.  Jonrn.^  for  Februar}'  and  March, 
1867,  and  in  Mr.  Heath's  work  already  referred  to. 

DiHlocalion  of  the  Jaiv  is  an  injury  which  is  not  very  common,  but  which 
gives  rise  to  striking  symptoms,  and  which,  when  it  has  once  occurred, 
is  liable  to  recur  from  very  slight  causes.  It  is  generally  caused  by  a 
blow  or  fall  on  the  chin  with  the  mouth  wide  open,  whereby  the  condyle 
of  the  jaw  is  driven  forward;  but  when  the  jaw  has  once  been  dislocated 
the  displacement  is  easily  reproduced  in  extreme  yawning,  and  the  acci- 
dent also  often  occurs  for  the  first  time  during  yawning  or  in  convulsions. 
The  symptoms  are  very  characteristic.  If  botli  joints  be  dislocated,  as  is 
most  usually  the  case,'  the  mouth  is  widely  ojjcu,  and  cannot  be  closed  ; 
the  ciiin  is  advanced  ;  the  saliva  dribbles,  partly  as  a  consequence  of  in- 
creased secretion  from  ii-ritation  of  the  ])arotid  gland,  partly  from  defi- 
cient power  of  deglutition ;  the  speech  is  almost  unintelligible;  there  is  a 
hollow  just  in  front  of  the  ear  vvhere  the  joint  should  be,  and  a  promi- 
nence near  the  malar  protuberance  caused  l»y  the  displaced  coronoid  pro- 
cess, over  which  the  fil^res  of  the  temporal  muscle  are  stretched.  If  the 
dislocation  is  unilateral  the  chin  is  generally  much  twisted  to  the  oppo- 


1  Mr.  Bryant  6ay.s  two  out  of  every  three  cases  lire  bilateriil  ;  while  Nolaton  believes 
that  the  frequency  of  bilateral  is  only  u  little  greater  than  tliat  of  unilateral  disloca- 
tion. 


DISLOCATION    OF    THE    JAW. 


201 


site  side,  as  in  the  annexed  drawing ;  thongh  this,  as  Mr.  He_y  states,  is 
not  always  the  case;  but  he  points  out  as  an  infallible  sign  of  the  dislo- 
cation the  hollow  which  is  to  be  felt  behind  the  dislocated  condyle.  Prof. 
Smith,  in  quoting  these  observations  of  Mr.  Hey,  says  that  he  has  seen, 
in  a  dislocation  of  the  right  condyle,  the  efforts  at  reduction  applied  to 
the  left.     I  conclude,  iiow- 

ever,  that   Mr.    Hey's    re-  fig.  62. 

marks  must  apply  to  old 
dislocations;  for  if  the  dis- 
location lie  left  unreduced 
(which  strangely  enough  is 
sometimes  the  case)  the 
patient  recovers  the  power 
of  closing  the  mouth  and 
retaining  the  saliva,  and  to 
a  great  extent  tliat  of  pei'- 
fect  articulation  (see  the 
figure  in  Smith,  oj).  cit.^  p. 
289). 

Reduction  is  generally 
very  easy,  and  has  been 
efl[ected  even  as  late  as 
four  months  after  the  in- 
jury. The  surgeon  grasps 
the  chin  and  jaw  in  l)oth 
hands,  the  thumbs  resting 
inside  the  mouth  on  the 
angle  between  the  body 
and  ramus  behind  the  last 
molar  teeth,  while  the  fin- 
gers embrace  the  chin.  The 
thumbs  are  of  course  pro- 
tected with  a  cloth,  or  they 

would  be  severely  bitten  as  the  jaw  returns  to  its  place.  The  perpendic- 
ular ramus  is  thus  forced  down,  whereby  the  condyle  is  disengaged  from 
its  unnatural  position,  while  the  chin  is  pushed  back  and  raised;  and 
when  the  condyle  is  thus  disengaged  the  tense  fibres  of  the  temporal  and 
masseter  muscles  will  contract  and  replace  the  jaw  with  a  snap.  The 
process  in  unilateral  dislocation  is  similar,  the  main  point  being  to  dis- 
engage the  condyle,  and  then  to  assist  the  reduction  by  pressing  the  chin 
in  the  reverse  direction  to  that  in  which  it  has  been  thrown  b}'  the  violence. 
Some  surgeons,  not  caring  to  trust  their  thumbs  inside  the  mouth,  de- 
press the  angle  of  the  jaw  by  pressing  on  the  hinder  part  of  its  ramus 
with  two  pieces  of  stick,  or  some  other  kind  of  lever,  held  by  an  assistant, 
and  having  its  fulcrum  against  the  upper  teeth,  while  the  surgeon  raises 
the  chin  with  his  hands.  Sir  A.  Cooper  directs  that  the  posterior 
teeth  should  l)e  separated  from  each  other  by  corks,  while  the  chin  is 
raised  by  the  hands.  In  a  case  of  four  months'  standing  Mr.  Pollock 
effected  reduction  by  separating  the  jaws  with  wedges  inserted  between 
the  molar  teeth,  while  he  drew  the  chin  upwards  by  means  of  the  strap 
of  a  tourniquet  applied  round  the  head  and  beneath  the  jaw,  so  that  the 
screw  might  exert  its  power  upon  the  dislocated  bone. 

Two  views  have  prevailed  as  to  the  mechanism  of  this  dislocation,  and 
therefore  as  to  the  obstacles  to  its  reduction  ;  and  I  have  thought  it 
better  to  preface  what  I  have  to  say  on  this  point  by  describing  the 


Unilateral  dislocation  of  the  lower  jaw. — From  R.  W.  Smith. 


202 


INJUEIES    OF    THE    FACE. 


method  of  reduction,  since  the  latter  has  considerable  bearing  on  the  ques- 
tion of  tlie  pathology  of  the  injury.  Nelaton,  who  has  given  great  atten- 
tion to  this  subject,  and  wliose  description  of  tlie  injury  is  well  worthy 
of  careful  study,'  remarks  on  the  rarity  of  the  dislocation,  and  on  the 
fact  that  there  is  very  little  to  separate  the  displacement  of  luxation  from 
the  ordinary  and  natural  displacement  of  the  condyle  forwards  which 
occurs  in  all  cases  of  extreme  separation  of  the  jaws,  and  which  requires 
no  reduction,  since  the  bone  returns  spontaneously  into  its  place.  He 
also  shows  that  the  ligaments  are  so  lax  (in  order  to  allow  of  these  nat- 
ural displacements)  as  to  oppose  no  obstacle  to  reduction  ;  and  the  pro- 
jection of  bone  (eminentia  articularis)  in  front  of  the  glenoid  cavity  is 
also  too  slight  to  have  much  influence  in  that  direction.  But  he  says  if 
the  anterior  part  of  the  capsule  be  cut  through  on  the  dead  subject,  and 
the  condyle  of  the  jaw  be  forced  through  it  far  enough  to  bring  the  tip  of 
the  coronoid  process  in  front  of  the  malar  prominence,  then  it  will  be 
found  that  if  the  coronoid  process  is  long  enough  its  summit  will  abut 
against  the  z3'goma,  and  this  will  prevent  any  reduction  until  it  has  been 
forced  back  again.  This  view  is  supported  by  the  preparation  here  re- 
produced from  Malgaigne,  b}-  looking  at  which  the  I'cader  will  see  at 
once  that  the  displaced  coronoid  process  will  effectually  prevent  reduc- 
tion ;  but  that  by  pi'essing  on  the  angle  of  the  jaw  from  within  the  mouth 

the  surgeon  might  easily  send  it 
Yia.  G3.  back  again,  and  so  far  disengage 

it  that  the  fibres  of  the  temporal 
muscle  (which  in  the  drawing 
are  seen  bent  or  twisted  over  the 
tip  of  the  process)  would  become 
straight  again,  and  with  the 
masseter  would  easily  restore 
the  bone  to  its  place  as  the  chin 
was  lifted. 

But,  on  the  other  hand,  Mai- 
sonneuve  and  Otto  Weber  have 
experimented  upon  the  dead 
body,  and  deny  that  any  such 
locking  of  the  coronoid  process 
against  the  zygomatic  arch  ex- 
ists, at  least  in  all  cases.  They 
would,  therefore,  attribute  the 
mechanism  of  the  dislocation  to 
the  tension  of  the  muscles.  In 
Nelaton's  view,  then,  dislocation 
can  only  occur  when  the  coro- 
noid process  is  so  long  as  to 
catch  against  the  zygomatic 
arch;  and  it  is  to  the  rarity  of 
this  peculiarity  of  the  coronoid 
process  that  Ndlaton  attributes 
the  rarity  of  the  injury;  while 
in  the  other  view  the  dislocation 
is  caused  by  the  muscles  drawing 
the  displaced  condyle  through 
the  lacerated  capsule,  and  fixing 


Dislocation  of  the  lower  jaw.— From  MalgaiKHf.  In 
this  casn  tlu' jaw  had  hccii  often  di.slocated.  The  liga- 
ments are  entire.  The  condyles  do  not  appear  to  have 
been  thrown  further  forward  than  in  ordinary  gnaw- 
ing; but  the  coronoid  processes,  which  are  very  much 
pushed  upwards,  and  remarkably  nearer  the  condyles 
than  in  the  ordinary  bone,  ride  up  groaily  over  Ihc 
uiular  bone,  so  as  to  lie  external  to  the  malar  promi- 
nence. The  patient  was  under  Nfilaton's  care. — Rev. 
Med.-Chir.,  vol.  vi,  p.  286. 


»  Path.  Chir.,  vol.  ii,  p.  306. 


INJURIES    OF    THE    NECK.  203 

it  there  by  their  contraction;'  and  in  snpi)ort  of  tliis  view  the  fact  is 
mentioned  that  Roser  was  unable  to  reduce  a  dislocation  of  eight  weeks' 
standing,  even  after  cutting  through  both  coronoid  processes  from  within 
the  mouth.  I  must  refer  tlie  reader  who  wishes  to  follow  the  subject  more 
minutely' to  Mr.  Heath's  work. 

Subluxation. — In  the  ordinary  dislocation  the  interarticular  cartilage 
remains  attached  to  the  condyle ;  but  there  is  a  condition  descril)ed  by 
Sir  A.  Cooper  as  subluxation,  in  which  he  says  "  the  jaw  appears  to  quit 
the  interarticular  cartilage,  slipping  before  its  edge,  aud  locking  the  jaw 
with  the  mouth  slightly  opened."  He  also  points  out  that  this  usually 
subsides  of  itself,  but  says  that  he  has  seen  it  persist  for  a  length  of  time, 
and  the  motion  of  the  jaw  and  the  power  of  closing  the  mouth  have  still 
returned.  If  necessary,  it  may  generally  be  easily  reduced  by  drawing 
the  jaw  directly  downwards  and  then  manipulating  it  into  place. 

Somewhat  allied  to  this  is  the  siiapping  which  Sir  A.  Cooper  describes 
as  felt  in  the  joint,  accompanied  with  some  amount  of  pain,  in  young 
women  aud  others  of  relaxed  fibre,  and  which  will  subside  spontaneously 
if  the  parts  acquire  more  strength.  ''  Hamilton  says  that  he  frequently 
suffered  from  the  atfection  when  a  youth,  but  as  he  became  older  the  an- 
noyance ceased  without  any  special  treatment."  Sir  Astley  prescribes 
ammonia  and  steel,  shower-baths,  and  a  blister. 


CHAPTER   X. 

INJURIES  OF  THE  NECK. 

Sprains,  contusions,  and  superficial  wounds  of  the  neck  i)resent  no 
features  which  render  them  worthy  of  special  description  ;  but  the  wounds 
which  lay  open  the  deeper  structures,  such  as  the  windpipe,  the  pharynx 
and  oesophagus,  or  the  great  vessels,  must  be  studied  separately;  and  as 
these  wounds  are  most  commonly  suicidal,  it  is  better  to  descril)e  the 
usual  features  and  the  proper  treatment  of  cut  throat.  The  same  prin- 
ciples are  easily  ai^plied  to  the  somewhat  rare  cases  in  which  injuries 
occur  accidentally.  One  point  which  may  be  noticed  in  stab-wounds  of 
the  upper  part  of  the  neck  with  arterial  bleeding  is  the  impossibility  in 
many  cases  of  distinguishing  the  exact  source  of  hfBuiorrhage,  so  nu- 
merous are  the  great  vessels  in  tliat  neighborhood.  In  such  cases  it  is 
justifiable  to  tie  the  common  carotid,  and  the  operation  has  often  proved 
successful. 

The  wound  in  cut  throat  is  more  commonly  situated  in  the  laryngeal 
than  the  tracheal  region.  This  is  accounted  for  partly  by  the  greater 
prominence  of  that  region,  and  partly  by  the  easier  accessibility  of  the 

1  That  is  to  say,  the  externul  pterygoid  muscles  would  draw  the  condyle  directly 
forward,  while  the  masseter,  temporal,  and  internal  pterygoid  would  fix  the  bone 
against  the  base  of  the  skull. 


204  TNJURIKS    OF    THE    NECK. 

air-tiilie  there;  for  suicides  very  often  think  tliat  a  wound  of  the  windpipe 
is  necessary  fatal,  and  that  therefore  tliey  can  better  accomplish  their 
purpose  by  cutting  through  or  near  the  thyroid  cartilage.  For  the  same 
reason  the  carotid  artery  usually  escapes  injury,  since  it  becomes  relatively 
deeper  at  that  part;  at  least,  though  not  really  fiTrther  from  the  surface, 
it  is  farther  from  the  middle  line  as  it  ascends  from  the  level  of  the  cricoid 
cartilage;  and  as  the  cut  is  begun  not  very  far  on  the  left  side  of  the 
middle  line,  it  usually  fails  to  hit  the  left  carotid,  while  the  force  becomes 
exhausted  and  the  cut  ceases  before  the  right  carotid  is  reached.  Still, 
I  have  seen  a  case  in  which  both  the  common  carotids  and  both  jugular 
veins  were  divided.  Wounds  in  which  the  carotid  artery  even  of  one 
side  is  at  all  freely  opened  generally  i)rove  fatal  before  medical  aid  is 
summoned.  Otherwise,  the  first  thing,  of  course,  is  to  stop  all  arterial 
bleeding,  and  it  is  not  often  difficult  to  secure  the  wounded  vessel,  for 
the  parts  have  jjrobably  been  freely  divided  and  will  gape  widely.  But 
the  lingual  artery  is  more  commonly  wounded  than  any  other,  or  the 
superior  thyroid  may  be  divided;  or  the  facial.  Having  secured  the 
arteries,  the  surgeon  must  attend  to  the  veins.  They  can  generally  be 
commanded  by  pressure  with  a  graduated  compress,  but  I  see  no  danger 
in  tying  them  ;  and  as  this  makes  them  almost  absolutely  secure  from 
an}'  irregular  impulse  on  the  patient's  part,  it  seems  far  better  to  include 
any  considerable  vein  which  may  be  bleeding  freely  in  a  ligature  of  car- 
boiized  catgut,  or  silk,  with  the  ends  cut  short.  The  condition  of  the 
air-tube  next  demands  attention.  If  it  has  entirely  escaped,  the  injury 
(apart  from  the  general  condition  of  the  patient)  can  hardly  be  regarded 
as  serious;  but  generally  it  is  perforated  more  or  less  extensively,  as  will 
be  evident  by  the  whistling  of  the  air  in  the  wound.  If  this  perforation 
is  simple,  and  especially  if  it  involves  only  soft  parts,  the  knife  having 
passed  between  the  cartilages,  it  will  rapidly  close.  But  often  the  weapon 
used  has  been  blunt,  the  force  considerable,  and  the  attempt  repeated 
more  than  once ;  hence  the  cartilages  are  often  hacked  and  fractured  as 
well  as  cut.  Loose  portions  hang  down,  partially  obstructing  respiration 
even  at  first,  and  any  such  obstruction  will  increase  as  the  tissues  around 
the  loose  pieces  swell  with  oedema  or  inflammation.  This  displacement 
of  portions  is  especially  liable  to  take  place  when  the  wound  has  gone 
backwards  far  enough  to  injure  the  epiglottis,  or  when  the  arytenoid 
cartilages  have  been  cut  into.  When  the  epiglottis  is  trenched  upon, 
the  wound  often  also  lays  open  the  mouth,  and  a  piece  of  the  tongue  or 
of  the  floor  of  the  mouth  may  fall  back  over  the  air-tube.  Finally,  the 
-wound  may  pass  through  the  back  of  the  air-tube  into  the  pharynx,  or, 
more  commonly,  into  the  cBsophagus ;  and  the  latter  may  even  be  com- 
pleteh'  severed  without  any  large  bloodvessel  having  been  wounded. 

The  treatment  of  the  simpler  wounds  where  the  windpipe  is  not  injured 
is  merely  that  of  similar  wounds  in  any  other  part.  They  may  be  brought 
together  with  sutures  or  strapping,  the  patient's  head  being  drawn  down 
towards  his  chest  and  fixed  tliere.  For  this  purpose  a  bandage  is  passed 
round  the  head,  and  is  attached,  by  means  of  two  lateral  strips,  to  another 
bandage  going  round  the  chest.  In  the  first  dressing  of  cases  presenting 
unusual  complications  ana'sthesia  may  be  useful. 

In  cases  where  the  windpipe  is  opened  it  is  better  to  avoid  sutures;  at 
least,  there  is  a  traditional  horror  of  them,  and  they  are  said  to  lead  to 
erysipelas,  and  to  produc^e  a  tendency  to  emphysema,  and  so  to  obstruc- 
tion of  the  discharges  from  the  wound  and  even  of  the  lireathing.  How 
fiir  all  this  is  true  I  cannot  say.  Sutures  are  in  ordinary  cases  unneces- 
sary, for  the  edges  of  the  wound  can  be  kept  tolerably  in  apposition 


CUT    THROAT.  205 

without  them  ;  and  as  primary  union  can  liardly  be  anticipated,  tliere  is 
no  motive  for  sewing  tlie  edges  together.  They  are  tlierelbre  rarely  used 
in  sncli  cases,  and  we  have  little  experience  of  their  alleged  ill  conse- 
quences. But  in  complicated  cases,  where  fragments  of  cartilage  or 
portions  of  the  tongue  or  month  cannot  otherwise  be  kept  out  of  the  air- 
passages,  sutures  must  be  employed  to  support  them,  and  I  cannot  sa}^ 
that  they  seem  really  to  do  much  harm. 

There  are  cases  in  which  the  obstruction  to  respiration  from  such 
detached  portions  is  so  great  that  it  is  better  to  insert  a  canula  into  the 
lower  portion  of  the  windpipe  through  the  wound,  or  to  perform  trache- 
otomy, after  which  the  displaced  portions  can  be  lietter  manipulated  into 
position  and  kept  in  place. 

In  wounds  of  the  gullet  the  chief  anxiety  of  the  surgeon  is  to  get  the 
patient  to  take  sufficient  nourishment,  and  yet  not  to  interfere  with  the 
closure  of  the  opening.  I  must  remind  the  reader  that  the  mere  fact  of 
the  escape  of  fluid  nourishment  by  the  wound  does  not  at  all  prove  that 
the  gullet  is  opened.  The  opening  may  be  in  the  mouth,  or  there  may 
even  be  no  wound  at  all  except  that  in  the  larynx.  We  see  the  same 
thing  constantly  after  laryngotomy.  The  folds  which  connect  the  larynx 
to  the  mouth  get  inflamed,  the  larynx  is  no  longer  I'aised  under  cover  of 
the  hj^oid  bone,  and  drink  runs  into  it  and  escapes  by  the  wound.  It  is 
a  distressing  but  not  a  very  dangerous  complication,  and  may  be  expected 
to  disappear  in  a  few  days.  Meanwhile,  if  the  patient  is  thereby  hindered 
from  taking  nourishment  which  is  necessary  for  his  life,  he  must  be  fed 
by  the  stomach-pump.  If  the  oesophagus  is  wounded,  and  the  wound  is 
fairly  within  reach,  it  would  be  better,  I  think,  to  bring  its  edges  into 
apposition  with  one  or  two  carbolized  gut  sutures  before  dressing  the 
rest  of  the  wound,  for  the  sutures  require  no  removal,  and  will  hold  the 
parts  together  and  allow  of  their  speedy  union  ;  but  I  have  not  had  an 
opportunity  of  trying  this  since  the  introduction  of  this  form  of  suture. 
Any  other  is  inapplicable  ;  the  silk  from  the  ulceration  which  they  cause, 
and  the  silver  from  their  tendency  to  irritate  the  parts  around  by  their 
ends.  Then  the  patient  must  be  treated  as  after  oesopliagotomy,  i.  e.,  the 
wound  must  be  disturbed  as  little  as  possible,  yet  the  patient  must  be  fed. 
It  is  even  more  necessarj'  after  suicidal  than  after  operative  wounds  of 
the  oesophagus  that  the  patient  should  be  well  supported  ;  and  hence  it 
is  usually  more  advisable  even  from  the  first  to  pass  a  small  tube  or 
catheter  be^'ond  the  wound  (taking  great  care  to  keep  it  against  the 
spine,  so  as  not  to  touch  the  wound  if  it  can  possibly  be  helped),  and 
thus  to  fill  the  stomach  moderatel}^  and  slowly  with  concentrated  nutri- 
ment twice  a  day.  Great  care  must  be  taken  not  to  pass  the  tube  through 
the  wound,  and  especially  to  avoid  the  air-passages.' 

In  themselves  all  wounds  of  the  throat  which  are  not  immediately  fatal 
may  be  expected  to  do  better,  cseieris  paribus^  than  those  in  any  other 
region  of  the  body,  except  perhaps  the  face.  It  is  true  that  dittuse  infiam- 
mation  when  it  attacks  tlie  cellular  tissue  of  the  neck  is  peculiarly  fatal, 
but  it  is  a  rare  complication  of  these  wounds  in  healthy  subjects.  The 
experience  of  Larry,  Langenbeck,  Dietfenbach,  and  others  in  the  extirpa- 
tion of  large  tumors  from  the  neck,  proves  that  if  the  immediate  dan- 
gers of  these  formidable  operations  are  avoided  the  cases  do  perhaps 


'  One  of  our  museums  contains,  I  believe,  a  preparation  showing  the  bronchial 
tubes  of  the  lungs  filled  with  plaster  of  Paris  injected  through  a  stomach-pump  tube, 
which  it  was  intended  to  pass  into  the  stomach  in  a  case  of  poisoning.  Such  an 
accident  might  much  more  readily  occur  in  cut  throat. 


206  INJURIES    OF    THE    NECK. 

belter  than  any  others  in  surgery.'  IJiit  the  state  of  both  mind  and 
body  of  the  unhappy  victims  of  cut  throat  is  far  from  healthy.  Many 
have  a  desire  for  death,  wiiich  seems  often  to  lead  to  its  own  fulfilment; 
others  are  broken  down  in  constitution  by  years  of  intemperance;  in 
others  delirium  tremens  supervenes,  or  the  wound  has  been  inflicted 
during  an  access  of  delirium  ;  and  some  are  obstinately  bent  on  destroy- 
ing themselves,  and  unless  closely  watched  will  commit  some  renewed 
attemi)t  on  their  lives  or  tear  open  the  healing  wound.  Much  care,  there- 
fore, is  required  in  these  cases;  careful  nursing,  the  judicious  use  of 
opium  or  other  sedatives,  and  a  liberal  suppl3'of  nutriment  in  small  quan- 
tities and  at  rejjcated  intervals. 

After-com}jhcations. — If  the  patient  has  escaped  the  first  dangers  of  the 
wound  he  may  yet  be  troubled  by  its  remoter  consequences.  Of  these 
the  commonest  is  fistula,  either  communicating  with  the  o?sophagus  or 
trachea,  or  sometimes  leading  from  the  one  into  the  other.  Tracheal 
fistula  may  often  be  closed  by  a  plastic  operation,  but  the  fistula^  which 
communicate  with  the  cesophagus  are  permanent,  and  if  they  are  so  free 
as  to  prevent  the  patient  from  taking  food  at  all,  the  only  thing  that  can 
be  done  is  to  feed  him  with  the  stomach-pump.  He  can  generally  learn 
to  pass  this  for  himself,  and  indeed  often  more  dexterously  than  the  sur- 
geon can  pass  it  for  him  ;  and  I  have  seen  life  thus  supported  and  the 
patient  keep  his  strength  and  flesh  apparently  undiminished  for  nearly  a 
year,  after  which  he  passed  out  of  observation.  In  this  case  the  oesopha- 
gus had  been  so  freely  opened  that  nothing  could  be  swallowed. 

Another  distressing  complication  is  the  loss  of  voice,  and  sometimes 
the  growing  d^^spncea  which  follows  on  the  cicatrization  of  the  wound  in 
the  air-passage.  This  arises  from  various  causes:  either  from  narrowing 
of  the  tube  in  consequence  of  the  cicatrization  which  follows  free  (possi- 
bly complete)  division  of  its  walls,  or  from  irregular  union  of  wounds 
implicating  the  vocal  cords,  or  from  permanent  displacement  of  detached 
portions,  or  from  granulations  springing  into  and  obstructing  the  glottis. 
The  occurrence  of  these  irregularities  in  union  furnishes  a  strong  motive 
for  uniting  the  wound  in  the  larynx  or  trachea  accurately  with  sutures  at 
once,  whenever  this  is  practicable,  and  especially  when  the  trachea  is  en- 
tirely divided.  Tlie  treatment  of  granulations  obstructing  the  glottis  will 
more  fitly  be  considered  in  discussing  the  general  subject  of  Tracheotomy. 
Of  course  when  it  is  necessary  to  relieve  dyspnoea  in  any  of  these  condi- 
tions tile  windi)ipe  must  be  opened  below,  as  a  preliminary'^  step  in  the 
treatment  of  the  cause  of  obstruction. 

Other  conij^lications,  such  as  abscess  extending  down  the  neck,'  inflam- 
mation running  along  the  trachea  to  the  lungs,  or  inflammatory  oedema 
making  pressure  on  the  neighboring  parts,  must  be  treated  on  general 
principles. 

Contusions  of  the  larynx  without  fracture  are  generally  produced  in 
attempts  at  strangulation  or  throttling.  They  cause  temporary  pain  and 
loss  of  voice,  but  rarely  lead  to  any  further  ill  consequences,  and  require 
only  rest  and  soothing  applications. 

iJislocalion  of  the  hi/oid  bone  from  tlie  thyroid  cartilage,  or  more  prop- 
erly speaking,  displacement  of  the  former  point  of  bone  with  respect  to 

'  See  Syst.  of  Surg.,  2d  ed.,  vol.  v,  p  984. 

'^  Such  abi^cesses  sometimes  pass  down  to  the  pleura,  and  from  the  external  surface 
of  that  membrane  the  inflammation  is  projtagated  to  its  cavity. 


FRACTURE    OF    THE    LARYNX.  207 

the  latter,  is  spoken  of  by  Gibb,  in  Path.  T7'ans.,  vol.  x,  p.  67.  He  de- 
scribes the  displacement  as  being  caused  either  by  violence  or  disease, 
though  tlie  instances  which  he  adduces  appear  to  have  been  all  sponta- 
neous, and  due  to  relaxation  of  the  ligament  which  naturally  unites  the 
parts,  and  which  in  the  instance  dissected  and  exhibited  to  the  Society 
was  replaced  by  a  pouch  or  capsule  of  new  formation.  The  symptoms 
are  a  "click"  in  the  neck,  the  sensation  of  something  sticking  in  the 
throat,  and  the  appearances  of  displacement  on  examination,  which,  how- 
ever, are  not  clearly  described.  The  displacement  is  to  be  reduced  by 
throwing  the  head  backwards  and  towards  the  side  opposite  to  that  dis- 
placed, thus  relaxing  the  lower  jaw,  and  if  necessary  manipulating  the 
displaced  bone  into  position. 

Fracture  of  the  Hyoid  Bone. — Tlie  hyoid  bone  and  the  cartilages  of 
the  larynx  are  occasionally  though  rarely  fractured  b}^  direct  violence, 
such  as  grasping  the  person  by  the  throat,  attempts  at  strangulation, 
blows  and  falls  on  projecting  objects.  The  hyoid  bone  is  said  to  be  often 
fractured  injudicial  hanging.  Fracture  of  this  bone  produces  great  dis- 
tress when  the  fragments  are  driven  inwards,  and  especially  if  the  mucous 
membrane  is  lacerated.  All  movements  of  the  tongue,  all  attempts  to 
swallow  or  speak,  are  attended  with  much  pain  and  difficulty.  The  injury 
is  easy  to  diagnose  by  the  separation  and  mobilit}-  of  the  fragments,  and 
crepitus  may  be  obtained  when  they  have  been  restored  to  position,  which 
is  generally  quite  easy.  If  there  should  be  any  difficulty  an  anaesthetic 
should  be  administered,  the  mouth  full}'  opened  and  ke|)t  so  by  means  of 
a  o^ao-,  while  the  fragments  are  disengaged  by  one  finger  in  the  mouth  and 
•another  externally.  After  reduction  the  parts  are  to  be  kept  perfectly 
quiet.  The  patient's  instinct  will  prevent  him  from  talking  or  other 
voluntary  movements  so  long  as  they  are  i)ainful,  and  he  must  be  fed 
with  sops,  conveyed  well  into  the  back  of  the  mouth.  In  about  a  fort- 
night the  parts  will  be  so  far  consolidated  that  much  of  the  inconvenience 
will  have  passed  by,  and  the  accident  is  not  likely  to  lead  to  serious  con- 
sequences. 

Fractureti  of  the  laryngeal  cartilages  or  of  the  trachea  are  of  more  se- 
rious import  than  those  of  the  hyoid  bone,  and  when  the  fragments  are 
displaced  so  far  as  to  penetrate  the  lining  membrane  of  the  air-passages 
active  and  immediate  treatment  is  necessary.  The  injury  most  frequently 
affects  the  thyroid,  and  next  the  cricoid  cartilage.  Pain  and  dyspnoea 
follow  the  fracture;  and  if  the  mucous  membrane  is  lacerated  there  is 
blood-spitting,  constant  cough,  and  frequently  difficulty  of  breathing, 
which  may  rapidly  increase  and  end  in  absolute  suffocation.  Of  course 
the  nearer  the  injury  is  to  the  vocal  cords,  so  much  the  more  acute  will 
be  the  symptoms,  and  so  much  the  more  decisive  must  be  the  treatment. 
The  diagnosis  is  generally  obvious.'  Whether  absolute  crepitus  will  be 
distinguished  depends  in  a  great  measure  on  the  patient's  age  and  the 
consequent  extent  of  calcification  in  the  cartilage. 

The  chief  point  in  the  treatment  is,  as  to  the  necessity  or  advisability 
of  tracheotomy.  An  interesting  collection  of  these  cases  was  made  some 
time  since  by  Dr.  Hunt,'^  from  which  it  results  that  when  the  fragments 


1  Mr.  Le  Gros  Clark  gives  a  useful  caution  in  the  diagnosis  of  these  injuries  :  tliat, 
"in  moving  the  larynx  from  side  to  side  on  the  cervical  spine,  or  in  deglutition,  the 
manipulato'r  may  be  deceived,  especially  when  the  larynx  is  largo,  and,  in  elderly 
persons,  by  the  peculiar  feeling  of  roughness  and  inequality  which  is  thus  elicited." 

2  Out  of  twenty-seven  cases  ten  recovered,  six  with  and  four  without  operation. 
Only  two  patients  died  in  whom  tracheotomy  was  performed,  while  out  of  nineteen 


208 


INJURIES    OF    THE    NECK. 


are  displaced  and  the  mucous  membrane  lacerated  it  is  always  desirable 
to  perform  tracheotomy  at  once,  since  in  all  cases  it  becomes  ultimately 
necessary;  and  by  having  an  opening  made  at  once  below  the  seat  of  in- 
jury the  "patient  is  saved  from  the  risk  of  sudden   dyspnoea  produced  by 


Fjg.  Hi. 


A,  front,  and  b,  back  view  of  a  preparation  of  extensive  fracture  of  the  thyroid  and  cricoid  cartilages, 
taken  from  the  body  of  a  person  who  was  murdered  by  her  cook.  Death  resulted,  in  all  probability, 
from  the  violence  inflicted  on  the  larynx.  The  hyoid  bone  was  also  fractured  and  comminuted,  butis 
not  shown  here.— From  a  preparation  in  the  Museum  of  St.  George's  Hospital. 

an  accidental  displacement.  When  there  is  no  evidence  of  such  perfora- 
tion the  patient  must  be  kept  perfectly  quiet,  and  the  case  must  be  watched 
with  a  view  to  tracheotomy  if  necessary. 

Complete  Rupture  of  Trachea.— Sometimes  the  injury  has  been  known 
to  involve  the  complete  subcutaneous  rupture  of  the  trachea,'  so  that  there 
is  a  large  depression  in  tlie  neck  where  the  trachea  should  be,  and  the 
patient  breathes  with  great  difficulty  by  the  indirect  passage  of  air  from 
the  upper  part  of  the  windpipe  through  the  interval,  which  must  be  partly 
occupied  with  blood,  and  so  into  tlie  retracted  lower  end  of  the  trachea. 
Under  such  circumstances  not  a  moment  should  be  lost  in  attempting  to 
find  tlie  lower  end  of  the  trachea  and  fixing  it  by  introducing  a  tube.  The 
parts  are  to  be  very  freely  divided  in  the  median  line,  and  the  trachea 
drawn  up  to  the  surface.  If  it  is  very  movable  and  retracts  easily  there 
is  no  ol)jection  that  I  can  see  to  fixing  it  temporarily  with  a  suture. 

Foreifjn  Bodies  in  the  Air-Paamges. — The  entrance  of  a  foreign  body 
into  the  air-passages  is  a  formidable  accident,  and  one  which  not  unfre- 
quently  proves  fatal.  It  may  occur  at  any  period  of  life,  but  is  more  fre- 
quent in  children,  both  from  their  natural  want  of  caution  and  experience, 
and  from  their  frequent  habit  of  playing  with  things  in  their  mouth.  The 
accident  is  caused  by  a  sudden  inlialation  while  holding  something  in 
the  mouth,  as  by  laughing  or  gasping  with  fright  while  taking  food,  by 
catching  a  coin  in  the  open  mouth,  etc. ;  and  in  some  rarer  cases  the 
foreign  body  has  been  driven  in  from  the  outside,  as  in  the  case  of  a 


who  were  not  operated  on  fifteen  died  ;  and  in  no  case  where  emphysema  and  bloody 
expectoration  testified  to  perforation  of  the  mucou.s  membrane  by  the  fragments  did 
recovery  ensue  without  tracheotomy.— Am.  Jour.  Med   Sci.,  April,  1866. 
«  See  Mr.  Halford's  case,  in  Syst.  of  Hurg.,  2d  ed.,  vol.  ii,  p.  464. 


FOREIGN    BODY    IN    WINDPIPE.  209 

child  who  was  cracking  a  whip  in  the  lash  of  which  a  large  copper  pin 
had  been  fixed.  The  pin  got  loose,  and  passed  through  the  trachea.  For- 
tunately the  surgeon  recognized  the  small  i)uncture,  and  cut  down  on  the 
foreign  body.^  And  I  think  there  can  be  no  doubt  that,  although  in 
swallowing  the  larynx  is  usually  so  drawn  up  that  no  foreign  substance 
can  pass  into  it,  yet  occasionally  a  pointed  body  (such  as  a  piece  of  bone) 
may  hitch  under  the  epiglottis  and  pass  into  the  upper  part  of  the  larynx, 
in  swallowing,  without  an  inhalation.'^ 

Another  comparatively  frequent  accident  is  the  impaction  of  a  large 
mass  of  food  in  the  pliarynx,  obstructing  the  upper  opening  of  the  larynx, 
and  causing  speedy  death  if  not  dislodged.  The  treatment  is  simple,  if 
the  nature  of  the  case  be  recognized  in  time.  The  mass  being  pushed 
down  or  hooked  up,  the  breathing  may  be  at  once  restored  ;  if  not,  artifi- 
cial respiration  is  to  be  sedulously  practiced. 

Foreign  bodies  which  have  passed  fairly  into  the  windpipe  may  be 
lodged  in  various  situations.  They  may  be  detained  above  the  rimaglot- 
tidis,  and  then  may  be  thrust  more  or  less  completely  into  the  ventricle 
of  the  larynx  ;  they  may  be  caught  between  the  vocal  cords  ;  may  stick 
in  the  cavity  of  the  larynx;  may  lie  either  fixed  or,  more  commonly, 
loose  in  the  trachea;  or  may  pass  down  beyond  the  bifurcation  of  the 
trachea  into  one  of  the  bronchi,  or  even  lower,  into  one  of  the  bronchial 
tubes  of  the  lung  itself.^ 

The  symptoms  vary  partly  with  the  size  and  shape  of  the  foreign  body, 
partly  with  its  position.  The  larger  and  rougher  the  foreign  body  is,  the 
more  acute  will  probably  be  the  symptoms;  the  nearer  it  is  lodged  to  the 
vocal  cords  the  more  spasm  is  it  likely  to  cause;  the  more  firmly  it  is 
impacted  in  one  of  the  bronchi  the  more  complete  is  the  loss  of  breathing 
on  one  side. 

In  their  most  marked  form  the  symptoms  of  a  foreign  body  in  tlie  air- 
passages  are  as  follows  :   The  patient  being  previously  in  his  usual  health, 

1  De  la  Martiniere,  Mem.  de  I'Acacl.  de  Cliir.,  v.  521. 

'■^  This  was  the  case  with  a  little  child  under  mj-  care  a  short  time  ago,  in  whom  a 
large  piece  of  the  bone  of  a  rabbit  was  lodged  in  the  upper  orifice  of  the  larj'n.x,  ex- 
citing great  dyspnoea,  and  having  set  up  extensive  tracheitis  and  bronchitis  extending 
through  both  lungs.  It  was  extracted  through  the  mouth  about  thirty-six  hours  after 
the  accident.  The  bone  was  too  large  and  too  irregular  to  have  been  easily  inhaled, 
and  the  mother  said  the  child  took  the  spoonful  of  food  quite  quietly  and  choked  im- 
mediately afterwards.  From  the  position  and  shape  of  the  bone  there  could  be  no 
doubt  that  a  large  prong  of  it  was  sticking  through  the  glottis  and  irritating  the  air- 
tube. 

3  "  Out  of  twenty-one  cases  analyzed  by  Professor  Gross,  in  which  death  took  place 
without  operation,  and  witiiout  expulsion  of  the  foreign  body,  in  four  the  foreign  sub- 
stance was  situated  in  the  larynx  ;  in  one,  partly  in  the  trachea,  partly  in  the  larynx  ; 
in  three,  in  the  trachea ;  in  eleven,  in  the  right  bronchial  tube  ;  in  one,  in  the  lung ; 
in  one,  in  the  right  pleural  cavity. 

"  Out  of  forty-two  cases  subjected  to  operation  or  general  treatment  the  extraneous 
substance  was  situated  twice  positively,  and  eleven  times  probably,  in  the  right  bron- 
chial tube  ;  four  times  certainly,  and  four  tunes  probably,  in  the  left  bronchial  tube; 
seven  times  in  the  trachea,  smd  fourteen  in  the  larynx.  Out  of  fifteen  cases  under 
observation  in  Guy's  Hospital  during  the  last  few  years,  in  .seven  the  foreign  body 
was  in  the  larynx  ;  in  five,  in  the  trachea  ;  in  two,  in  the  right  bronchus  ;  and  in  one, 
in  the  left  bronchus.  It  would  thus  appear  tiuit  the  larynx  and  the  right  bronchial 
tube  are  the  most  frequent  situations  in  which  foreign  substances  are  arrested.  This 
conclusion,  however,  does  not  precisely  coincide  with  that  derived  by  M.  Bourdillat 
from  the  analysis  of  15G  cases.  In  eighty  of  these  the  foreign  body  was  in  the  tra- 
chea; in  thirty-five  in  the  larynx;  in  twenty-six,  in  the  right  bronchus;  and  in 
fifteen,  in  the  left  bronchus." — Durham,  in  Syst.  of  Surg.,  vol.  ii,  p.  477. 

14 


210 


INJURIES    OF    THE    NECK. 


has  been  smlilenly  incized  witli  (.'onvulsive  cough  and  dyspiuva,  aggravated 
into  severe  parox^'sms.  At  the  same  time  it  is  possible  that  he,  or  if  a 
child  his  parents,  may  know  that  he  has  swallowed  something,  or  that 
something  which  was  in  his  mouth  has  disai)peared.  The  speech  will  be 
more  or  less  affected,  and  the  breathing  whistling  or  stridulous.  There 
ma^'  be  some  pain  about  the  part  where  the  body  is  lodged  (probably 
about  the  thyroid  cartilage),  aggravated  by  pressure.     The  foreign  body 


From  a  preparation  (Ser.  vii,  No.  97  a,  in  St.  George's  Hospital  Museum),  showing  a  piece  of  tobacco- 
pipe  impacted  in  the  right  bronchu.s  ola  child.  The  symptoms  were  very  obscure,  perhaps  because  the 
air  passed  throu;^!!  the  pipe  into  the  lung.  Ultimately  tracheotomy  was  performed,  but  the  foreign 
body  could  not  be  reached.  Man.  The  lungs  and  bronchi  have  been  somewhat  displaced  in  making  the 
preparation,  so  that  the  right  bronchus  looks  much  more  perpendicular  than  it  is. 


can  in  some  cases  be  felt  by  exploration  from  the  mouth,'  and  in  others 
can  l)e  seen  by  the  laryngoscope.  More  rarely  it  can  be  felt  in  the  neck. 
Diagnosis. — The  diagnosis,  in  cases  where  a  foreign  body  is  not  per- 
ceptible and  the  history  is  not  clear  (which  is  very  commonly  the  case  in 
childhood)  is  by  no  means  easy.  It  rests, mainly  on  the  sudden  accession 
of  the  symptoms  during  a  condition  of  complete  health,  and  is  therefore 
easier  the  sooner  after  the  supposed  accident  the  patient  is  seen.  In  case 
the  history  should  be  doulttful  the  diagnosis  between  the  irritation  pro- 
duced by  a  foreign  body  and  the  dyspnoea  of  croup  or  laryngitis  rests  in 
a  great  measure  upon  the  cumparative  absence  of  fever  in  the  former  case, 
tlie  patient  being  sometimes  almost  well  during  the  intervals  between  the 


'  Such  nn  oxploration  should  never  be  ne<:!;l('cted.  unless  the  .symptoms  are  so 
urgent  lis  to  render  the  instantaneous  opening  of  tlie  windpipes  a  matter  of  nece.ssity. 
Under  chloroform  the  finger  can  he  pas.-icd  into  the  upper  part  of  llu;  larynx  easily  in 
a  child,  and  usually  can  be  got  beyond  the  epiglottis  in  an  adult. 


FOREIGN     BODY    IN    WINDPIPE. 


211 


spasms.  In  some  cases,  where  the  foreign  body  moves  about  in  the 
traeliea,    tlie    patient   is    liimself 

quite  cf)nscious  of  its  movements,  fio.  or..   ^ 

When  it  lias  dropped  into  one  of 
tlie  bronchi  tlie  entrance  of  air 
into  that  lung  is  prevented,  either 
totally  or  in  great  part,  and  there- 
fore there  is  absence  of  the  re- 
spiratory murmur  and  of  the  dila- 
tation of  the  lung,  without  dul- 
ness  to  percussion  or  any  other 
sign  of  pleurisy  or  pneumonia. 
In  some  cases  a  whistling  and 
cooing  rhonchus  has  been  heard 
at  the  point  where  the  foreign 
body  is  lodged.^ 

The  right  bronchus  is  rather 
more  commonly  the  seat  of  lodg- 
ment than  the  left,  since  the  sep- 
tum is  placed  somewhat  to  the 
left,  tliough  the  more  horizontal 
direction  of  the  right  bronchus 
to  some  extent  neutralizes  this 
tendency.     (See  the  footnote  on 

Da<^'e  209.)  Bifurcation  of  the  trachea,  seen  from  behind,  show- 

'  fn  cases  where  a  nerfectlv  con-    ing  tl^e  septum  to  the  leftof  the  median  line,  and  show- 
in  Ccibes   niieie  .l  peiie<.ti_\   i^iJU      ^^^^^^^^  tl^e  ,uore  vertical  direction  of  the  left  bron- 

fident  diagnosis  cannot    be  made,    chus.— FroniDurhara,Syst.ofSurg.,2ded.,vol.  ii,p.  478. 

yet  there  seems  good  reason  for 

thinking  that  there  may  be  a  foreign  body  in  the  windpipe,  it  is  better 
to  treat  the  patient  as  though  this  were  the  case,  since  an  opening  may 
relieve  dyspnoea  from  other  causes,  and  the  operation  does  not  add  very 
much  to  the  patient's  danger.'' 

Treatment. — When  the  diagnosis  of  foreign  body  has  been  made,  the 
surgeon  should  allow  no  delay  in  removing  it  at  once.  It  is  true,  that 
substances  have  remained  for  years  in  the  trachea  innocuous ;  but  it  is 
far  more  probable  that  a  foreign  body  which  may  be  setting  up  no  very 
marked  symptoms  at  the  moment,  will  afterwards  get  displaced  and  cause 
urgent,  perhaps  fatal,  dyspnoea  when  there  is  no  help  at  hand. 

There  are  cases  in  which  the  foreign  body  can  be  seen  with  the  laryngo- 
scope and  extracted  by  means  of  forceps  introduced  by  the  mouth  ;  but 
these  are  rare.  A  case  has  lately  been  recorded^  in  which  a  brass  ring 
had  been  lodged  near  the  upper  opening  of  the  larynx  for  four  years. 
The  patient  was  a  child  ('>l  years  old,  and  was  then  sutferiug  from  aphonia 
and  laryngeal  spasms.  The  position  of  the  ring  is  thus  described:  "It 
encircled  the  left  aryteno-epiglottidean  fold  and  ventricular  band  ;  but, 
except  where  it  passed  deeply  into  the  tissues,  it  did  not  come  into  con- 
tact with  the  larynx."  It  should  be  remarked  that  the  ring  had  a  fissure 
at  one  part.  Extraction  by  the  help  of  the  lai-yngoscope  being  found 
impossible,  on  account  of  the  child's  indocility,  the  foreign  body  was  suc- 
cessfully removed  by  making  a  transverse  incision  through  the  thyro-hyoid 

'  Le  Gros  Clark,  op.  cit. ,  p.  237. 

2  Mr.  Barwell  gives  references  to  seven  cases  in  which  the  foreign  body  was  not 
found  at  the  operation,  yet  the  patients  recovered;  probably  from  the  unnoticed 
escape  of  the  substance. — Clin.  Soc.  Trans.,  vol.  vi,  p.  120. 

3  London  Med.  Kecord,  April  14,  1875. 


212  INJURIES    OF    THE    NECK. 

membrane,  drawing  the  epiglottis,  with  the  cushion  of  fat  and  cellular 
tissue  at  its  base,  downwards,  and  thus  penetrating  between  the  hyoid 
bone  and  epiglottis  into  the  space  above  the  glottis.  To  this  operation 
the  operator  gives  the  name  of  "subhyoidean  larvngotoray,"  and  it  is  a 
proceeding  wliich  in  rare  cases  may  prove  useful;  but  in  general  foreign 
bodies  lodged  in  this  situation  can  be  extracted  with  forceps  of  appropri- 
ate sliape  from  the  mouth  when  the  patient  is  full^'  narcotized. 

If  the  symptoms  are  not  very  urgent  (in  which  case  the  windpipe  must 
be  opened  without  a  moment's  delay)  chloroform  should  be  given  ;  and 
unless  the  position  of  the  foreign  body  is  known  the  first  step  is  to  ex- 
amine the  parts  as  far  as  the  finger  can  reach.  If  it  cannot  be  extracted 
from  the  mouth,  but  appears  to  be  lodged  near  the  glottis,  the  crico-thy- 
roid  membrane,  cricoid  cartilage,  and  in  children  one  or  two  rings  of  the 
trachea,  should  be  divided,  so  as  to  have  a  very  free  opening.  Possibly  the 
bod}'  may  now  be  removed  or  ma}-  shoot  out  of  the  wound  ;  otherwise 
the  larynx  must  be  examined  with  a  large  instrument,  such  as  a  female 
catheter,^  and  the  substance  pushed  up  through  the  glottis  or  extracted 
with  forceps.  If  this  cannot  he  done,  yet  the  substance  can  be  felt  lodged 
just  above  the  glottis,  a  canula  should  be  placed  in  the  lower  part  of  the 
wound,  the  two  alae  of  the  thyroid  cartilage  cautiously  divided,  and  the 
foreign  body  picked  out  of  the  ventricle  of  the  larynx.  When  the  body 
is  loose  in  tlie  trachea,  a  free  opening  low  down  will  generally  procure  its 
exit.-'  When  in  one  of  the  bronclii,  all  that  can  be  done  is  to  open  the 
trachea  as  low  down  as  is  prudent,  and  by  a  ver}^  free  incision.  Tlien,  if 
tlie  situation  of  the  foreign  body  can  be  ascertained  b}'  probing,  it  may 
be  possible  to  extract  it  with  forceps  or  to  dislodge  it  with  a  hook ;  or  the 
patient's  body  being  inverted  and  shaken,  the  foreign  substance  may  be 
discharged  either  from  the  glottis  or  from  the  wound. 

Sir  B.  Brodie's  celebrated  case^  of  Sir  I.  Brunei,  in  wliich  a  half- 
sovereign  had  dropped  into  the  right  bronchus,  shows  the  advantage  in 
these  cases  of  making  an  opening  in  the  trachea,  even  if  the  foreign  body 
is  not  extracted  from  it.  The  inversion  of  the  bod}',  which  before  produced 
great  dyspnwa  from  the  coin  striking  on  the  glottis,  became  perfectly 
tolerable  afterwards,  and  tlie  coin  dropped  quietly  into  the  mouth.  The 
same  case  shows  also  the  great  difficulty  which  may  be  met  with  in  ex- 
ploring the  trachea  with  forceps  or  other  instruments.  The  walls  of  the 
air-tube  are  so  very  irrital)le  that  any  contact  of  the  instrument  is  sure 
to  provoke  spasmodic  cough,  and  the  instrument  is  as  likely  to  poke  the 
foreign  body  further  down  as  to  bring  it  up,  besides  the  risk  of  catching 
"the  bifurcation  of  the  trachea,  or  one  of  the  subdivisions  of  the 
broncluis,  instead  of  the  foreign  body."  So  that  it  is  better,  after  liaving 
made  a  free  opening  in  the  trachea,  to  try  and  dislodge  the  foreign  body 
by  changes  of  position,  by  inversion  of  the  l)ody,  by  shaking  or  slapping 
the  chest,  ratlier  than  to  risk  tlie  evil  consequences  which  ma}'^  follow  tlie 
introduction  of  instruments  ;  and  if  such  introduction  becomes  neces- 
sary, to  try  rather  to  dis[)lace  the  body  by  getting  a  hook,  wire-snare,  or 
bent  prol)e  below  it  than  to  catch  it  with  the  forceps.  At  the  same  time, 
as  the  forceps  have  no  doubt  been  used  successfully  in  such  cases,^  the 
attempt  ought  to  be  made  when  the  circumstances  call  for  it. 

'  Mr.  DurhaiTi  rfcommends  the  ivory  top  of  a  gum  ciith(^lxT. 

'''  Mr.  llilton  is  in  liivor  <>(' making  thi.soponiiii;  transversely  valvular. — Med.  Times 
and  Gaz.,  vol    i,  18G7,  p   AOT. 

'  Mcd.-Cliir.  Trans.,  vol.  xxvi,  p.  1^80. 

*  Liston  sueei'cded  in  (^xtracling  a  picee  of  bone  from  a  point  bi'low  the  right 
sterno-clavicular  joint  with  forc(!ps  ;  and  Diekin,of  Middleton,  near  Manchester,  ex.- 


FOREIGX    BODY    IN     WINDPIPE.  213 

Foreign  bodies  may  also  be  successfully  treated  in  some  cases  by  in- 
version of  the  body  and  succussion  without  any  previous  operation.  In 
many  cases  the  substance  has  become  loose  and  lias  fallen  through  the 
glottis,  and  tlie  plan  is  well  wortii  trying,  particularly  in  cases  where  the 
body  is  smooth  and  heavy ;  but  as  tiiere  is  a  risk  that  the  substance,  if 
dislodged,  may  be  caught  by  the  spasmodic  closure  of  the  vocal  cords, 
and  instant  suffocation  be  tluis  i)roduccd,  it  is  well  before  resorting  to  this 
plan  to  be  prepared  for  laryngotomy  in  case  of  any  such  emergency. 

The  afler-consequencea  of  the  lodgment  of  a  foreign  l)ody,  if  it  be  not  ex- 
tracted, are  very  vai'ious  Tliey  vary,  as  the  immediate  symptoms  do,  with 
the  position,  size,  shape,  and  smoothness  of  the  substance.  Pointed  rougli 
substances,  wherever  they  may  be  impacted,  produce  a  rapidly  spreading 
inflammation  of  the  internal  membrane  of  tlie  air-passages,  spreading  down 
the  trachea  into  tlie  smallest  bronchial  tubes.  Thus,  in  the  cases  referred 
to  on  page  209,  vote^  a  pointed  thorn  of  bone,  sticking  through  the  glottis 
into  the  larynx,  produced  in  the  course  of  a  day  bronchial  effusion  over 
both  lungs.  On  the  other  hand,  a  smooth  body  (like  Sir  I.  Brunei's  half- 
sovereign)  may  remain  impacted  in  the  lower  part  of  the  trachea,  in 
one  of  the  bronchi,  or  even  in  a  large  bronchial  tube  of  the  lung  itself, 
for  a  considerable  period  without  exciting  any  such  symptoms.  Nor  are 
cases  wanting  to  prove  the  possibilitj^  of  a  smooth  foreign  substance  be- 
coming encysted  or  encased  by  inspissated  mucus  and  remaining  perfectly 
innocuous.'  But  such  cases  are  exceptional,  and  ought  not  to  deter  the 
surgeon  from  the  necessary  operation  in  any  case  in  which  he  has  certain 
evidence  of  the  lodgment  of  a  foreign  body.  The  case  far  more  com- 
monly proves  fatal,  and  death  is  produced  in  various  ways.  The  rougher 
substances  cause  acute  inflammation,  as  above  stated,  paroxysms  of 
cough  proving  fatal  either  b}' loading  of  the  lungs  or  spasm  of  the  glottis. 
In  some  cases  a  body  which  has  long  lain  quiet  changes  its  position,  irri- 
tates the  vocal  cords,  and  so  produces  spasm  of  the  glottis.  In  many 
cases  in  which  a  smooth  body  lias  been  lodged  in  the  deeper  parts  of  the 
tube  it  has  ulcerated  into  the  lungs  and  produced  all  the  symptoms  of 
phthisis;'^  so  that  Sir  B.  Brodie  says:  "The  records  of  surgery  furnish 
abundant  evidence  that,  under  such  circumstances,  disease  of  the  lungs 
sooner  or  later  is  induced,  and  that  the-death  of  the  patient  invariably 
ensues."  And  even  when  the  body  is  lodged  higher  up,  in  the  larynx  or 
upper  part  of  the  trachea,  there  is  good  reason  to  apprehend  that  it  will 
set  up  ulceration  at  the  seat  of  its  lodgment,  and  that  disease  of  the 
lungs  will  follow.  This  is  strikingly  illustrated  by  a  case  reported  liy 
South  (op.  cit.,  p.  396),  in  which  a  child  died  six  weeks  after  the  lodgment 
of  a  pebble  in  the  larynx.  The  nature  of  the  case  was  mistaken,  and  the 
severe  paroxysms  of  cough  attributed  to  pertussis.  The  cricoid  cartilage 
in  which  the  stone  was   lodged  was  laid  bare  by  ulceration,  and    botli 

tnicted  :i  button  which  had  lodged  in  and  completely  obstructed  the  right  bronchus, 
producing  the  most  characteristic  signs  of  total  suppression  of  breathing  on  the  right 
side.  The  latter  case  is  the  more  remarkable,  since  the  opening  was  made  between 
the  cricoid  and  thyroid  cartilages,  and  therefore  tlie  wound  was  further  than  neces- 
sary from  the  foreign  body.  (See  South's  Chelius,  vol.  ii,  p.  402,  or  Liston's  Practical 
Surgery,  pp.  415-420.) 

1  Sir  T.  Watson  relates  a  case  in  which  a  piece  of  gold  remained  for  years  in  one  of 
the  ventricles  of  the  larynx  without  distressing  consequences;  and  there  are  other 
cases  recorded  in  which  a  foreign  body  has  become  glued  to  the  wall  of  the  trachea, 
or  has  ulcerated  into  its  substance  and  tlius  become  encysted. 

2  Characteristic  cases,  which  want  of  space  forbids  me  to  introduce,  wi 
in  South's  Chelius,  vol.  ii,  p.  397. 


nil  be  found 


214  INJURIES    OF    THE    NECK. 

lungs  were  extensively  hepatized,  while  one  pleura  was  filled  with  turbid 
serum. 

Bi(7-)i  and  Scald  of  the  Larynx. — The  implication  of  the  larynx  in  a 
burn  or  scald  is  a  very  grievous  and  dangerous  complication  of  such  an 
injury,  and  one  which  unluckily  is  by  no  means  rare.  The  parts  below 
the  glottis  are  protected  by  the  s[)asmodic  closure  of  the  vocal  cords  at 
the  moment  of  the  accident,  but  great  oedema  of  the  mucous  lining  of 
the  fauces,  epiglottis,  and  orifice  of  the  larynx,  comes  on  with  fits  of 
spasmodic  dysi)na?a,  which  are  always  exceedingly  alarming  and  not  un- 
frequently  fatal  ;  the  voice  is  hoarse,  the  respiration  croupy,  and  the 
mouth  probably  so  much  injured  that  the  patient  (especially  if  a  child) 
can  hardly  be  got  to  take  food.  The  accident  is  more  frequent  in  child- 
hood, and  is  often  caused  in  very  3'oung  children  by  sucking  the  spout 
of  the  kettle.  The  great  danger  is  from  the  spasms,  and  the  prognosis 
depends  mainly  on  their  severity  and  frequency ;  but  even  after  surviv- 
ing this  danger  the  patient  may  still  sink  from  bronchitis  or  broncho- 
pneumonia, the  result  of  inflammation  spreading  downwards. 

In  such  cases  the  first  point  is  that  the  patient  must  never  be  left  until 
all  immediate  danger  is  over,  since  the  spasms  come  on  quite  irregularly 
and  with  little  warning.^  Leeches  should  be  freely  applied  to  the  throat, 
and  fi'equent  small  doses  of  calomel  and  antimony,  or  antimony  and 
aconite,  given.  The  dose  must  of  course  vary  in  proportion  to  the  age. 
Mr.  Durham  prescribes  one  or  two  minims  of  vin.  ant.  with  a  quarter  or 
half  minim  of  tinct.  aconit.,  at  first  ever}'^  quarter  of  an  hour,  then  every 
half-hour,  and  then  at  longer  intervals.  Possil)ly  the  cautious  adminis- 
tration of  chloroform  will  relieve  the  spasms,  and  then  the  mouth  can  be 
fully  opened  and  the  cedematous  parts  around  the  fauces  freely  scarified. 
Finally,  in  the  last  resort,  laryngotomy  or  tracheotomy  must  be  per- 
formed ;  but  my  experience  of  these  cases  has  been  that  those  which  are 
so  severe  as  to  demand  operation  generally  die,  and  that  it  is  better  if 
possible  to  refrain  from  opening  the  windpipe,  remembering  that  even 
very  alarming  spasm  seldom  proves  fatal.^  Some  surgeons  prefer  the 
operation  of  tracheotomy  to  that  of  laryngotomy  in  these  cases,  in  order 
to  get  further  from  the  injured  parts  ;  but  as  the  oedema  is  always  limited 
to  the  tissue  above  the  vocal  cords,  the  operation  of  laryngotomy  is  suf- 
ficient. Much  benefit  is  obtained  in  the  treatment  of  the  broncho-pneu- 
monia which  accom|)anies  these  and  other  injuries  of  the  windpipe  from 
the  use  of  the  "jacket-poultice."  Cases  occur  in  which  the  larynx  is 
injured  by  corrosive  fluids  ;  these  must  be  treated  on  the  same  principles. 

"^{'he  operative  procedures  for  opening  various  parts  of  the  air-passage, 
and  the  indications  for  each  of  them,  will  be  found  in  a  future  chapter, 
under  the  head  of  Diseases  of  the  Larynx. 

Foreign  Bodies  in  the  (Esophagus. — Nothing  is  more  common  than  for 

1  Mr.  Bryant  speaks  of  a  case  "in  which  the  symptoms  were  so  slic;ht  that  no 
anxifty  was  folt;  but  on«  spasm  took  place  two  and  a  half  hours  after  the  accident, 
which  put  an  end  to  life."  (Practice  of  Surcjery,  p.  139  )  A  striking  instanceof  tlie 
necessity  of  constant  watchfulness  and  preparation  for  constant  operation  in  these  as 
in  all  other  cases  in  which  spasm  of  the  glottis  appears  imminent. 

2  I  would  refer  the  reader  to  a  striking  case  related  by  Mr.  Le  Gros  Clark  (op.cit  , 
p.  280),  in  which  the  symptoms  were  so  acute  that,  "  though  not  entertaining  a  favor- 
able o|iinion  of  tracheotomy,"  he  thoug])t  it  his  duty  to  offer  the  alternative  to  the 
child's  parents,  who,  however,  declined  the  operation,  and  the  patient  ultimately 
struggled  through.  Mr.  Le  Gros  Clark's  remarks  on  the  advisability  of  avoiding 
tracheotomy  as  much  as  possible  quite  coincide  with  the  view  stated  in  the  text. 


FOREIGN    BODY    IN    CESOPHAGUS.  215 

a  patient  to  imagine  that  he  (or  she)  has  got  some  foreign  substance 
lodged  in  the  pharynx  or  oesophagus,  when  no  such  thing  is  really  the 
case.  Something  sharp  has  been  swallowed  with  the  food,  such  as  a 
sharp  edge  of  bone,  and  the  sensation  of  the  scratch  remains  after  the 
substance  itself  has  passed  away,  and,  indeed,  may  remain  for  a  consid- 
erable time,  rendering  deglutition  painful  and  difficult.  At  the  same 
time  cases  occur  pretty  frequently  in  which  a  pin  or  a  small  bone  or 
bristle  has  been  hidden  behind  the  arches  of  the  fauces  and  has  escaped 
a  hasty  examination  ;  so  that  all  such  cases  should  be  patiently  and  com- 
pletely investigated,  and  in  doubtful  cases  the  laryngoscope  will  be  very 
useful,  though  the  examination  can  of  course  only  extend  to  the  fauces 
and  upper  part  of  the  pharynx.  Large  foreign  bodies  are  generally  ar- 
rested in  the  a\sophagus  opposite  the  cricoid  cartilage,  but  they  may  pass 
lower.  I  have  spoken  above  of  those  cases  in  which  a  voluminous  mass 
rests  above  the  pliaryngeal  opening  of  the  larynx,  and  must  be  displaced 
or  instant  death  results.  But  in  cases  of  foreign  bodies  lodged  in  the 
oesophagus  there  is  no  such  urgent  danger.  The  impaction,  however,  of 
a  solid  body  is  inconsistent  with  prolonged  life,  since  it  prevents  deglu- 
tition either  by  mechanically  filling  the  gullet  or  by  the  pain  which  it 
produces  when  it  sticks  into  the  walls  of  the  tube,  as  a  pin  or  a  sharp 
bone  sometimes  does.  The  nature,  size,  and  shape  of  these  foreign 
bodies  are  very  various.  A  tooth-plate  carrying  one  or  two  artificial 
teeth  not  unfrcquently  dro[is  into  tlie  month  and  is  swallowed  during 
sleep ;  a  coin  swallowed  intentionally ;  a  ragged  piece  of  bone  ;  a  pin  or 
piece  of  wire,  or  a  fishbone,  are  familiar  instances.  Some  obstruct  the 
gullet  entirely,  others  partially ;  some  are  organic  and  soluble,  others 
metallic  and  insoluble ;  some  have  smooth  edges,  others  are  jagged  or 
sharp.  The  first  point  is  to  ascertain  as  nearly  as  may  be  what  the  size 
and  shape  of  the  substance  is,  and  where  it  is  lodged,  in  order  to  settle 
the  important  question  whether  it  can  be  pushed  down  into  the  stomach 
or  fished  up  from  the  mouth.  A  smooth  metallic  body  deepl^y  lodged  is 
best  dealt  with  by  gently  pushing  it  down  into  the  stomach  with  a  pro- 
bang  having  a  sponge  at  the  end  ;  and  even  somewhat  rough  bodies  may 
be  successfully  treated  this  vvay,  though  the  practice  is  not  without  its 
dangers.^  If  more  superficially  lodged  it  may  possibly  he  extracted  with 
the  long  oesophagus  forceps,  which  must,  liowever,  be  very  gently  man- 
aged, in  order  to  avoid  injury  to  the  coats  of  the  oesophagus.  Coins  can 
often  be  dislodged  and  fished  up  by  a  blunt  hook  at  the  end  of  a  probang. 
The  situation  of  the  coin  having  been  ascertained,  by  means  of  a  long 
probe  or  a  urethra  sound,  the  hook  is  pushed  beyond  it,  turned  round  to- 
wards the  coin,  and  withdrawn.  Pins,  small  bones,  etc,  may  be  caught 
in  the  horsehair  probang,  shown  in  Fig.  GT,  p.  216. 

Pieces  of  meat  and  bone  have  been  known  to  be  so  far  disoi'ganized 
and  softened  by  the  constant  use  of  dilute  mineral  acid  as  to  be  at 
length  swallowed.  Vomiting  has  sometimes  been  successful  in  dislodg- 
ing foreign  substances.     It  is  dangerous  to  the  integrity  of  the  oesopha- 

1  Mr.  Pollock,  in  the  Lancet,  1869,  vol.  i,  pp.  456-490,  records  two  cases  in  which 
a  toothplate  slipped  into  the  oesophagus.  In  one,  where  the  plate  was  small,  carry- 
ing only  two  teeth,  but  with  very  sharp  edges,  the  patient  seemed  to  be  in  danger  of 
sinking  from  want  of  food,  the  plate  being  lodged  near  the  stomach,  whence  it  was 
somewhat  dislodged  by  means  of  an  cesophagus-tube,  and  then  it  passed  into  the 
stomach,  on  the  nineteenth  day  after  the  accident  Here  it  remained  for  ninety- 
seven  days,  and  was  then  ejected  by  vomiting.  In  the  other  case  a  much  larger 
plate,  but  with  much  smoother  edges,  passed  through  the  whole  alimentary  canal, 
and  was  expelled  in  defecation  in  three  days. 


216 


INJURIES    OF    THE    NECK. 


gns ;  but  \\hen  a  large  and  tolerabl^y  smooth  foreign  body  is  lying  in  the 
stomach  and  cannot  pass  the  pylorus,  it  is  probably  best,  as  Mr.  Pollock 
directs,  to  attempt  its  removal  by  inducing  vomiting  after  a  full  meal,  so 
that  the  foreign  substance  may  be  rejected  along  with  the  mass  of  food. 


The  horsehair  probang  for  extracting  foreign  bodies  from  the  oesophagus,  such  as  coins,  bones,  etc., 
which  are  lodged,  but  do  not  entirely  obstruct  the  tube.  The  instrument  contains  a  skein  of  horsehair 
inserted  near  its  extremity,  which  is  dilated  by  pulling  its  handle  out.  It  is  introduced,  as  seen  in 
Fig.  A,  with  the  skein  closed,  past  the  foreign  substance.  Then  the  liandle  is  pulled  out  (Fig.  b)  and 
the  instrument  withdrawn  with  the  skein  opened,  in  order  that  the  horsehair  may  catch  and  bring 
away,  or  at  least  dislodge,  the  foreign  body. 

(Eiiopliagotomy. — Finally,  there  remain  a  few  cases  where  the  surgeon 
thinks  it  his  duty  to  cut  down  on  the  foreign  body  and  remove  it  at  once. 

This  operation  is  most  easily  performed  on  the  left  side,  in  conse- 
quence of  the  inclination  of  the  oesophagus  to  that  side,  but  the  shape  of 
the  body  raa}^  render  it  necessary  to  seek  it  from  the  right.  In  consists 
essentiall}'  in  making  an  incision  between  tlie  carotid  sheath  and  the 
lar\-nx  or  trachea,  drawing  the  latter  tube  inwards,  while  the  vessels  are 
displaced  outwards,  and  seeking  for  the  foreign  substance  through  the 
wall  of  the  oesophagus,  which  is  now  exposed.  The  incision  and  the 
early  steps  of  the  operation  are  much  the  same  as  for  the  ligature  of  the 
carotid.  The  centre  of  tlie  incision  should  be  about  opposite  the  cricoid 
cartilage.  If  it  be  too  high  the  superior  laryngeal  nerve  will  be  endan- 
gered ;  if  too  low,  the  inferior  th^'roid  artery.  When  the  foreign  body 
is  too  small  to  be  perceptible  externally  its  situation  and  the  position  of 
the  (jesophagus  are  to  be  fixed  by  passing  a  staff  or  catheter  down  the 
tube.  When  tlie  surgeon  lias  felt  the  foreign  body  he  divides  the  oesoph- 
agus longitudinall}',  just  enough  to  enable  him  to  catch  it  and  draw  it 
into  the  wound;  it  must  tl'.en  be  freed  from  the  fibres  of  the  (jesophagus 
as  gently  and  with  as  small  an  opening  as  possible.  No  sutures  have 
hitherto  been  used  to  close  the  wound  in  the  oesophagus,  but  it  seems 
probable  that  one  or  two  fine  catgut  sutures  might  hasten  its  closure,  and 
melt  without  producing  any  ulceration. 

Some  sui'geons  feed  the  patient  by  the  rectum  for  a  few  days  after  the 
operation,  but  Mr.  Cock  tliinks  it  better  to  pass  a  small  tube  or  elastic 
catheter  l)eyond  the  wound,  and  let  the  patient  have  food  in  the  stomach 
from  a  very  early  period  after  tlie  opening. 

Foreign  bodies  have  been  extracted  from  a  part  of  the  aesophagus 
mucii  lower  tlian  can  be  readied  by  the  incision.  Thus  Mr.  Syme  re- 
moved a  foreign  l)ody  lodged  just  op[)osite  the  top  of  the  sternum,  and 
Dr.  Cheever  one  which  was  fixed  below  the  sternum.' 

1  Cheever,  On  two  cases  of  cesophagotoiny.     Boston,  U.  S.,  1868. 


INJURIES    OF    THE    CHEST.  217 

The  operation  has  hitherto  proved  very  successful.  Twenty-one  cases 
are  tabulated  in  Mr.  Duriiam's  essay  on  injuries  of  the  neck  in  the  second 
edition  of  the  Siji^lem  of  Surgery,  of  which  only  four  proved  fatal ;  and 
it  seems  undeniable  that  in  some  at  any  rate  of  these  a  more  speedy  per- 
formance of  the  operation  would  have  given  the  patient  a  better  chance  ; 
for  in  one  case  (Arnott's),  where  the  operation  was  not  allowed  till  five 
weeks  after  the  accident,  the  patient  died  of  pneumonia,  which  had  been 
developed  previously,  and  in  another  (Martini's),  where  sixty  attempts 
had  been  made  to  dislodge  the  foreign  body  (which  was,  in  fact,  swal- 
lowed during  the  operation),  the  pharynx  was  found  to  be  gangreuous. 
Hence  the  propriety  of  the  rule  laid  down  by  Mr,  Arnott'  is  now  generally 
recognized  :  that,  "■  when  a  solid  substance,  though  only  of  moderate  size 
and  irregular  shape,  has  become  fixed  at  the  commencement  of  the  oisoph- 
agus  or  low  down  in  the  pharynx,  and  has  resisted  a  fair  trial  for  its 
extraction  or  displacement,  that  its  removal  should  at  once  be  effected 
by  incision,  although  no  urgent  symptoms  may  be  present." 

In  several  cases  where  the  foreign  body  has  not  produced  complete  in- 
ability to  swallow  it  has  nevertheless  occasioned  death  by  ulceration  into 
the  aorta  or  into  the  spinal  column,  pleura,  or  other  parts.  In  one  case 
even  the  heart  was  perforated.'' 

Injuries  to  the  esophagus  by  the  passage  of  foreign  bodies,  or  by  swal- 
lowing corrosive  liquids,  will  sometimes  produce  a  severe  form  of  cica- 
tricial stricture  ;  but  on  this  subject,  and  on  the  subject  of  gastrotoray,  or 
opening  the  stomach  in  order  to  remove  a  foreign  body,  or  to  obviate 
starvation  in  stricture  of  the  oesophagus,  I  must  refer  the  reader  to  a 
future  chapter  in  which  the  latter  subject  is  treated. 


CHAPTER  XL 

INJURIES    OF    THE    CHEST. 

In  describing  the  injuries  of  the  chest,  the  pleura  is  always  taken  as 
the  boundary  between  its  parietes  and  its  contents,  so  that  wounds  are 
classified  as  penetrating  or  non-penetrating,  according  as  they  do,  or  do 
not,  open  the  pleural  cavity.  At  the  same  time  it  must  be  recollected 
that  the  pleura,  or  any  of  the  thoracic  viscera  or  vessels,  or  even  the 
viscera  of  the  abdomen,  may  be  injured  in  contusions  and  in  non-pene- 
trating wounds  by  fragments  of  fractured  ribs,  and  also  that  (though  in 
very  rare  cases)  the  lungs  or  heart  may  be  lacerated  in  contusions  not 
involving  any  fracture  of  the  ribs. 

Contusions  and  Flesh-ivounds. — There  is  little  that  is  peculiar  to  the 
region  of  the  body  in  contusions  or  flesh-wounds  of  the  chest.     It  may, 

1  His  interesting  paper  in  tiio  eighteenth  volume  of  the  Med.-Chir.  Trans,  relating 
to  the  iirst  case  of  oesophagotomy  performed  in  this  country  is  well  worthy  of  study. 
^  See  Durham,  in  Syst.  of  Surg.,  vol.  ii,  p.  521. 


218  INJURIES    OF    THE    CHEST. 

however,  be  worth  mention  that  the  pectoral  muscle  is  sometimes  ruptured 
in  severe  sprains  or  other  injuries  in  which  the  patient's  arm  is  violently 
jerked  while  his  body  is  in  rapid  motion  in  the  other  direction  (as  when 
in  a  fall  a  man  grasps  at  a  bar).  The  injury  ma}'  be  known  at  once,  by 
the  great  gap  which  is  found  in  the  front  walls  of  the  axilla,  and  the  loss 
of  the  functions  of  the  muscles.  Sometimes  also  large  extravasations  or 
blood-tumors  form  under  the  pectoral  muscle,  which  can  only  be  distin- 
guished from  subpectoral  abscess  by  their  rapid  formation,  and  the  absence 
of  any  inflammatory  symptoms  or  appeai'ances. 

The  treatment,  liowever,  of  these  complications  differs  in  no  respect  from 
that  of  ruptured  muscle,  or  of  htematoma,  in  other  parts  of  the  bod_y. 

Subpeclo7-aI  Abscess. — Abscess  beneath  the  pectoral  muscle  is  met  with 
as  the  result  of  injury,  and  also  forms  spontaneously.  The  main  point  is 
to  diagnose  it  from  deepseated  hematoma  and  from  rapidly  forming  can- 
cer. The  oedematous  infiltration  and  inflammation  of  tlie  surrounding 
cellular  tissue,  and  the  clearness  of  the  fluctuation,  are  the  main  features 
which  distinguish  it  from  both,  and  in  case  of  need  the  grooved  needle 
will  settle  the  question.  A  free  and  deep  incision  is  necessary,  and  this 
is  best  made  under  anpesthesia,  especially  as  large  vessels  may  be  divided. 
It  is  usuall}^  recommended  to  make  the  incision  across  the  fibres  of  the 
muscle,  a  recommendation  from  which  I  venture  to  dissent.  Quite  as 
satisfactory  exit  for  the  matter  may  be  procured  l)y  an  incision  running 
between  the  fibres,  provided  it  be  free  enough,  for  which  purpose,  wlien 
the  matter  is  reached,  the  incision  maybe  dilated  with  the  finger  ;  and  a 
large  tent  of  lint  should  be  kept  in  for  the  first  three  or  four  days. 

Fro.cture  of  the  rihs  is  a  very  common  accident,  and  occurs  either  as 
the  result  of  direct  violence,  in  which  case  usually  onl}'^  one  or  two  ribs 
are  broken,  or  of  indirect  force  from  compression  of  the  thorax  by  a  crush 
either  from  the  back  or  front,  when  a  good  many  ribs  give  way  at  or  near 
their  angles  and  sometimes  on  both  sides  of  the  chest.  A  rib  may  also 
be  fractured  by  muscular  action  in  coughing,  an  occurrence  which  is  some- 
what ominous  of  the  presence  of  disease  in  the  fractured  rib,  but  has  been 
known  to  occur  without  any  evidence  of  such  disease.  Tiie  broken  ends 
of  the  ribs  may  be  driven  into  the  pleura,  the  lung,  the  diaphragm,  and 
even  througli  the  diaphragm  into  the  liver  or  spleen,  but  the  last-named 
lesions  are  very  rare,  and  are  usually  only  found  in  extensive  and  neces- 
sarily fatal  injuries.  It  will  be  sufficient  for  practical  purposes  to  discuss 
merely  fractures  of  the  rib:  (1)  uncomplicated,  and  (2)  complicated  with 
injury  to  the  lung. 

Simp^le  uncomplicated  fracture  of  one  or  tvvo  ribs  is  a  very  trivial  acci- 
dent, hardly  ever  followed  by  any  grave  consequences  if  properly  treated. 
But  the  danger  increases  considerably  when  many  ribs  are  broken,  and 
particularly  on  both  sides.  I  have  seen,  however,  a  young  woman  recover 
from  an  accident  in  which,  as  far  as  could  be  ascertained,  every  rib  in  the 
body  was  broken  and  extensive  injury  inflicted  on  tlie  bracliial  plexus  of 
one  side.  The  first  and  (tliougii  to  a  less  extent)  the  second  ribs  are  not 
80  liable  to  fracture  as  tliose  below  tliem,  the  projection  of  the  clavicle 
and  the  mass  of  the  pectoral  muscle  shielding  them  to  a  certain  extent; 
and  the  floating  ribs  by  their  extreme  mol)ility  also  more  commonly  escape 
fracture.  Fracture  of  the  ujiper  ribs  is  looked  upon  as  a  more  serious  in- 
jury than  of  the  lower,  since  the  lung  is  more  often  wounded.  The  pos- 
terior part  of  the  ribs  is  less  exposed  to  fracture  than  the  middle,  being 
under  the  protection  of  the  tliick  muscles  of  the  spine.  The  ribs  do,  how- 
ever, give  way  sometimes  near  their  tubercles,  and  the  injury  is  diflicult 


FRACTURED    RIBS.  219 

of  diagnosis  ;  sometimes  discovered  after  deatli  in  eases  where  it  has  not 
been  possible  to  form  a  distinct  diagnosis  during  life.  The  signs  of  frac- 
ture of  the  ribs  are  pain  at  the  part,  aggravated  l»y  deep  breathing  or 
coughing,  and  crepitus.  '^Plie  breathing  is  often  very  shallow,  and  there  is 
short  hacking  cough.'  Emphysema  of  the  cellular  tissue  can  only  occur 
if  the  fragment  has  penetrated  the  lung,  and  is  decisive  of  the  nature  of 
the  injury  without  further  examination.  It  is  not  l)y  any  means  always 
easy  to  detect  the  crepitus  of  a  fractured  rib.  The  periosteum  is  often 
untorn,-  and  then  it  is  difficult  to  produce  sufficient  movement  of  the  frag- 
ments on  each  other,  or  they  may  perhaps  be  interlocked,  though  we  can 
hardly  conceive  them  to  be  absolutely  impacted.  At  any  rate,  it  is  cer- 
tain that  in  many  cases  where  we  have  every  reason  to  believe  fracture  to 
have  occurred  it  is  not  possible  to  elicit  crepitus.  The  best  plan  is  to  lay 
the  hand  flat  on  the  suspected  part  and  get  the  patient  to  breathe  deeply 
or  cough,  if  it  does  not  give  too  much  pain.  If  this  does  not  succeed 
each  rib  may  be  traced,  and  manipulated  at  either  side  of  the  supposed 
fracture  like  any  other  bone,  care  being  taken  not  to  handle  portions  of 
two  different  ribs,  as  unskilful  or  careless  persons  sometimes  do.  Aus- 
cultation is  recommended,  but  I  cannot  sa}'  that  it  seems  to  me  of  any 
use.  I  have  heard  the  crepitus  of  an  undoubted  fracture  through  the 
stethoscope,  but  never  succeeded  in  thus  hearing  a  crepitus  that  I  could 
not  feel. 

Tlie  union  of  fractures  of  the  ribs  takes  place,  it  is  said,  in  about  thirty 
to  thirty-five  days,  but  I  believe  that  this  is  very  variable,  and  that  the 
time  required  for  union  is  often  much  longer.  I  have  felt  crepitus  a  fort- 
night after  the  injury  as  fresh  and  distinct  as  at  the  time  of  its  infliction. 
And  the  impossibility  of  keeping  the  fragments  at  rest  causes  fractures 
of  the  rib  to  unite  by  provisional  callus  more  frequently  than  those  of  any 
other  bone  in  the  human  subject.  In  fact,  excluding  some  very  excep- 
tional cases  (like  that  represented  in  Fig.  33),  all  the  instances  of  regular 
ensheathing  callus  in  the  human  subject  are  taken  from  fractures  of  the 
ribs  (see  Fig.  32,  p.  14()). 

The  treatment  consists  in  avoiding  the  movements  of  respiration  as 
much  as  is  compatible  with  the  patient's  comfort.  Confinement  to  bed 
is  necessary  only  in  the  severer  cases,  but  all  active  exertion  should  be 
forbidden.  A  bandage  to  the  chest  usually  aflTords  great  relief.  It  should 
be  aiiplied  around  the  whole  thorax,  as  low  as  the  end  of  the  sternum, 
and  should  be  commenced  when  the  patient  has  emptied  the  chest  as 
much  as  possible;  the  roller  should  be  six  inches  broad,  and  should  be 
adapted  to  the  varying  size  of  the  chest  b}^  reverses  where  necessary. 
When  the  bandage  is  finished  a  piece  long  enough  to  go  across  the  chest 
should  be  left  hanging,  being  secured  by  a  pin  or  tacking  ;  this  should 
be  split  half  way  down  and  the  two  ends  brought  over  the  shoulders  and 
fastened  on  the  other  side  like  a  pair  of  braces,  in  order  to  keep  the 
bandage  from  slipping  down  ;  or  a  piece  of  this  kind  should  be  sewn  on. 
Another  plan  is  to  fix  the  injured  side  only  of  the  chest  by  broad  pieces 
of  strapping  applied  from  the  spine  to  the  sternum.  This  is  thought  to 
embarrass  the  breathing  less,  but  it  does  not  seem  to  me  to  give  such 

1  Mr.  Le  Gros  Clark  conjectures  that  these  symptoms  are  sometimes  the  result  of 
injury  to  or  pressure  on  the  intercostal  nerve  by  the  broken  bone. 

'^  M.  Coulon  cites  in  his  Traite  des  Fractures  chez  les  Enfants,  p.  90,  a  case  pub- 
lished in  the  Bull,  de  la  Soc.  de  Chir.,  2nde  ser  ,  torn,  i,  p.  675,  of  a  child  who  died  of 
rupture  of  the  lung,  and  in  whom  incomplete  fractures  of  two  or  three  ribs  were 
found  on  both  sidesT  This  author  believes  incomplete  fracture  of  the  ribs  to  be  very 
common  in  childhood. 


220  INJURIES    OF    THE    CHEST. 

efficient  relief.  Sometimes  a  mere  belt  is  applied  round  the  injured  part, 
fixed  Avitli  buckles. 

The  bandage  is  to  be  worn  till  the  patient  can  dispense  with  it  with 
comfort,  say  for  a  month.  When  any  noticeable  displacement  is  felt,  in 
consequence  of  one  end  lyin^  below  the  other,  an  attempt  may  be  made 
to  repress  it  by  i)lacino-  a  pad  on  the  projecting  part  of  the  rib  which  is 
driven  in,  so  as  to  prize  outwards  its  buried  end. 

Fracture  with  Wound  of  Lung. — When  the  lung  is  injured  the  compli- 
cation is  at  once  marked  b}'  the  resulting  em])hysema.  The  fractuied 
end  of  the  rib  or  ribs  must  be  driven  through  the  pleural  cavity  into  the 
lung,  an  occurrence  much  more  likely  to  take  place  in  fracture  from  direct 
violence,  when  the  bone  is  driven  directly  downwards,  than  in  that  from 
indirect  force,  wlien  (the  curve  of  the  bones  being  increased)  tlie  tendency 
is  for  the  ends  to  spring  outwards ;  the  air-cells  of  the  lungs  being  thus 
opened,  the  elevation  of  the  ribs  in  inspiration  draws  the  air  into  the 
pleural  cavity,  from  which  it  is  forced  into  the  wound  which  the  broken 
rib  has  caused  in  the  parietal  i)leura,  and  thence  into  the  subcutaneous 
tissue  by  the  descent  of  the  ribs  in  expiration.  The  sensation  of  emph}^- 
sema  is  so  peculiar  that  when  once  recognized  it  can  never  afterwards 
be  mistaken.  It  is  a  dry  crackling  sensation,  perceptible  on  the  very 
slightest  touch,  quite  unlike  any  other  phenomenon  presented  either  in 
health  or  disease;  and  in  cases  of  injury  to  the  chest  there  is  hardly  any 
other  source  from  which  it  can  come  except  a  wound  of  the  lung.^  At 
the  same  time  it  should  be  remembered  that  a  small  quantity  of  air  may 
be  forced  into  an}-  punctured  or  lacerated  wound.  I  have  seen  it  in  a 
wound  of  the  leg,  and  once  I  saw  a  case  in  which  emphysema  existed  to 
a  slight  extent  over  the  back  of  the  chest,  and  it  had  been  hastily  con- 
cluded that  the  ribs  had  been  fractured,  the  only  injury  being  a  spike- 
wouud  at  the  back  of  the  scapula.  Such  mistakes,  however,  must,  be 
very  uncommon,  and  very  little  care  is  necessary  to  avoid  them.  When 
fracture  of  the  ribs  is  complicated  with  a  wound  of  the  lung  the  injury  is, 
of  course,  much  more  serious  than  when  no  such  complication  exists. 
At  the  same  time  the  lung  is  so  prone  to  rapid  union  that  if  the  injury 
be  only  slight  the  prognosis  is  not  unfavorable.  The  first  question  is, 
whether  or  not  to  bandage  the  chest.  Great  surgical  authority  may  be 
qnoted  on  both  sides.  The  fragments  have  certainly  been  displaced 
inwards,  and  if  this  displacement  be  reproduced  by  bandaging,  it  may 
perpetuate  an  irritation  which  it  is  very  important  to  stop  at  once.  On 
the  other  hand,  the  movements  of  tlie  chest  may  also  produce  irritation 
around  the  fractured  ends,  and  so  in  the  wounded  portion  of  the  lung. 
The  patient's  feelings  are  the  best  guide.  If  the  steady  pressure  of  the 
hand  on  the  seat  of  fracture  is  gratelul  to  liim,  it  is  well  to  try  the  effect 
of  a  bandage,  which,  however,  must  be  removed  at  once  if  it  increases 
the  dyspnea  or  causes  pain.  Bandaging  is  certainly  contraindicated 
wlien  there  is  much  comminution  or  tearing  of  the  parietes  of  the  cliest, 
as  happens  sometimes  in  such  accidents  as  a  blow  from  a  carriage-pole, 
where  a  large  rent  may  l)e  seen  in  the  chest-walls,  into  whicli  the  air 
bulges  in  the  form  of  a  large  bladder  under  the  skin  with  each  expiration. 
The  rest  of  the  treatment  of  fractured  ribs  with  wound  of  the  lung  con- 


'  In  an  open  wound  of  the  plfurn  without  wound  of  the  lung  emphysema  may- 
occur,  though  it  rarely  does  (see  Gunshot  Wounds),  and  (unphysema  may  also  occur 
in  stabs,  implicating  one  of  the  large  bronchi,  and  in  rupture  of  the  lung  without 
fracture  or  wound.  Spontaneous  emphysema  from  rupture  of  a  vomica,  or  even  from 
rupture  of  the  healthy  lung  in  viohmt  ctforts,  such  as  those  of  parturition,  is  a  rare 
and  curious  affection. 


EMPHYSEMA  —  HEMOTHORAX.  221 

sists  in  perfect  repose,  with  low  diet  (unless  the  patient  be  very  weak  at 
the  time),  until  all  fear  of  inflammation  has  passed  over.  The  occurrence 
of  inflammation  will  be  noted  more  by  the  general  symptoms  of  feverish- 
ness  and  dyspna^a,  with  rusty-colored  sputa  and  hacking  cough,  than  by 
any  physical  signs,  since  the  condition  of  the  part  often  forliids  percus- 
sion or  auscultation.  When  this  is  not  the  case  the  use  of  the  stetho- 
scope is  imperative.  When  inflammation  is  clearly  marked  nothing 
afljords  so  much  relief  as  bleeding,  especially  if  done  early.  Venesection 
is  of  course  inadmissible  if  the  pulse  is  very  weak,  but  when  there  is  much 
dyspna?a  and  a  strong,  hard  pulse,  the  relief  given  by  the  abstraction  of 
a  moderate  quantity  (as  10  or  12  ozs.)  of  blood  on  the  first  accession  of 
the  symptoms  is  often  decisive.  Antimony  in  moderate  doses  fsa}'  jo^'^ 
to  |th  of  a  grain  every  four  hours)  may  also  be  given  to  robust  patients; 
and  if  the  symptoms  call  for  it  the  bleeding  may  be  repeated.  In  the 
weakly  or  in  conditions  of  much  depression  a  jacket-poultice  should  be 
applied,  small  doses  of  morphia  combined  with  squills  or  some  demulcent 
mixture  ordered,  and  it  may  even  be  necessary  to  administer  a  little  wine 
cautiously. 

Emphysema. — The  emphysema  in  itself  is  usually  of  no  consequence 
whatever.  Cases  are  on  record  in  which  the  cellular  tissue  has  been  said 
to  be  so  blown  up  with  air  as  to  produce  a  real  embarrassment  to  the 
patient's  breathing,  and  to  require  evacuation  by  scarifications,  but  I 
have  never  met  with  anything  of  the  sort.  If  necessary,  however,  any 
quantity  of  air  might  easil}^  be  let  out  through  an  exploring  trocar  intro- 
duced in  a  few  convenient  places.  The  air  generally  disappears  of  itself, 
being  probabl}^  taken  up  by  the  fluids  of  the  part.^ 

The  other  complications  of  fractured  ribs  are  very  numerous.  Air, 
blood,  serum,  or  pus,  or  a  mixture  of  several  of  these  fluids,  may  be 
efl['used  in  the  pleura;  and  in  most  cases  of  emphysema  some  air  will 
probably  remain  in  the  pleural  cavity,  though  if  its  exit  into  the  cellular 
tissue  be  unimpeded  the  quantity  Avill  not  usually'  be  sufiicient  to  cause 
any  symptoms.  Pneumothorax  may,  however,  be  present  to  an  extent 
sufficient  to  cause  embarrassment  to  the  breathing,  particularly  if  the 
wound  in  the  parietal  pleura  has  become  closed  and  thus  requires  treat- 
ment. Besides  dyspnoea,  there  will  be  unnatural  resonance  to  percussion 
in  parts  away  from  the  injury,  flattening  or  convexity  replacing  the  natural 
concavity  of  the  intercostal  spaces,  increase  in  the  circumference  of  that 
side  of  the  chest,  and  loss  of  respiratory  murmur.  If  the  quantit}'^  eff'used 
be  so  great  as  to  impede  respiration  the  air  must  be  drawn  off"  by  a  trocar 
or  exhausting  syringe,  and  this  must  be  repeated  as  often  as  necessary; 
but,  as  Mr.  Le  Gros  Clark  has  pointed  out,  it  hardly  ever  is  necessary, 
since  when  the  air  is  in  quantity  suflScient  to  press  on  the  lung  that  very 
pressure  opposes  further  extravasation  of  air. 

Hspviothorax,  again,  may  occur  from  wound  of  an  intercostal  arter^'^  or 
of  some  large  vessel  or  vessels  in  the  lung.  Along  with  the  dyspnoea 
there  is  in  well-marked  cases  much  depression  or  complete  syncope,  with 
other  symptoms  of  internal  ha?morrhage.  The  physical  symptoms  are 
those  of  fluid  in  the  pleura  (dulness  on  percussion,  bulging  of  the  inter- 
costal spaces,  loss  of  respiratory  murmur),  and  often  metallic  tinkling  or 
splashing  from  the  admixture  of  air  with  the  fluid,  and  combined  with 
these  often  a  dark  color  under  the  skin  of  the  loins,  as  if  from  sugillation 
of  the  blood  through  the  pleura  into  the  intermuscular  spaces.     If  the 


1  An  interesting;  discussion  on  the  mode  of  removal  of  the  extravasated  air  will  be 
found  in  Mr.  Le  Gros  Clark's  work,  p.  204. 


222  INJURIES    OF    THE    CHEST. 

patient  seems  to  be  really  likely  to  die  from  the  mere  pressure  of  the 
blood,  it  is  doubtless  necessary  to  draw  off  the  fluid  part  with  the  aspi- 
rator; or  if  this  does  not  give  the  required  relief,  to  make  an  incision  and 
evacuate  the  semi-coagulated  mass ;  but  such  measures  are  hardly  ever 
required,  and  are  deprecated  by  many  good  surgeons  as  interfering  with 
the  closure  of  tiie  wound  in  the  artery,  which  is  favored  by  the  pressure 
of  the  clot. 

The  occurrence  of  hydrothorax  or  empyema  as  the  result  of  pleurisy 
after  an  injury  is  marked  by  the  same  symptoms,  and  requires  the  same 
treatment  as  when  such  conditions  occur  under  other  circumstances,  for 
which  I  must  refer  to  works  on  medicine. 

The  other  complications  are  much  more  rare,  viz.,  lesion  of  the  pericar- 
dium and  heart,  injury  to  the  intercostal  arteries,  wounds  of  the  diaphragm, 
causing  laceration  of  the  alxlominal  viscera.  As  all  these  injuries  are 
much  more  common  from  other  causes  than  from  fracture  of  the  ribs  the3^ 
are  best  treated  of  separately'. 

Fractures  of  the  ribs  are  not  unfrequently  compound,  i.  e.,  the  ribs  are 
often  fractured  in  gunshot  and  other  wounds  of  the  chest,  but  the  frac- 
ture of  the  rib  is  in  these  cases  only  a  subordinate  part  of  a  much  graver 
injury,  which  usually  involves  the  lungs,  heart,  or  great  vessels.  The 
general  features  of  such  injuries  will  best  be  understood  from  the  remarks 
on  Gunshot  Wounds  in  a  subsequent  chapter,  and  from  those  which  fol- 
low presently,  on  Penetrating  Wounds  of  the  Chest. 

Fracture  of  Costal  Cartilage!<. — The  costal  cartilages  may  be  fractured, 
although  I  am  not  aware  that  the  injury  can  be  accurately  diagnosed  un- 
less one  fragment  overlaps  the  other,  which  does  occasionally  happen. 
Delpech  is  quoted  by  Mr.  Poland  as  saying:  "If  the  fracture  takes  place 
near  the  sternum  the  internal  fragment  passes  in  front  and  crosses  the 
external;  the  contrary  when  the  fracture  is  nearest  the  rib.'"  In  such 
cases  it  seems  difficult  to  get  the  fragments  into  tiieir  proper  position  ; 
and  as  no  serious  inconvenience  results  from  the  displacement  it  is  un- 
wise to  use  any  severe  measures  for  that  purpose.  If  the  fragments  can 
be  manipulated  into  position  a  bandage  should  be  applied  to  keep  them 
so.  If  not,  I  should  be  disposed  to  leave  them  to  unite  as  they  are.  Mal- 
gaigne  speaks  favorably  of  the  use  of  a  kind  of  truss.  The  injury  is 
usually  repaired  by  bone,  sometimes  by  a  mixture  of  bone  and  cartilage. 
(See  page  155.) 

Fracture  of  the  alernum  rarely  occurs  as  a  separate  injury,  but  it  is 
not  very  uncommon  as  a  complication  of  fracture  of  the  spine,  and  it 
sometimes  though  rarely  accompanies  fracture  of  t lie  ribs.  The  rarity  of 
fracture  in  a  bone  so  exposed  to  violence  as  the  sternum  testifies  to  the 
etliciency  of  the  protection  afforded  to  it  by  the  costal  cartilages,  which 
supi^ort  it  exactly  like  so  many  elastic  springs.  The  sternum,  however, 
is  sometimes  fractured  l)y  direct  violence,  by  indirect  force  (as  in  frac- 
ture of  the  spine),  and  even  by  muscular  action.'-'  Some  surgeons  seem 
to  l)elieve  that  a  frequent  cause  of  fracture  of  the  sternum  is  the  forcible 
impact  of  the  chin  against  the  top  of  the  bone  in  a  violent  bend  of  the 
neck.     The  fracture  occurs  generally  tiuough  or  near  the  junction  of  the 

1  Syst.  of  Surg  ,  vol.  ii,  p.  561. 

2  "'Chaussier  rolatos  two  examples  of  the  kind.  Both  patients  were  females,  of  the 
ages  of  twenty-four  and  twenty-five,  and  the  fracture  occurred  during  the  efforts  of 
labor  with  a  fir.-it  child."— Poland,  in  Syst.  of  Surg.,  vol.  ii,  p.  503. 


DISLOCATION    OF    THE    RIBS.  223 

first  and  second  pieces  of  the  bone,  and  what  is  called  a  (ractuve  is  often, 
as  Mr.  Rivinoton^  has  shown,  a  true  dislocation,  there  being  a  regular 
diarthrodial  joint  in  this  situation.  The  symptoms  somewhat  resemble 
those  of  fracture  of  a  rib,  and  there  is  not  generally  much  difficulty  in 
detecting  it  by  manipulation  even  when  tiiere  is  no  displacement,  but 
very  commonly  the  upper  fragment  is  found  behind  the  lower,  leaving  no 
doubt  of  the  nature  of  the  case.  In  fracture  involving  only  the  sternum 
there  are  rarely  any  visceral  complications. 

The  treatment  is  much  the  same  as  for  fracture  of  the  ribs  ;  the  dis- 
placement often  remains  permanent,  but  no  evil  consequences  need  be 
feared  from  it,  nor  is  the  accident  in  itself  a  formidable  one.  Longitudi- 
nal fissures  in  the  sternum  have  been  dissected  in  the  dead  body,  and 
more  rarely  recognized  in  the  living  by  the  displacement  of  the  fracture. 

Dislocation  of  the  Bibs. — Dislocation  of  the  head  of  the  rib  from  the 
spinal  column,  or  of  its  extremity  from  the  sternum,  or  from  the  carti- 
lage, can  hardly  be  spoken  of  as  a  separate  surgical  injur}-,  since  it  is 
usually  only  a  subordinate  part  of  the  case,  and  in  any  event  its  treat- 
ment would  be  exactly  the  same  as  that  of  fractured  rib.  In  Mr.  Poland's 
article  in  the  System  of  Surgery,  the  reader  will  find  references  to  the 
recorded  cases  of  this  rare  injury. 

Penetrating  wounds  are  such  as  either  open  the  pleural  cavity  only  or 
pass  more  deeply,  wounding  the  lungs,  heart,  or  great  vessels.  There 
are  no  absolute  signs  by  which  a  wound  of  the  pleura  only  can  be  dis- 
tinguislied  from  one  of  the  lung,  since  the  passage  of  air  out  of  the  wound 
(traumatopnea)  is  noticed  in  wounds  which  terminate  in  tiie  pleural 
cavity.  As  the  parietes  of  the  chest  rise  up  in  inspiration  the  air  finds 
its  way  through  the  wound  into  the  pleura,  from  whence  it  is  expelled 
into  the  cellular  tissue  (emphysema),  or  through  the  wound  (traumatop- 
ncEa)  in  expiration.^  However,  when  the  lung  is  also  wounded  the  ex- 
pelled air  is  usually  churned  up  with  the  blood  in  the  lung  into  a  fine 
bloody  froth,  the  absence  of  which  sign  in  a  penetrating  wound  encourages 
the  hope  that  the  pleura  only  is  wounded.  E^xploration  with  the  finger 
or  probe  is  only  permissible  when  there  is  good  reason  for  suspecting  that 
a  foreign  body  is  lodged  in  the  wound.  Haemoptysis  may  be  present  to 
a  certain  extent  when  the  lung  is  not  wounded,  and  on  the  other  hand  it 
may  be  (though  it  rarely  is)  absent  when  the  weapon  has  passed  into  the 
lung.  These  remarks  apply,  however,  of  course  rather  to  small  punctures 
than  to  free  wounds  of  the  lung,  the  nature  of  wliich  is  usually'  obvious 
enough.  In  the  graver  cases  of  wound  of  the  lung  much  air  and  blood 
will  be  effused  into  the  pleura,  and  blood  will  also  be  extravasated  into 
the  tissue  of  the  lung  itself,  so  that  the  patient  is  menaced  with  death 

^  Med.-Cliir.  Trans,  vol.  Ivii,  p.  101. 

^  JSelaton  eivos  four  conditions  under  which  emphysema  may  occur  :  1.  In  a  wound 
of  the  hmg  with  external  wound.  The  air  passes  during  inspiration  into  tiie  pleural 
cavity  fmni  the  open  air-cells  and  from  the  outer  air  through  the  wound,  and  in  ex- 
piration is  pressed  out  through  the  wound  or  into  the  cellular  tissue.  '2.  In  a  wound 
penetrating  the  parietal  [ileura  but  not  the  visceral,  if  there  is  any  impediment  to 
the  free  passage  of  the  air  out  again  through  the  wound.  3.  In  wound  of  the  lung 
without  external  wound,  as  in  fracture  of  the  ribs.  4.  In  rupture  of  the  lung  with- 
out injury  to  the  visceral  pleura  the  air  may  be  extravasated  between  the  lobules  of 
the  lung,  causing  emphysema  at  the  root  of  the  lung,  which  extends  to  the  lower 
part  of  the  neck.  [I  cannot  remember  ever  seeing  this  accident.]  In  rupture  of 
the  lung  without  injury  to  the  parietal  pleura,  pneumotliorax'will  occur,  but  no 
emphysema.     (Nelaton,  Path.  Chir.,  vol.  lii,  p.  447.) 


224  INJURIES    OF    THE    CHEST. 

both  from  apiio?a,  the  result  of  pressure  on  the  luug,  and  syncope,  caused 
by  loss  of  blood  and  shock.  The  chief  danger  in  wound  of  the  lung,  ac- 
cording to  Mr.  Le  Gros  Clark,  is  in  the  early  loss  of  blood;  "if  this  peril 
be  survived  the  risk  of  fatal  inttanimation  would  appear  to  be  less,  under 
favoring  conditions,  than  might  be  anticipated  "  (op.  cit.,  p.  217). 

All  penetrating  incised  wounds  of  the  chest  not  involving  fracture 
should  be  closed  at  once  after  the  removal  of  any  foreign  substance,  and 
it  is  a  good  practice  in  the  severer  cases,  and  those  in  which  tlie  lung  is 
believed  to  be  wounded,  to  strap  the  chest  and  apply  ice  externally.  The 
collapse  should  not  be  interfered  with  at  first,  unless  it  be  so  severe  tliat 
it  threatens  to  prove  fatal.  The  patient  should  be  kept  perfectly  quiet 
and  \evy  cool.  In  fact,  the  object  of  the  surgeon  should  be  to  avert 
biemorrhage.  In  reaction  as  the  pulse  rises  bleeding  may  be  indicated, 
and  afterwards,  when  inflammation  threatens  or  has  commenced,  the 
treatment  already  described  must  be  pursued  (p.  220). 

Wounds  of  the  lung,  under  favorable  circumstances  and  in  healthy 
persons,  unite  rapidly,  and  the  prognosis  is  by  no  means  desperate.  It 
need  hardly  be  said  that,  if  dyspna^a  seems  to  be  excited  or  kept  up  by 
the  collection  of  air  or  blood  in  the  pleura,  the  surgeon  may  find  it  neces- 
sary to  reopen  the  wound  in  order  to  give  it  exit. 

Pneumocde.,  or  the  protrusion  of  a  portion  of  the  lung  through  the 
wound,  takes  place  either  immediately  on  the  accident  (primary),  or  after 
an  interval  (consecutive). 

Primary  hernia  of  the  lung,  when  the  protruding  lung  is  exposed  by  a 
wound,  forms  a  globular  mass,  varying  in  size  from  a  marble  to  a  cricket- 
ball,  the  dark  color,  shining  surface,  and  crepitating  feel  of  which  suffi- 
ciently indicate  its  nature.  If  recent,  and  if  it  can  be  reduced  without 
violence,  this  should  be  done,  the  tissues  of  the  wound  which  constrict 
the  neck  of  the  protrusion  being,  if  necessary,  divided,  in  order  to  allow 
of  the  easy  return  of  the  lung  into  the  thoracic  cavit}',  when  the  wound 
is  to  be  united.  But  if  some  time  have  elapsed,  and  the  lung  be  altered 
in  structure,  no  attempt  at  reduction  should  be  made,  nor  is  any  other 
mechanical  interference  permissible — the  herniated  lung  must  be  allowed 
to  slough  off.  Some  surgeons  think  it  better  to  tie  a  ligature  round  the 
herniated  portion,  which  may  afterwards  be  removed  if  it  be  thought  ad- 
visable, when  the  protruded  part  has  contracted  adhesions  to  the  parietes.^ 

Primary  hernia  of  the  lung  takes  place  also  beneath  the  skin  in  cases 
of  extensive  fracture  of  the  parietes  of  the  chest  accompanied  by  free 
laceration  of  the  soft  parts.  In  such  cases  it  is  useful  to  repress  the 
protrusion  b}'  a  carefully  applied  pad. 

Consecutive  hernia  takes  place  after  the  wound  has  cicatrized,  so  that 
the  lung  is  covered  by  skin  or  cicatrix.  It  forms  a  globular,  elastic 
tumor,  which   falls   in    during  inspiration,^  disappears    in    holding   the 

1  Sec  a  case  very  clearly  and  succinctly  described  in  Mcd.-Ciiir.  Trans.,  vol.  xx, 
p.  378,  by  Mr.  Forde. 

'■^  This'is  the  usual  account  in  the  present  day  of  the  changes  in  volume  in  herni- 
ated lung  during  the  movements  of  respiration.  See  Nelaton,  Path.  Chir.,  vol.  iii, 
p.  408  ;  Poland,  Syst.  of  Surg.,  2d  ed.,  vol.  ii,  p.  583.  But  Mr.  Le  Gros  Clark  (op. 
cit.,  p.  20G),  in  relating  a  case  of  primary  hernia  of  the  lung  with  fracture  of  the 
ribs,  distinitly  observed  that  "at  each  inspiration  a  large  tumor,  of  the  size  of  the 
doubled  fist,  presented  itself  below  the  clavicle  ;  and  tliis  disappeared  at  each  expira- 
tion, leaving  a  deep  depression."  Nelaton  gives  a  mechanical  explanation  of  the 
falling  in  of  the  herniated  lung  during  inspiration,  which  does  not  appear  to  mo 
quite  clear,  lie  says:  "  During  the  dilatation  of  the  chest  the  portion  of  lung  situ- 
ated outside  is  not  able  to  participate  in  the  distension  of  the  viscus  contained  in  the 


WOUND    OF    THE    HEART.  225 

breath,  and  swells  in  expiration,  and  particularly  in  coughing.  On  ma- 
nipulation it  crepitates,  and  auscultation  detects  a  harsh-toned  vesicular 
murmur. 

Nothing  can  be  done  beyond  protecting  it,  if  it  seems  necessary,  from 
any  accidental  injury  by  adjusting  a  concave  shield  over  it.  This  will 
also  obviate  an}'  chance  of  tlie  increase  of  the  protrusion. 

Foreign  Bodien  in  the  Thorax. — Foreign  bodies  whi(di  are  lodged  in  a 
wound  of  the  chest  must  be  extracted  at  once,  and  many  histories  testify 
to  the  possiliility  of  recovery  even  after  complete  perforation  of  the  tho- 
rax by  a  very  voluminous  foreign  body,  as  in  the  celebrated  preparation 
in  the  College  of  Surgeons  Museum,  from  a  man  who  lived  ten  years 
after  having  a  gig-shaft  run  through  his  chest  from  one  side  to  the  other. 
And  life  is  not  incompatible  even  with  the  permanent  lodgment  of  a  for- 
eign body,  as  in  Velpeau's  case  of  a  man  who  lived  fifteen  years  with 
part  of  a  fencing-foil  in  his  chest,  which  had  entirely  traversed  the  thorax, 
the  point  being  implanted  in  the  spine,  the  broken  end  fixed  in  one  of  the 
ribs,  and  the  weapon  itself  buried  in  the  lung,  where  it  was  surrounded 
b}'  calcareous  deposit.^  But  such  exceptional  cases  as  this  do  not  invali- 
date the  general  rule  that  foreign  bodies  should  be  removed  at  once, 
whenever  it  can  be  done  without  too  great  risk.  Sometimes  the  foreign 
body  (usually  a  bullet)  drops  into  the  pleura,  and  thus  may  entirely  es- 
cape detection,  though  in  some  such  cases  the  substance  has  been  found 
by  a  probe,  and  has  been  extracted  either  by  a  pair  of  forceps  or  by  di- 
rect incision.  If  the  foreign  body  be  left  in  the  pleura  it  will  probably 
produce  death  by  pleurisy  and  empyema,  though  it  is  certainly  not  im- 
possible that  it  might  become  encysted. 

Wounda  of  the  Mediaatimim^  Pericardium^  and  Heart. — In  some  cases 
weapons  liave  penetrated  the  mediastinum  without  wounding  any  im- 
portant parts,  and  in  still  rarer  cases  the  pericardium  has  been  wounded, 
and  yet  the  heart  has  escaped  injury;'^  but  no  diagnosis  can,  I  think,  be 
made  between  tlie  latter  injury  and  that  in  which  the  heart  is  also  wounded. 

Tlie  symptoms  of  wound  of  the  heart  are  chiefly  those  of  acute  internal 
haemorrhage,  whicli  usually  proves  rapidly  fatal.  There  is  a  peculiar 
tremor  about  the  heart,  with  intermittent  small  pulse  ;  and  there  is  also 
a  peculiar  undulous  crepitation  and  bruit  accompanying  the  heart's  ac- 
tion, and  due  to  the  blood  effused  around  it  into  tlie  sac  of  the  peri- 
cardium. The  position  of  the  wound,  and  the  severe  symptoms  which 
accompany  it,  are  the  only  tests  of  the  reaJitj'  of  the  injury  to  the  heart 
itself. 

Death  is  the  ordinary  but  not,  as  it  seems,  the  inevitable  consequence 
of  wound  of  the  heart.  The  wound  usually  proves  fatal  by  haemorrhage 
into  the  pericardium,  the  blood  collecting  about  the  heart  and  impeding 
its  motion  ;  or  in  case  of  a  free  opening  into  one  of  the  cavities  the  mechan- 
ism of  the  heart  may  be  destroyed,  the  blood  passing  so  freely  out  of  the 

cavity  "  [but  query  why  ?]  "  and  as  there  is  a  tendency  to  a  vacuum  in  the  intratho- 
racic part  of  the  organ,  if  the  hernia  is  reducible  it  enters  the  chest ;  if  not  it  empties 
itself  completely.  These  results,"  he  adds,  "are  confirmed  by  accurate  observation, 
but  are  contrary  to  what  is  found  in  authors."  We  must  conclude  that  both  condi- 
tions are  found.  I  saw  a  case,  many  years  ago,  in  which,  if  I  can  trust  my  memory 
(for  I  cannot  now  find  the  notes),  the  movements  were  as  described  in  the  text. 

1  Syst.  of  Surg.,  vol.  ii,  p.  593. 

2  On  this  subject  consult  Fischer,  Ueber  die  Wunden  des  Herzens  und  des  Herz- 
beutels.     Langenbeck's  Archiv,  1868. 

15 


226  INJURIES    OF    THE    CHEST. 

heart  tluat  its  pumping  action  is  suspeiuled,^  A  wound  of  the  heart  may 
also  |)rove  fatal  at  once  by  the  "  shock  "  to  the  heart  or  subsequenti}'  by 
pericarditis,  or  from  some  of  the  many  complications  of  penetrating 
wounds  of  the  thorax.  But  there  seems  no  question  that  in  man  and 
other  warm-blooded  animals  wounds  of  the  heart  do  not  always  prove 
fatal.  Animals  have  been  dissected  in  whom  foreign  bodies  have  been 
found  which  had  been  lodged  for  years  in  the  substance  of  the  heart,  and 
others  bearing  the  plainest  marks  of  old  scars.  Nor  are  similar  cases  by 
an}' means  so  uncommon  as  is  sometimes  supposed  in  the  human  subject. 
Fischer  has  recorded  452  cases  in  whicli  wound  of  the  heart  or  pericar- 
dium was  diagnosed,  and  out  of  these  72  recovered,  and  the  diagnosis 
was  in  36  cases  verified  to  the  satisfaction  of  the  surgeon  by  post-mortem 
examination. 

In  a  case  the  preparation  of  which  is  in  the  Museum  of  St.  George's 
Hospital  the  symptoms  were  at  the  time  ill-marked,  though  the  heart  was 
perforated  :  the  bayonet  having  passed  through  the  wall  of  the  left  ven- 
tricle and  opened  its  cavity.  The  patient  was  a  young  man,  a  volunteer, 
who  accidentally  fell  on  his  bayonet.  He  withdrew  the  weapon,  ran  a 
short  distance,  and  then  fainted.  When  seen  at  the  Nottingham  Hospital, 
an  hour  afterwards,  he  bore  traces  of  great  loss  of  blood  internally,  but 
this  seemed  chiefl,y  in  the  left  pleura,  from  which  a  pint  and  a  half  of  blood 
was  drawn  off  next  day.  On  the  day  after  the  accident  pericardial  fric- 
tion was  detected.     He  lived  four  da3's.^ 

'•  Treatment,"  says  Mr.  Poland,  "  will  be  mainly  directed  to  prevent 
and  arrest  internal  haemorrhage,  by  absolute  repose,  local  and  general  em- 
ployment of  cold,  and  early  venesection  to  relieve  the  heart ;"  and  he 
also  recommends  the  internal  use  of  belladonna  and  digitalis. 

FaracenteMa  Pericardii. — Paracentesis  of  the  pericardium  has  been 
contemplated  in  wounds  of  the  heart  in  order  to  disembarrass  the  heart 
of  the  etlused  blood,  but  has  never  been  performed  for  that  cause.  It 
has,  however,  been  occasionally  resorted  to  when  effusion  into  the  peri- 
cardium, the  result  of  disease,  could  be  distinguished  to  such  an  extent 
as  seemed  likely  to  prove  fatal.  The  operation  is  best  performed  in  the 
fourth  or  fifth  intercostal  space,  just  to  the  left  of  the  sternum,  in  exactly 
the  same  manner  as  paracentesis  of  the  pleura,^  or  the  parts  may  be  dis- 
sected until  the  distended  pericardium  is  exposed.  In  a  case  recently 
published/  the  operation  is  thus  described  :  "A  fold  of  skin  having  been 
raised  over  the  (if'th  intercostal  space,  an  incision  a  little  more  than  an 
inch  long  was  made  jjarallel  to  the  ribs,  in  the  centre  of  the  space,  com- 
mencing about  two-fifths  of  an  inch  to  the  lel'tof  tlic  sternum.  The  layers 
of  muscle  were  then  carefully  divided,  and  an  elastic  dilatation  was  felt, 
which  resisted  a  little  under  pressure,  while  the  impulse  of  the  apex  of 
the  heart  could  be  indistinctly  perceived.  A  puncture  having  been  made 
in  this,  the  point  of  a  small  trocar  was  introduced,  and  about  10  ozs.  of 
fluid  were  removed,  with  immediate  relief." 


'  Mr.  Le  Gros  Chirk  describes  and  figures  a  most  interesting  case  of  bullet-wound 
of  the*  heart,  in  which  tl)e  niiin  survivod  fourteen  diiys,  though  there  was  a  transverse 
laceration  an  inch  in  Icnj^lii  in  tl)('  right  ventricle  near  its  root,  and  the  tricuspid 
valve  was  also  lacerated  (op.  cil.,  ]>.  2GU). 

*  Med.  Times  and  traz.,  18G3,  vol.  ii,  p.  487.  St.  George's  Hospital  Museum,  ser. 
vi,  No.  224. 

*  On  paracentesis  of  the  pericardium  see  AUbutt,  in  Lancet,  June  12,  1869. 

*  Lond.  Med.  Record,  May  5,  1875,  p.  275. 


WOUNDS    OF    MAMMARY    AND    INTERCOSTAL    VESSELS.      227 

Wounds  of  the  Internal  Mammary  and  Intercostal  Vessels. — Many  great 
vessels  may  be  wounded  in  the  cavit}'^  of  the  chest,  but  the  only  cases 
which  need  engage  our  attention,  since  they  are  the  only  ones  susceptible 
of  definite  diagnosis  and  treatment,  are  tiie  wounds  of  the  internal  mam- 
mary and  of  the  intercostal  arteries,  and  these  are  very  rare,  at  any  late 
as  substantive  injuries.  It  is  possible  that  an  intercostal  artery  may  be 
occasionally  injured  in  fracture  of  the  ribs,  but  I  am  not  aware  that  this 
has  l)een  proved  by  dissection.  The  internal  mammary  artery  may  be 
wounded  in  any  of  the  first  three  spaces  by  a  stab-wound  on  either  side 
of  the  sternum  without  any  division  of  the  costal  cartilages.  Below  the 
fourth  costal  cartilage  it  is  said  that  it  can  only  be  divided  by  section  of 
the  cartilage,  and  in  more  than  half  the  cases  that  have  been  noted  the 
costal  cartilage  has  also  been  cut.^  An  artery  laid  open  through  a  wound 
of  so  dense  a  structure  as  the  costal  cartilage  can  hardly  be  brought  into 
view.  When  the  artery  is  wounded  in  any  of  the  upper  three  intercostal 
spaces  it  maj^,  according  to  M.  Tourdes,  be  tied  by  direct  incision. 

The  intercostal  artery  may  be  wounded  in  paracentesis  or  in  a  punc- 
tured wound  or  gunshot  injury,  and  it  may  be  perfectly  impossible  to 
secure  it,  from  its  remote  position  as  vvell  as  the  retraction  of  its  divided 
ends. 

It  is  not  eas}'  in  either  case  to  distinguish  the  source  of  tlie  bleeding, 
though  there  would  be  less  hesitation  in  the  case  of  the  internal  mammar}'^ 
artery  than  in  that  of  the  intercostal.  The  symptoms  of  bleeding  from 
the  latter  differ  but  little  from  those  of  haemorrhage  from  a  wound  of  a 
vessel  in  the  lung,  for  in  accidental  injuries  at  least  the  lung  is  also  in  all 
probability  wounded.  The  main  diagnostic  sign  is  the  effect  of  pressure 
with  the  finger  introduced  into  the  wound,  which  may  be  enlarged  for  the 
purpose.  It  has  also  been  proposed  to  introduce  a  strip  of  card  or  a  thin 
spatula  into  the  wound,  and  judge  of  the  source  of  the  haemorrhage  by 
seeing  on  which  side  of  the  card  the  blood  runs  down.  If  the  card  is  in- 
troduced into  the  pleura  beneath  the  intercostal  arter^^  it  is  clear  that  if 
that  artery  be  the  source  of  the  bleetling  the  blood  will  run  along  the 
outside  of  the  card,  and  if  the  bleeding  be  from  the  lung,  along  its  inside. 

The  treatment  of  wounds  of  either  of  these  vessels  has  generally  been 
unsatisfactory.  There  are,  indeed,  some  cases  in  which  the  surgeon  can 
tie  the  wounded  artery,  but  the}'  are  exceptional.  In  other  cases  it  may 
be  possible  to  keep  up  pressure  by  the  fingers  of  a  relay  of  skilled  assist- 
ants long  enough  to  avert  death  by  lu^morrhage  ;  or  possibly  the  plan  of 
uncipression  recommended  b}'  Signor  Vauzelti  might  find  its  use  here 
(see  page  125);  or  an  oval  sponge  on  a  ligature  might  be  introduced  into 
the  wound  so  shaped  that  when  it  swells  up  it  will  not  come  out  of  the 
opening  when  the  ligature  is  drawn  outwards,  but  will  make  pressure 
outwards  on  the  bleeding  vessel.  Many  good  surgeons,  however  (as 
Larrey,^  in  the  case  of  the  internal  mammarj^,  and  Assalini  in  that  of  an 
intercostal  artery),  think  that  the  patient  has  on  the  whole  a  better 
chance  of  recovery  if  the  wound  is  simply'   closed,  and  coagulation   is 

^  See  Tourdes,  Annales  d'Hygiene  Publique,  vol.  xlii,  p.  165,  wliere  summary  notes 
are  given  of  eleven  cases;  in  live  of  wliieli,  however,  the  diagnosis  was  not  verified 
by  iiost-niorteni  examination.  This  author  insi?ts  strongly  on  the  necessity  of  liga- 
ture of  this  vessel  when  wounded,  but  I  am  not  aware  that  the  operation  has  ever 
really  been  iiracticed. 

2.  Larrey  speaks  thus  :  "  It  is  much  better  to  leave  htemorrhage  from  the  intercos- 
tal or  internal  mammary  artery  to  nature.  The  wound  being  closed,  the  blood  ac- 
cumulates in  the  thorax,  and  the  lung,  no  longer  compressed  by  the  air,  dilates  again 
and  fills  up  the  cavity." — Clin.  Chir.,  vol.  ii,  p.  18L 


228  INJURIES    OF    THE    CHEST. 

trusted  to  to  repress  the  hfemorrhage,  paracentesis  being  performed  if 
the  blood  accumulates  in  the  pleura'  to  such  an  extent  as  to  threaten  life. 

Bupture  of  Viscera  xvithout  Wound  07-  Fracture. — The  heart  is  some- 
times ruptured  even  in  cases  where  there  is  no  direct  injur}^  to  the  chest. 
Thus,  in  the  case  of  a  mason's  bo}^  who  fell  from  the  roof  of  St.  George's 
Hospital  and  was  killed  on  the  spot,  among  other  fatal  lesions  the  sep- 
tum ventriculorum  of  the  heart  was  found  ruptured  without  any  other  in- 
jury of  the  chest.  But  such  lesions  hardly  come  within  the  range  of 
practical  surgery. 

In  severe  contusions  of  the  chest  (and  usually  from  the  passage  of  a 
carriage-wheel  over  it)  the  lung  is  sometimes  lacerated  without  the  chest- 
walls  "sustaining  any  visible  injury.  Doubtless  at  the  time  of  the  acci- 
dent the  glottis  is  spasmodically  closed,  and  then  the  lung  is  torn  be- 
tween the  force  impressed  on  it  through  the  chest-walls  and  the  resistance 
of  the  air  confined  in  the  bronchi.  The  injury  may  be  diagnosed  when 
the  visceral  pleura  is  also  ruptured  ;  but,  I  should  think,  not  otherwise." 
The  symptoms  in  that  case  will  be  hydropneumothorax  (dulness  at  the 
lower  part  of  the  chest,  sonorous  resonance  at  the  upper,  and  metallic 
tinkling,  possibly  with  splashing  on  succussion),  and  at  the  same  time 
dyspnoea,  haemoptysis,  and  sometim.es  subcutaneous  emphysema,  without 
any  fracture  of  the  ribs.  The  accident  is  much  more  likel^^  to  occur  in 
childhood,  from  the  elasticity  of  the  chest-walls.  The  treatment  is 
directed  to  avoid  and  combat  the  resulting  inflammation,  as  in  any  other 
severe  injury  of  the  chest,  and  there  can  be  no  doubt  that  some  cases  end 
in  recovery.' 

Pflracentesis  Thoracis. — The  present  seems  the  best  place  to  introduce 
a  description  of  the  operation  of  paracentesis  thoracis,  or  thoracentesis. 

Tapping  the  chest  is  a  very  simple  operation,  and  one  which  has  now 
become  so  familiar  that  it  is  often  performed  by  students  or  junior  prac- 
titioners. In  fact,  with  some  simple  precautions,  it  involves  little  risk  of 
its  own.  At  the  same  time,  when  performed  on  account  of  disease,  or 
when  the  contents  of  the  chest  are,  from  previous  disease,  in  unnatural 
relations  to  each  other,  it  is  not  either  so  simple  or  so  harmless.  The 
objects  of  the  operation  are  to  evacuate  fluid  from  the  pleural  cavity 
without  injuring  the  intercostal  vessels,  the  lung,  or  the  diaphragm  ;  to 
avoid  the  entrance  of  air  in  place  of  the  fluid  removed  ;  and  to  do  this 
without  any  lesion  of  the  lung  due  to  the  change  in  the  conditions  of 
atniosplieric  pressure  which  may  be  caused  by  emptying  the  fluid  out  of 
the  pleura. 

In  order  to  fulfil  these  several  indications  the  first  thing  is  to  make  sure 
that  there  is  really  fluid  in  the  pleura  at  the  point  selected  for  tapping; 
by  percussion,  giving  dulness;  by  auscultation,  showing  the  absence  of 
respiratory  murmur;  and  by  the  change  in  the  shape  of  the  intercostal 
spaces,  bulging  outwards  from  the  pressure  of  the  contained  fluid,  instead 
of  being  concave,  as  in  the  natural  condition  ;  by  the  increased  measure- 
ment of  the  afliected  side  of  the  thorax,  together  with  the  displacement 


^  In  wounds  of  the  internal  mammary,  low  down,  even  the  pericardium  may  be 
opened  and  may  be  filled  with  blood. 

'^  See,  however,  above  (p.  222,  footnote),  N6hiton's  observations  on  the  occurrence 
of  cmiihysemfi  at  the  root  of  the  neck  in  cases  of  laceration  of  the  tissue  of  the  lung 
without  rupture  of  the  visceral  {)leura. 

3  The  chief  authority  on  this  subject  is  M.  Gosselin's  elaborate  article  in  the  first 
volume  of  the  Mem.  de  la  Soc.  de  Ohir.  de  Paris. 


PARACENTESIS    THORACIS. 


229 


of  viscera.  The  next  thing  is  to  make  the  opening  near  the  upper  border 
of  the  lower  rib,  since  the  main  intercostal  vessels  run  near  the  lower 
border  of  the  upper  rib.  The  best  plan,  I  think  (unless  the  parietes  of  the 
chest  are  unusually  thin),  is  to  make  a  lancet  puncture  on  the  lower  rib, 
put  a  finger  nail  into  the  puncture,  and  enter  the  trocar  above  the  finger- 
nail.    The  shape  of  the  trocar  seems  of  little  moment.     The  lung  can 

Fig.  68. 


The  aspirator,  a.  The  perforated  needle  or  sharp-pointed  canula,  which  is  introduced  into  the  col- 
lection of  tluid.  It  communicates  with  the  bottle,  rf,  by  means  of  an  india-rubber  tube,  which  is  inter- 
rupted at  6  by  a  portion  of  glass  tubing,  so  that  the  nature  of  the  fluid  evacuated  can  be  judged  of  at 
once,  and  the  canula  either  plunged  deeper  or  withdrawn.  When  the  handle,  c,  is  in  the  position 
shown  the  communication  between  the  canula  and  the  bottle  is  closed.  The  bottle  is  then  exhausted 
of  air  by  means  of  the  pump,/.  When  c  is  moved  to  c',  the  canula-tube  is  opened,  e  is  the  waste-tube 
of  the  bottle,  and  is  closed  by  a  button  at  e.  In  using  this  aspirator  the  vacuum  is  formed,  and  the 
handle,  c,  is  kept  in  the  position  shown  till  the  canula  has  been  introduced  into  the  fluid,  then  it  is 
turned  to  c',  and  the  fluid  fills  the  bottle.  If  tViere  is  still  more  fluid,  the  handle  is  turned  back  to  c, 
the  waste-pipe  opened,  and  the  fluid  emptied  out  of  the  bottle,  which  is  then  again  exhausted,  and  the 
handle  turned  back  to  c'.    This  is  one  of  the  simplest  of  the  many  forms  of  the  aspirator. 


hardly  be  injured  if  there  is  plenty  of  fluid  below  the  trocar.  The  dia- 
phragm is  avoided  by  not  going  too  low.  A  favorite  seat  for  paracente- 
sis is  in  the  fifth  or  sixth  intercostal  space,  and  just  in  front  of  the  angle 
of  the  scapula,  where  the  intercostal  spaces  are  at  their  broadest.  The 
entrance  of  air  may  be  best  prevented  by  using  an  exhausting  syringe. 
One  fashioned  like  a  stomach  pump  was  in  use  many  j'ears  ago,  and 
acted  very  well.  At  present  Dieulafoy's  aspirator  is  more  commonly 
employed,  and  certainly  answers  its  purpose  admirably.  But  in  tapping 
the  chest  it  must  be  recollected  that  if  fluid  is  to  be  removed  and  no  air 
is  to  replace  it,  this  is  only  mechanicall}^  possible  on  the  condition  that 
the  lung  shall  rise  up  to  take  the  place  of  the  fluid  ;  for  the  only  other 
wa_y  in  which  the  vacuum  could  be  filled  would  be  by  the  bulging  in- 
wards of  the  chest-walls.  But  in  ordinary  circumstances  the  parietes 
cannot  yield  to  any  appreciable  extent.  Now,  if  the  lungs  are  bound 
down  by  adhesion,  and  attempts  to  exhaust  the  fluid  are  made  with  con- 
siderable force,  the  atmospheric  pressure,  acting  through  the  air-passages 
on  the  tissue  of  the  lungs,  is  no  longer  balanced  by  the  pressure  of  the 
parietes,  and  the  tissue  of  the  lungs  is  forcibl}^  thrust  towards  the  pleura 
by  the  air  inside  them,  to  their  great  detriment.  Instances  are  not  want- 
ing in  which  the  lungs  have  thus  been  torn.  Therefore  the  attempt  to 
withdraw  the  fluid  without  the  admission  of  air  should  not  be  persevered 
in  if  there  is  much  resistance.     And  I  cannot  say  that  I  am  myself  con- 


230  INJURIES    OF    THE    ABDOMEN. 

viiiced  of  the  great  danger  of  the  admission  of  air  in  thoracentesis.  Much 
difference  of  opinion  exists  on  the  subject.^ 

The  patient  should  sit  across  tlie  bed,  supported  by  an  assistant,  and 
as  the  fluid  escapes  he  shouUl  be  lowered  nearer  the  horizontal  position, 
the  assistant  keeping  his  hands  on  the  two  sides  of  the  chest.  As  soon 
as  the  fluid  begins  to  stop  it  is  better  to  withdraw  the  trocar,  closing  the 
opening  at  once  with  the  finger,  and  then  witli  strapping,  and  restoring 
the  patient  to  the  horizontal  position. 

When  the  fluid  is  purulent,  especially  if  mixed  with  flakes  of  solid  sub- 
stance, it  seems  better  to  make  a  small  incision  along  the  upper  border 
of  the  rib.  This  is  conveniently  done  by  puncturing  the  pleura  with  a 
grooved  needle,  along  the  groove  of  which,  when  the  pus  has  been  found, 
a  small  knife  can  be  passed. 


CHAPTER  XII. 

INJURIES  OF  THE  ABDOMEN. 

Blows  on  the  abdomen  are  always  to  be  regarded  with  some  apprehen- 
sion. They  often  produce  a  good  deal  of  immediate  shock,  even  when  no 
permanent  ill  effects  follow.  That  a  severe  blow  on  the  epigastrium  may 
destroy  life  by  mere  shock,  without  any  visible  lesion,  is  an  old  doctrine 
which  cannot  be  said  to  be  exploded,  although  Mr.  Pollock  has  shown 
that  much  of  the  evidence  on  which  it  rests  is  highly  unsatisfactory."  If 
the  fact  is  true  its  explanation  is  probably  to  he  sought  for  in  some  direct 
effect  on  the  great  sympathetic  system  around  the  semilunar  ganglia, 
analogous  to  "concussion"  of  the  other  great  nervous  centres.  But  the 
event  is  unquestionably  a  very  rare  one,  and  its  treatment  would  resolve 
itself  into  that  of  collapse  (see  p.  129).  The  more  formidable  immediate 
dangers  in  contusions  of  the  abdomen  are  rupture  of  one  of  the  al)dominal 
viscera,  or  laceration  of  the  peritoneum,  followed  by  acute  peritonitis,  or 
by  chronic  peritonitis,  or  supjjuration  in  or  beneath  the  abdominal  walls.'' 
Cases  where  there  is  no  symptom  of  visceral  lesion,  but  where  the  blow 
has  been  severe,  and  the  |)ain  is  great  or  extravasation  extensive,  should 
be  watched  with  much  care.  'I  he  bowels  should  be  kept  inactive  for 
several  days  by  doses  of  opium  proportioned  to  the  amount  of  pain,  warm 
fomentations  sprinkled  with  laudanum  or  turpentine  should  be  applied 

•  Soe  a  controvorsy  in  the  Brit.  Mod.  .Journal  (1871,  vol.  i)  between  Dr.  Fuller, 
Dr.  Pliiyfair,  Dr.  Doui^las  Powcli,  and  others,  as  to  the  possibility  of  preventing  the 
entrance  of  air  into  th(!  pleura  in  paracentesis,  and  as  to  the  importance  of  doing  so, 
if  pos.sible. 

2  See  Syst.  of  Surg.,  vol.  ii,  p.  020.  Mr.  Le  Gros  Clark,  whilst  admitting  the  pos- 
sibility of  fatal  shock  witlKJUt  visible  b-sion,  says  that  be  has  never  met  with  such  a 
case.     (Op.  cit.,  p.  267.) 

3  In  some  ca.ses  of  severe  contusion  of  the  abdomen  the  muscles  may  be  more  or 
less  lacerated.     It  is  the  rectus  which  is  usually  the  seat  of  this  injury. 


RUPTURE    OF    INTESTINE.  231 

over  the  bell_y,  or  leeches  to  the  painful  part;  and  all  distension  of  the 
intestines  should  be  sedulously  avoided,  the  patient  being  kept  on  meagre 
diet,  given  in  very  small  quantity,  at  short  intervals.  If  peritonitis  comes 
on  it  must  be  treated  according  to  the  general  symptoms  and  the  patient's 
state  of  healtii.  In  all  cases  opium  is  to  be  given  by  the  mouth,  or 
morphia  injected  subcutaneously ;  in  cases  of  sthenic  inflammation  I 
entertain  no  doubt  of  the  good  effects  of  mercury;  and  in  such  cases  free 
bloodletting  is  very  advantageous — twenty  or  thirty  leeches  to  the  abdo- 
men, repeated  if  necessary — or  even  venesection.  In  cases  of  low  diffuse 
suppuration  (whether  internal  or  external  to  the  peritoneal  cavity),  vt'ith 
quick  weak  pulse,  vomiting,  tympanitis,  and  dry  tongue,  stimulants  even 
in  large  quantity  may  be  required.  Suppuration  near  the  seat  of  injury 
should  be  carefully  watched  for,  and  an  early  and  free  exit  given  to  the 
matter. 

Rupture  of  the  Stomach. — The  stomach  is  very  seldom  ruptured  with- 
out direct  wound,  and  when  this  does  take  place  the  collapse  is  sudden 
and  complete,  and  death  occurs  in  a  few  hours.  In  a  well-marked  case 
pulilished  by  the  late  Mr.  Moore, ^  one  of  the  main  symptoms  was  the 
excruciating  pain  which  was  caused  by  the  administration  of  small  quan- 
tities of  brandy.  There  will  probably  be  urgent  thirst,  but  there  will  be 
no  vomiting,  unless  the  rupture  be  very  small  or  incomplete.  No  accu- 
rate diagnosis  is  possible,  and  no  treatment  can  be  of  any  avail.  Mr.  Pol- 
lock conjectures  that  in  some  cases  of  small  laceration,  occurring  possi- 
bly between  the  attachments  of  the  layers  of  omentum,  the  patient  ma}'^ 
temporarily  recover,  with  a  gastric  fistula,  and  quotes  a  case  which  may 
be  so  interpreted. 

The  diaphragm  may  also  be  ruptured  by  a  severe  contusion.  The  only 
known  consequence  is  a  phrenic  hernia.  The  subject  is  discussed  in  the 
chapter  on  Hernia. 

Bupture  of  the  Boicel. — Rupture  of  some  part  of  the  intestine  is  a  tol- 
erably frequent  and  a  very  fatal  injury.  It  occurs  in  any  part  of  the 
bowel,  "  from  the  commencement  of  the  duodenum  to  the  termination  of 
the  sigmoid  flexure  of  the  colon  "  (Pollock).  The  laceration  varies  in 
extent,  being  sometimes  little  more  than  a  pinhole,  at  others  involving 
the  whole  or  almost  the  whole  circumference  of  the  bovvel. 

The  injury  is  cansed  by  severe  contusion,  such  as  the  kick  of  a  horse 
or  the  passage  of  a  wheel  over  the  abdomen  when  the  intestine  is  full ; 
for  there  is  no  evidence  as  far  as  I  know,  that  the  intestine  can  be  rup- 
tured when  collapsed  ;  and  this  is  a  very  important  distinction  between 
rupture  from  contusion  and  perforation  by  direct  wound.  Many  instances 
of  sword  and  bullet  wounds  of  the  intestines  have  been  recorded  in  which 
recovery  has  ensued,  though  the  occurrence  of  fa,'cal  fistula  has  proved 
the  reality  of  the  lesion  of  the  bovvel.'^  And  such  cases  are  easily  intel- 
ligible if  vve  suppose  that  the  bowel  was  empty  at  the  time  of  the  wound, 
so  that  no  foecal  fluid  or  gas  escaped  into  the  peritoneal  cavity  at  the  mo- 
ment of  the  perforation.     For  the  mucous  membrane  of  the  bowel  pro- 

1  See  Syst.  of  Surg,  vol.  ii,  p.  641,  2d  ed. 

2  Amongst  many  other  equally  convincing  cases  I  would  refer  the  reader  to  one 
illustrated  by  a  very  striking  photograph  in  the  Circular  No.  6  of  the  American  Sur- 
geon-General, Nov.  1,  1865,  p.  26."  In  this  case  the  ball  had  passed  clean  through 
the  abdomen  and  emerged  near  the  spine.  There  had  been  ftecal  discharge  from  both 
wounds,  and  a  mass  of  sphacelated  omentum  was  discharged  from  one  of  them.  Still 
the  patient  recovered,  and  was  in  perfect  health  at  the  date  of  the  report. 


232  INJURIES    OF    THE     ABDOMEN. 

trudes  at  once  through  the  lips  of  the  wound  in  tlie  muscular  and  serous 
coats,  and  assisted  by  the  contraction  of  the  muscular  fibres,  so  effectually 
closes  the  aperture  that  no  extravasation  takes  place  at  the  moment  of 
tlie  wound  ;  nor  would  any  extravasation  occur  at  all,  if  renewed  disten- 
sion could  be  prevented.  By  the  time  that  the  injured  bowel  becomes 
distended  with  f.eces  its  wounded  part  has  contracted  adhesions  to  the 
neighboring  coils  and  to  the  parietes,so  that  the  faeces  find  their  way  out 
of  the  external  wound,  not  into  the  peritoneal  cavity.  This  protrusion  of 
the  mucous  coat  occurs  also  in  the  case  of  internal  rupture.'  But  here, 
since  the  bowel  is  distended  when  ruptured,  and  as  there  is  no  other  exit 
for  the  contents  except  through  the  wound,  there  must  occur  instantane- 
ously on  the  rupture  a  free  escape  of  faecal  gas  at  an3'rate,  and  in  all  prob- 
ability an  effusion  also  of  faecal  fluid  into  the  peritoneal  cavity,  though 
the  latter  may  sometimes  be  in  such  small  amount  as  not  to  be  discover- 
able after  death.  Thus  the  germs  of  fatal  inflammation  are  in  all  proba- 
bility implanted  on  the  serous  membrane;  and  there  is  not,  as  far  as  I 
can  discover,  any  perfectly  satisfactory  proof  that  complete  rupture 
through  all  the  coats  of  the  bowel  without  external  wound  has  ever  been 
followed  by  recovery.  At  the  same  time  there  have  unquestionably  been 
cases  in  which  the  symptoms  have  been  held  to  justify  the  diagnosis  of 
ruptured  bowel  w^hich  have  ended  in  recovery  ;  and  the  theoretical  pos- 
sibility of  recovery,  even  in  cases  of  complete  rupture,  has  not  been  dis- 
proved ;  for  we  are  not  entitled  to  assert  that  the  effusion  of  fiecal  gas 
must  inevitably  prove  fatal ;  and  there  is  again  the  remote  possibility 
that  although  the  bowel  may  be  ruptured,  3'et  the  rupture  may  not  impli- 
cate the  peritoneum.  Consequently  the  injury  must  be  treated  with  a 
view  to  recovery. 

Rupture  of  the  intestine  can  generally  be  diagnosed.  After  a  severe 
blow  on  the  abdomen  acute  pain  comes  on  shortly,  before  the  pain  of  the 
injury  has  subsided,  often  accompanied  with  much  collapse  (though  not 
always  so''),  with  urgent  vomiting,  intense  thirst,  great  tenderness  of  the 
abdomen,  involuntary  contraction  of  the  abdominal  muscles,  usually  rapid 
sinking,  with  coldness  of  the  surface,  lividity,  and  loss  of  pulse  some 
time  before  death.  As  the  case  goes  on  the  vomit,  which  at  first  consists 
merely  of  food,  becomes  bilious,  and  then  more  and  more  resembles  the 
contents  of  the  small  intestines  ;  but  I  have  never  seen  absolute  faecal 
vomiting.  Tympanitis  usually  succeeds,  probably  from  paralysis — the 
result  of  an  impression  on  the  sympathetic  system  of  nerves.  The  col- 
lapse which  depends  on  general  shock  may,  as  Mr.  Le  Gros  Clark  points 
out,  be  distinguished  from  tliat  caused  by  haemorrhage,  since  in  the  latter 
case  "the  patient  usually  refers  his  suffering  to  some  isolated  spot,  where 
fulness  or  dulness  on  percussion,  or  l)otli,  may  be  detected." 

Treatment  must  of  course  be  directed  to  prevent  any  reopening  of  the 
laceration — i.  e.,  to  keep  the  lacerated  bowel  perfectly  quiet  until  union 
has  occurred  ;  and  this  is  the  more  important  wlien  we  recollect  that  even 
if  we  believe  all  complete  lacerations  of  the  bowel  to  be  fatal,  yet  we  often 
see  the  distended  intestine  partiall_y  lacerated  on  its  external  surface  in 
cases  of  hernia  by  injudicious  violence,  and  that  if  the  same  thing  took 


1  See  a  case  by  Mr.  Partridge,  Path.  Trans  ,  vol.  xii,  p.  109,  where  death  occurred 
eifjht  days  after  laceration  of  almost  the  whole  circumference  of  the  jejunum.  The 
mucous  membrane  had  so  completely  plu^'ged  the  opening  that  there  was  no  trace  of 
extravasation  of  the  contents  of  the  bowel  into  the  i)eritoncal  cavity. 

^  See  in  Syst.  of  Surg.,  2d  cd.,  vol.  ii,  p.  043,  a  striking  instance  of  the  complete  ab- 
sence of  collapse  an  hour  after  the  receipt  of  an  injury  in  which  the  bowel  was  rup- 
tured. 


IIUPTURE    OF    THE     LIVER.  233 

place  in  contusion  it  might  produce  s3'mptoms  very  similar  to  those  above 
described.  Now,  such  an  incomplete  laceration  would  doubtless  heal 
under  favoral)le  circumstances,  if  the  i)art  is  kept  at  perfect  repose,  whilst 
distension  and  movement  might  easily  render  it  complete,  or  set  up  fatal 
inflammation. 

Ab.^olute  vest  must  be  enforced — i.  e.,  the  patient  must  be  not  only  con- 
fined to  bed,  but  prevented  from  making  the  sliglitest  movement  which 
can  disturb  the  abdomen  ;  opium  must  be  administered  in  small  doses 
often  enough  to  relieve  the  pain,  if  possible,  and  to  keep  the  bowels 
quite  quiet,  while  any  renewed  distension  of  the  intestine  must  be  avoided 
by  a  rigid  abstinence  from  food.  Just  so  much  fluid  nutriment  must  be 
given  in  very  small  quantities  as  will  support  life,  and  thirst  must  be  alle- 
viated by  sucking  small  pieces  of  ice. 

If  the  patient  survives  for  some  days,  and  peritonitis  then  comes  on, 
it  must  be  treated  according  to  the  usual  indications. 

Rupture  of  the  liver  is  a  tolerably  common  injury,  and  one  which  is  not 
necessarily  fatal,  though  it  usually  is  so.'  Cases  have  occurred  in  which 
a  rupture  of  the  interior  of  the  liver  has  been  found,  the  peritoneal  coat 
being  untorn,  and  such  injuries  are  evidently  susceptible  of  repair,  if  they 
do  not  involve  too  large  vessels.  But  it  seems  certain  also  that  small 
lacerations  of  the  surface  of  the  liver  ma}'  heal.  I  once  saw  a  case^  in 
which  all  the  symptoms  of  laceration  of  the  liver  were  certainly  present. 
The  man  recovered,  and,  about  a  year  afterwards,  died  from  another 
cause.  On  dissection  traces  of  some  injury  were  found  on  the  surface  of 
the  liver,  though  it  was  impossible  to  say  exactly  what  the  extent  of  the 
lesion  had  been.'^ 

Rupture  of  the  liver  is  also  sometimes  produced  by  fragments  of  the 
ribs  perforating  the  diaphragm.  Such  injuries  are  almost  of  necessity 
fatal.  Uncomplicated  rupture  of  the  liver  causes  death  primarily,  either 
by  haemorrhage  or  by  extravasation  of  bile  into  the  peritoneal  cavity,  and 
secondarily  by  peritonitis.  When,  therefore,  the  laceration  extends  into 
one  of  the  large  bile-ducts  or  the  gall-bladder^  the  injury  must  prove  fatal; 
and  when  the  substance  of  the  organ  is  so  deeply  broken  up  that  several 
large  vessels  are  laid  open  the  bleeding  can  liardly  be  expected  to  stop. 
It  is  only  the  more  superficial  injuries  in  which  recovery  can  be  antici- 
pated. 

The  diagnosis  of  rupture  of  the  liver  must  commonly  be  only  conjec- 
tural, resting  on  the  nature  of  the  accident,  the  pain  over  the  region  of 
the  liver  (which  is  by  no  means  always  observed),  the  collapse,  the  symp- 
toms of  hseraorrhage,  and  occasionally  the  accumulation  of  fluid  in  the 
peritoneum. 

The  treatment  must  be,  as  in  all  other  similar  injuries,  absolute  rest, 
small  and  rei)eated  doses  of  opium,  the  application  of  ice  to  the  part,  and 
possibly  the  administration  of  styptics. 

If  peritonitis  comes  on  afterwards  the  usual  treatment  must  be  adopted, 
though  antiphlogistic  measures  must  only  be  employed  with  the  greatest 
caution. 


'  Mr.  Le  Gros  Clark  takes  a  still  more  favorable  view  of  these  injuries.  He  says  : 
"If  the  first  efl^"ects  of  shock  and  haemorrhage  are  survived,  recovery  from  lesion  of 
the  liver  or  kidney  is  probablj'  not  infrequent."     (Op.  cit.,  p.  292.) 

*  Path.  Soc   Trans.,  vol.  xi,  p.  140. 

3  Mr.  Pollock  quotes  from  the  records  of  St.  George's  Hospital  a  still  more  conclu- 
sive case.  A  man  died  from  the  effects  of  fracture  of  the  spine  three  weeks  after  the 
accident.  An  extensive  but  not  deep  laceration  of  the  liver  was  found,  which  had 
almost  entirely  healed.     Syst.  of  Surg.,  vol.  ii,  p.  648,  2d  ed. 

''  For  a  case  of  rupture  of  the  gall-bladder  see  Fergus,  Med.  Chir.  Trans.,  vol.  xxxi. 


234  INJURIES    OF    THE    ABDOMEN, 

Bupiurc  of  ihc  SpJpen. — The  s^Mnptoms  of  rupture  of  the  spleen  are 
practically  indistinguishable  from  those  of  rupture  of  the  liver.  The 
situation  of  tlie  contusion,  if  known,  will  justify  a  conjecture  that  it  is 
the  spleen  rather  than  tlie  liver  which  is  rui)tured,  but  no  exact  diagnosis 
can  be  made.  The  treatment,  however,  being  identical,  no  importance 
attaches  to  the  differential  diagnosis.  The  spleen  being  a  still  more 
vascular  organ  than  the  liver,  its  laceration  usually  produces  even  more 
acute  haemorrhage. 

Rupture  of  the  lidney  is  more  common  than  that  of  either  the  liver  or 
spleen,  and  it  is  a  far  less  formidable  injury,  since  it  seldom  involves  the 
peritoneum.  In  fact,  it  seems  probable  that  the  real  nature  of  the  injury 
in  many  of  the  cases  classified  as  "ruptures"  might  be  more  correctly 
described  as  "  bruise,"  there  being  probably  no  visible  laceration.  There 
is  no  doubt,  however,  that  extensive  lacerations  may  heal,  and  a  prepara- 
tion in  the  Museum  of  St.  George's  HospitaP  shows  a  rupture  which  has 
divided  the  kidney  into  two  parts  and  obliterated  the  ureter,  but  from 
which  the  patient  entirely  recovered,  d3'ing  a  year  afterwards  in  conse- 
quence of  granular  degeneration  of  the  other  uninjured  kidney. 

The  symptoms  of  uncomplicated  rupture  of  the  kidney  are  merely  those 
of  a  bruise  on  the  back,  with  haemorrhage  into  the  bladder,  occurring 
immediatel}'  on  the  injur3\  In  the  case  above  referred  to  this  hsematuria 
was  very  transient,  lasting  only  a  single  day,  for  the  ureter  had  evidently 
been  obstructed  by  coagula,  and  thus  all  further  haemorrhage  was  sup- 
pressed. This,  however,  involved  the  entire  loss  of  the  kidney'  as  a 
secreting  organ.  Generall_y  the  bleeding  ceases  gradually,  and  the  viscus 
is  probably  not  seriously  altered  in  structure.  In  some  cases,  if  the  lacer- 
ation has  extended  through  the  capsule,  blood  and  urinous  fluid  get 
infiltrated  around  the  kidney,  and  an  abscess  results  which  usually  pre- 
sents in  the  loins,  and  to  which  an  early  opening  should  be  given.  Similar 
effects  are  attributed  to  laceration  of  the  upper  part  of  the  ureter  or  of 
the  pelvis  of  the  kidne}'.'-  Many  such  cases  have  been  brought  to  a 
favorable  issue.  When  rupture  of  the  kidney  is  complicated  with  lacer- 
ation of  the  peritoneum  in  front  of  it,  the  blood  and  urinous  fluid  will 
pass  into  the  peritoneal  cavity,  and  the  case  will  probably  prove  rapidly 
fatal.  Such  injuries  are  indistinguishable  from  laceration  of  the  liver 
and  spleen,  with  which  they  are  frequently  combined. 

Death  in  uncomi)licated  rupture  of  the  kidney  is  caused  either  primarily 
by  haemorrhage  or  secondarily  by  abscess,  and  this  abscess  may  either 
present  Ijchind  in  the  loin,  when  speedy  exit  is  to  be  given  to  the  matter, 
or  may  make  its  way  in  front,  and  cause  peritonitis  even  in  cases  where 
the  peritoneum  itself  is  quite  uninjured.''  The  treatment  must  therefore 
be  directed  at  first  to  the  suppression  of  haemorrhage  by  complete  rest, 
opium,  leeches  to  the  loins,  and  perhaps  st3q:)tics  (acetate  of  lead  gr.  iii, 
every  three  hours,  or  gallic  acid  in  10-gr.  doses  every  two  hours),  the 
bowels  being  kept  freely  open.  If  blood  collects  in  the  bladder  the 
urine  must  be  drawn  off,  and  the  clots  washed  away  bj'  a  stream  of  water 
injected  through  a  double-eyed  catheter. 

On  the  first  indication  of  abscess  an  exploratory  puncture  must  be 

'  Ser.  xi,  No.  4.    The  ciise  is  roported  in  Path.  Trans.,  vol.  xi.  p.  140. 

^  See  Stanley,  Med.  Chir.  Trans.,  vol.  xxvii,  for  two  cases,  one  of  which  proved 
fatal      The  pelvis  of  thij  kidney  was  found  ruptured. 

3  See  Pollock,  op.  eit..  p.  (>'^S.  May  not  tliis  be  the  explanation  of  a  case  reported 
by  Mr.  Lo  Gros  Clark  (Lectures  on  the  Principles  of  Surgical  Diagnosis,  p.  333),  in 
which  rupture  of  the  bladder  was  suspected  ? 


PENETRATING    WOUNDS.  235 

made,  and  the  abscess  either  opened  by  the  knife  ov  evacuated  with  the 
aspirator. 

Woirnds  of  the  abdomen  are  divided  into  (1 )  superficial  wounds — those 
which  implicate  the  parietes  only  ;  and  (2)  penetraiivg — those  in  which 
the  peritoneal  cavity  is  opened.  Penetratin<)^  wounds  may  be  (a)  simple, 
i.  f.,  there  may  be  no  indication  of  any  injury  to  the  viscera,  or  (b)  the 
viscera  may  be  wounded  but  not  protruding,  or  (c)  the  viscera  may  pro- 
trude, but  uninjured,  or  (f?)  the  protruding  viscera  ma}' also  be  wounded. 

1.  Superficial  wounds  are  to  be  treated  on  the  same  principles  as 
wounds  in  any  other  part  of  the  body,  but  with  this  caution  :  that  as  the 
subperitoneal  si)ace  may  very  probably  be  laid  open,  in  which  haemor- 
rhage may  go  on  to  any  extent,  or  in  whicii  suppuration  may  extend, 
producing  irritation  and  inflammation  on  either  or  both  sides  of  the 
peritoneum,'  the  surgeon  should  always  be  ready  to  enlarge  the  wound, 
with  the  view  of  securing  an}^  vessel  wiiich  may  bleed  deeply,  or  giving 
exit  to  inflammatory  products.  Sir  B.  Brodie's  case  of  ligature  of  the 
external  iliac  artery''  is  a  well-known  example  of  the  beneficial  effects  of 
laying  open  a  non-penetrating  wound  of  the  abdomen  when  suppuration 
is  going  on  in  the  subperitoneal  tissue. 

Foreign  Bodies  lodged  in  Wounds. — In  all  cases  of  wound  of  the  abdom- 
inal parietes  the  surgeon  must  also  be  most  actively  on  the  watch  for  the 
possibility  of  lodgment  of  foreign  bodies.  Many  histories  testify  to  the 
enormous  size  of  foreign  bodies  which  may  be  buried  in  the  abdomen  and 
may  entirely  escape  observation  for  the  time,  though  afterwards  they 
must  produce  most  serious  mischief.  It  is  quite  true  that  exploration 
without  urgent  motive  is  a  proof  of  very  bad  judgment,  but  when  there 
is  any  reason  to  suspect  the  lodgment  of  a  foreign  body  it  should  be  very 
gently  yet  thoroughly  carried  out,  and  the  foreign  substance  at  once  re- 
moved. 

When  any  foreign  body  present  has  been  removed  and  all  bleeding 
vessels  carefully  secured,  the  wound  is  to  be  sewn  up,  and  the  patient 
kept  in  such  a  position  as  will  keep  the  walls  of  the  belly  relaxed.  Even 
if  the  wound  is  somewhat  lacerated,  it  seems  better  to  bring  its  edges 
into  apposition.  In  cases  of  extreme  laceration  the  surgeon  must  use  his 
own  judgment,  inclining  towards  such  an  amount  at  any  rate  of  apposi- 
tion as  v/ill  secure  the  patient  against  the  protrusion  of  the  intestines 
through  the  wound.  Ventral  hernia  is  a  common  consequence  of  abdom- 
inal wounds,  which  is  spoken  of  in  the  chapter  on  Hernia. 

2.  (a)  Pevetraling  ivouvds,  in  which  there  is  no  indication  of  injnry  to 
the  viscera,  or  in  which  the  viscera,  being  exposed,  are  known  to  be 
uninjured,  are  to  be  treated  in  the  manner  so  familiar  to  surgeons  in 
operations  for  hernia  and  ovariotomy,  ?'.  p.,  they  should  be  brought  to- 
gether deeply  enough  to  insure  the  union  of  the  wounded  surfaces  of  the 
peritoneum,  and  the  patient  should,  if  it  seems  necessary,  be  kept  mode- 
rately under  the  influence  of  opium.  Whether  the  sutures  are  passed 
actually  througli  the  peritoneal  edges  or  not  seems  of  little  importance, 
provided  they  are  placed  so  close  to  the  peritoneum  as  to  keep  the 
wounded  portions  of  the  peritoneum  in  contact,  but  it  appears  to  me 
safer  to  take  up  the  peritoneum  as  well  as  the  abdominal  wall  in  the 

1  I  cannot  say  that  I  recognize  the  distinction  which  some  authors  endeavor  to  draw 
between  diffuse  peritonitis  and  ditluse  subperitoneal  inflammation.  As  far  as  I  have 
seen  they  produce  the  same  symptoms  and  often  coexist. 

2  See  Pollock,  op.  cit.,  p.  657. 


236  INJURIES    OF    THE    ABDOMEN. 

suture.  The  suture  will  really,  in  a  very  short  space  of  time,  be  outside 
the  peritoneal  cavity,  beino;  buried  in  ettased  lymph,  while,  if  the  stitches 
are  passed  outside  the  peritoneum,  and  the  edges  of  the  wound  in  the 
peritoneum  should  not  be  in  contact,  a  ready  way  is  left  open  for  the  per- 
colation of  inflammatory  material  into  the  cavity  of  the  peritoneum. 
With  reference  to  the  administration  of  opium,  it  is  well,  I  think,  to  be 
governed  more  by  symptoms  than  by  routine.  I  would  refer  the  reader 
on  this  head  to  remarks,  in  the  chapter  on  Hernia,  on  the  management 
of  cases  after  operation. 

(b)  Wounds  of  Viscera  ivhich  do  not  protrude. — Wounds  in  which  the 
viscera  are  wounded  but  do  not  protrude,  are  amongst  the  most  serious 
injuries  met  with  in  the  abdomen,  and  the  smaller  the  wound  is  the 
greater  may  be  the  danger.  Gunshot  wounds  are  spoken  of  in  another 
cliapter;  the  injuries  commonly  met  with  in  civil  practice  are  either 
stabs  or  incised  wounds.  In  these  the  surgeon  can  often  only  suspect 
the  visceral  injury  from  the  pain  and  collapse  which  are  present,  at  other 
times  the  escape  of  the  contents,  urine,  fiBces,  bile,  or  gas  through  the 
wound  affords  a  certain  proof  of  the  nature  of  the  lesion.  Unfortu- 
nately nothing  can  be  done.  It  would  be  useless  to  cut  down  on  the 
wounded  viscus  with  the  hope  of  preventing  the  escape  of  secretion  into 
the  peritoneum,  for  if  the  peritoneum  has  been  opened  this  effusion  has 
already  taken  place.  An  enterprising  surgeon  might  think  it  worth  while 
to  la}"  the  peritoneal  cavity  freely  open,  stitch  up  the  wounded  viscus, 
and  wash  the  membrane  out  with  an  antiseptic  lotion,  afterwards  uniting 
the  wound  ;  and  I  should  myself  regard  the  operation  as  fully  justifiable, 
but  I  am  not  aware  that  it  has  been  tried.  In  all  other  respects  the 
injury  must  be  treated  like  any  other  grave  wound  of  the  abdomen. 

(c)  Wounds  with  Protrusion  of  Uninjured  Viscera. — When  any  of  the 
abdominal  viscera  protrude  uninjured  through  a  wound,  the  first  care  of 
the  surgeon  should  be  to  free  their  adhesive  peritoneal  surface  from  any 
small  foreign  bodies  which  may,  and  very  often  do,  stick  to  them  ;  then 
return  them  into  the  belly  with  as  little  violence  as  possible,  and  treat  the 
case  exactly  as  after  strangulated  hernia.  The  bowel  or  omentum  pro- 
trudes much  more  often  than  any  of  the  solid  viscera  or  than  the  bladder. 
The  intestine,  if  unwounded,  should  in  all  cases  be  returned,  even  though 
somewhat  contused  or  abraded,  and  for  that  purpose,  if  the  accumulation 
of  air  in  the  bowel,  or  the  thickening  of  its  coats  from  obstruction,  has 
rendered  it  impossible  to  pass  it  back  otlierwise,  the  wound  is  to  be 
gently  enlarged  l\y  a  very  slight  nick  in  one  or  two  places,  just  as  in 
hernia.  A  precaution  is  to  be  observed  which  is  hardly  required  in 
hernia,  viz.,  to  be  very  careful  not  to  push  the  bowel  into  an  interstice 
between  the  muscles  or  into  the  subperitoneal  tissues.  The  finger  should 
be  passed  fairly  through  the  wound,  to  make  sure  that  the  reduction  has 
been  complete.  The  omentum,  though  not  absolutely  wounded,  is  often 
so  altered  in  texture  from  exposure  or  obstruction,  or  so  beset  with 
foreign  l)odies,  that  the  snrgeon  may  fairl}'  prefer  to  remove  it  after  pass- 
ing a  ligature  through  its  base,  of  course  making  sure  first  tliat  no  bowel 
is  implicated  in  its  folds. 

When  any  part  of  the  solid  viscera  jirotrudes  (which,  however,  rarely 
happens,  except  in  shell  or  other  gunshot  wounds),  the  surgeon  will  be 
guided  l)y  the  condition  of  the  protruding  part  and  the  ease  of  reduction, 
in  his  ciioice  between  returning  it,  encircling  it  with  a  ligature,  or  leav- 
ing it  in  situ  ;  nor  are  such  cases  frequent  enough  (at  least  in  civil  prac- 
tice) to  enable  me  to  lay  down  an}^  definite  rule,  but  in  ni}'  opinion  the 
last  course  would  usually  be  the  best. 


FOREIGN    BODIES    IN    STOMACH. 


237 


When  any  of  the  bladder  protrudes  uninjured  a  catheter  must  be 
passed,  and  after  the  bladder  has  been  emptied  reduction  can  hardly 
present  any  diflicnltv. 

(d)  Wounds  with  Protrusion  of  Wounded  Viscera.— If  the  omentum 
protrudes  and  is  injured,  it  should  be  removed.  The  solid  viscera  when 
protruding  ma}'  be  more  or  less  lacerated,  but  the  treatment  of  the  case 
is  not  very  much  affected  thereby.  The  best  plan  would  be  to  put  on  a 
ligature  or  clamp  tightly  enough  to  restrain  hoemorrhage,  and  leave 
things  to  themselves,  treating  the  symptoms  as  they  arise. 

But  the  more  common  case  is  where  the  intestine  protrudes  and  is 
opened.  The  prognosis  depends  mainly  on  whetlier  any  of  the  contents 
have  escaped  into  the  peritoneal  cavity,  whether  the  bowel  is  lacerated  as 
well  as  incised,  and  whether  it  is  or  is  not  entirel}'  divided.  In  the  first 
case  the  result  must  necessarily  be  fatal,  nor  do  the  others  leave  much 
hope  of  survival.  If  the  bowel  is  lacerated  as  well  as  incised  its  ends 
must  be  attached  to  the  wound,  and  an  artificial  anus  formed,^  and  prob- 
ably this  is  also  the  best  course  in  total  division  of  tlie  gut,  though  it  is 
certainly  justifiable  to  sew  the  two  portions  together  with  a  continuous 
suture. 

But  in  wounds  which  affect  only  a  part  of  the  circumference  of  the 
bowel,  the  wound  must  be  united  with  the  continuous  suture^  (just  as  in 
a  post-mortem  examination),  the  thread  divided  as  near  the  knot  as  is 
judged  to  be  safe,  and  the  suture  left 

to  ulcerate  through  into  the  cavity  of  Fk;.  go. 

the  bowel.  While  the  suture  is  thus 
producing  the  slough  of  the  small  por- 
tion of  the  coats  of  the  bowel  embraced 
within  it,  its  material  is  buried  in 
lymph,  which  unites  the  gut  either  to 
neighboring  viscera  or  to  the  parietes, 
so  that  on  the  fall  of  the  suture  no  ex- 
travasation occurs  into  the  cavit}'  of 
the  peritoneum.  The  suture  inclosing 
the  small  slough  falls  into  the  intestine 
and  is  passed  with  the  faeces.    But  this 

reparative  action  may  fail,  and  on  the  to  the  parietes  of  the  abdomen,  e,  or  to  neigh 

separation  of  the    suture    the  contents  boring  coils  of  intestine,  d,  d,  or  probably  in 

of  the  bowel  may  be  extravasated  into  nio^t  cases  to  both,    when  the  suture  separates 

•^    .  ....  it  falls  into  B,  the  cavity  of  the  bowel,  while  the 

the  peritoneal  cavity,  or  the  irritation,  eftuslon  a,  prevents  the  escape  ofthe  contents  of 

instead  of  producing  mere  limited  peri-  the  bowel  into  the  peritoneal  cavity. 

tonitis,  which  will  bury  the  suture  in 

a  circumscribed  mass  of  lymph,  may  set  up  diffused  inflammation  of  the 

whole  membrane,  and  this  may  prove  fatal. 

Foreign  Bodies  in  the  Viscera. — Foreign  bodies  which  lodge  within  the 
stomach  or  intestines  from  having  been  swallowed  are  either  ultimately 
voided  per  anum,  or  else  they  make  their  way  by  ulceration  through  the 
coats  of  the  viscera,  and  then  usually  cause  death  by  effusion,  or  they 
may  lodge  in  the  tube  and  produce  obstruction,  or  finally  they  may  set 
up  inflammation  of  the  viscus  and  of  the  peritoneum  without  having 
caused  perforation.  Mr.  Pollock  divides  these  substances  into  :  1.  Round 
and  flat  bodies,  such  as  money,  fruit-stones,  bullets,  pebbles,  calculi.  These 


Diagram  ofthe  repairof  a  wound  in  the  bowel 
when  united  by  a  suture,  a,  a,  a  represent  the 
lymph  which  is  effused  around  the  wound,  and 
which  glues  the  wounded  part  of  the  bowel,  B, 


'  The  subject  of  artificisil  anus  is  treated  of  in  tlie  chapter  on  Hernia. 
^  See  tlie  diagrams  of  sutures  in  the  chapter  on  Minor  Surgery. 


238  INJURIES    OF    THE    ABDOMEN. 

are  gonorally  the  least  dangerous  in  their  ellects  ;  2.  Materials  wliieh  by 
aecuniulation  form  large  masses,  such  as  hair,  string,  the  husk  of  the  oat ; 
sncli  substances  constitute  the  largest  foreign  masses  met  with  in  the 
food-tube ;  and  3.  Sharp-pointed  or  cutting  bodies,  such  as  pins,  fish  or 
otlier  bones,  knives.  These  are  generally  attended  by  fatal  consequences. 
The  treatment  in  ordinar3'  cases  consists  in  avoiding  purgatives,  giving 
the  i)atient  opium,  if  necessary,  to  quiet  the  bowels  and  alleviate  jmin, 
and  encouraging  him  to  take  a  large  quantity  of  l)ulky,  constipating  food, 
hard-boiled  eggs,  cheese,  etc.  This  is  well  illustrated  by  Mr.  Pollock 
from  the  [)lan  pursued  by  coiners  when  detected  in  their  attempts  to  pass 
false  coin,  'fhey  are  usually  able  to  swallow  and  get  rid  of  even  so  large 
a  piece  as  a  half-crown,  though  the  attempt  is  not  without  its  dangers.^ 

Finally,  in  some  few  cases,  the  operation  of  cutting  into  the  stomach 
and  removing  the  foreign  body  may  be  justifiable,  and  seven  cases  at 
any  rate  are  recorded  in  which  that  operation  has  been  successfully^ 
undertaken.'^  When  the  body  has  passed  through  the  stomach  and  is 
lodging  in  the  intestine  its  removal  by  operation  is  a  matter  of  much  more 
doubtful  prudence,  since  even  large  substances  will  often  ultimatel}' come 
down  to  the  anus.  Yet  in  the  case  of  a  long  pointed  body,  which  can 
hardly  be  expected  to  get  through  the  ileo-ca?cal  valve,  the  surgeon  may 
feel  justified  in  cutting  down  on  it,  where  it  can  be  distinctly  felt.  The 
bowel  must  then  be  drawn  to  the  surface  of  the  wound,  opened  by  as 
small  an  incision  as  possible,  the  body  removed,  the  wound  sewn  up,  the 
gut  returned  into  the  belly,  and  the  case  treated  as  a  wound  of  the 
intestine. 

There  are  other,  very  rare,  cases  in  which  a  foreign  body  becomes 
lodged  in  the  intestine,  which  has  been  passed  up  the  rectum,  and  has  from 
some  unknown  cause  worked  its  way  upwards.  1  once  saw  a  hoy  who 
presented  in  the  right  iliac  and  lumbar  regions  of  tlie  abdomen  a  long, 
hard  substance  which  seemed  to  be  a  foreign  bod}^  and  seemed  to  be 
lodged  in  the  caicum  and  ascending  colon.  It  occasioned  little  inconve- 
nience. The  boy  could  or  would  give  no  history  throwing  any  light  on 
the  matter,  and  the  diagnosis  could  be  only  conjectural.  Ultimately  a 
long  piece  of  wood  (I  believe  the  greater  part  of  a  cedar  pencil)  passed 
from  the  bowel,  which  must  have  been  pushed  up  the  anus  (though  the 
bo}'  would  not  admit  the  fact),  since  it  neither  could  have  been  swallowed 
nor  have  passed  through  the  abdominal  wall.  It  is  also  possible  that  a 
foreign  substance  ma}'  have  passed  into  the  intestine  in  a  gunshot  or 
other  wound  which  has  not  proved  fatal,  but  such  substances  will  only  iu 
the  rarest  instancs  lodge  in  the  intestine. 

The  lodgment  of  foreign  substances  in  the  rectum,  vagina,  and  bladder 
is  common  enough.     The  sul)ject  will  be  discussed  in  the  next  chapter. 

Gaiilrolomy. — It  I'emains  to  say  a  few  words  about  the  operation  by 
which  the  stomach  may  be  opened,  and  the  indications  for  it.  The  opera- 
tion is  i)roperl3-  called  (ja^tnAo^ny ;  but  unluckily,  in  consetpience  of  the 
identity  of  the  Greek  term  for  the  stomach  and  the  abdomen,  the  same 
name  is  also  applied  to  operations  in  which  the  abdomen  is  laid  open,  for 
the  purpose  either  of  relieving  obstiuction  or  of  removing  tumors. 


'  See  Syst.  of  Surg.,  vol  ii,  p.  701,  where  a  fatal  case  is  reported  in  wliicli  a  half- 
crown  h)dged  in  tlie  oesuphagus  prodiirecl  ulcoralion  and  fatal  hieinurrhage  from  the 
aorta.  Mr.  Qiiain  relates  one  in  which  a  pin  which  had  heen  swallowed  passed 
through  the  vermiform  ajjpendix  into  iht;  common  iliac  artery  and  caused  death. — 
Diseases  of  the  Kcctum,  p.  .S'JO 

*  Syst.  of  Surg.,  vol.  ii,  p.  bA^. 


GASTROTOMY    AND    GASTROSTOMY.  239 

Again,  the  operation  of  opening  the  stomach  is  performed  on  two  dif- 
ferent indications:  (1)  when  a  foreign  body  is  to  be  removed,  and  wlien 
the  surgeon  hopes  to  restore  the  patient  to  complete  health;  and  (2) 
when  through  injury  to,  disease  of,  or  pressure  on  the  oesophagus  the 
patient  cannot  take  food,  and  the  intention  of  the  surgeon  is  to  rescue 
him  from  starvation  and  secure  a  permanent  opening — a  sort  of  preter- 
natural mouth — in  the  walls  of  the  stomach,  through  which  food  is  to  be 
introduced  so  long  as  the  patient  lives.  The  latter  kind  of  ojieration  is 
now  often  called  Gastrostomy.  Such  operations  are  so  rare  that  I  must 
com])ress  what  I  have  to  say  about  them  into  a  very  short  space,  referring 
my  readers  who  wish  to  learn  the  details  of  the  recorded  cases  to  Mr. 
Durham's  essay  in  S;jf<f.  of  Surg.,  2d  ed.,  vol.  ii,  p.  543  and  seq.,  or  to  an 
interesting  article  on  the  sul)ject  lately  published  by  Dr.  Pooley  of  New 
York,  in  the  Richmond  and  Louisville  Medical  Journal  for  April,  1875. 
It  is  abundantly  shown  by  these  papers,  which  contain  all  the  recorded 
cases  of  each  kind,  that  gastrotomy,  for  removal  of  foreign  bodies,  is  a 
very  successful  operation.  Mr.  Durham  refers  to  seven  cases,  and  Dr. 
Pooley  adds  four  more,  in  which  foreign  bodies  were  removed,  and  out 
of  the  whole  eleven  only  one  died.^  The  analogy  also  of  accidental  wounds 
of  the  stomach  in  man,  and  of  cases  in  which  the  operation  has  been  per- 
formed experimentally  on  animals,  shows  that  success  may  fairly  be  looked 
for,  and  would  of  itself  amply  justify  the  performance  of  the  operation  in 
cases  where  it  is  clear  that  the  foreign  body  cannot  pass  the  pylorus,  or 
where  its  pointed  shape  or  rough  edges  cause  much  danger  from  its 
sojourn  in  the  stomach.  Out  of  the  eleven  cases  the  foreign  substance 
was  a  knife  in  seven,  and  a  fork  in  an  eighth  case. 

The  operation,  which  is  undertaken  on  account  of  obstruction  to  the 
oesophagus,  "Gastrostomy,"  presents  a  melancholy  contrast  in  its  results, 
for  it  has  proved  uniformly  fatal,  eighteen  cases  having  been  recorded. 
At  the  same  time,  no  one  can  deny  the  reasonableness  of  the  attempt — 
nay,  I  would  add,  that  it  is  the  urgent  duty  of  the  surgeon  to  make  it, 
when  the  cause  of  obstruction  is  injury  of  the  oesophagus  followed  by 
cicatricial  stricture  ;  for  in  such  cases  the  patient  may  possibly  be  kept 
alive  for  an  unlimited  period  if  the  fistula  can  be  established  before  he  is 
too  much  exhausted.  Nor  is  the  attempt  at  all  unreasonable  in  cases  of 
cancer,  especiallj'  if  the  patient  wishes  that  it  should  be  made,  to  rescue 
him  from  an  agonizing  death  by  starvation,  though  his  life  cannot  be  long 
preserved  ; "  and  in  several  of  the  cases  the  operator  has  testified  to  the 
relief  afforded,  and  has  only  regretted  that  he  postponed  the  operation 
so  long  that  the  patient  had  not  strength  to  rally  from  it. 

The  operation  is  generally  performed  by  an  incision  along  the  left  linea 
semilunaris — i.  e.,  from  the  cartilages  of  the  false  ribs  vertically  dovvn- 
wards  along  the  border  of  the  rectus  muscle;  and  the  various  layers  of 
tissue  l)eing  carefully  divided  on  a  director  till  the  peritoneum  is  reached 
and  opened  with  suHlcient  freedom,  the  stomach  will  be  easily  recognized. 
Sometimes  the  omentum  has  presented,  in  which  case  it  must  be  drawn 
downwards,  and  the  wound  extended  upwards  until  the  wall  of  the  stom- 
ach is  exposed.  If  there  be  a  foreign  body  in  the  stomach  its  projection 
will,  of  course,  guide  the  operator.    Then  the  stomach  is  to  be  held  firmly 

1  The  only  fatal  case  is  one  most  cursorily  and  unsatisfactorily  reported  by  Giin- 
ther  as  having  occurred  in  America,  in  the  practice  of  a  surgeon  named  Gliick  with 
no  refertnicc'S  or  details  whatever. 

2  In  one  case  (Maury,  Amer.  Jour.  Med.  Sc,  April,  1870)  the  stricture  was  re- 
garded as  syphilitic,  and  in  such  an  affection,  as  Dr.  Pooley  says,  the  operation,  if 
successful,  might  afford  time  for  the  definite  cure  of  the  disease. 


240  INJURIES    OF    THE    PELVIS. 

with  catch-forceps  suOiciently  far  out  of  the  wound  to  avoid  all  risk  of 
escape  of  its  contents  into  the  abdominal  cavity  ;  a  vertical  incision  is  to 
be  made  just  long  enough  to  extract  the  foreign  body,  and  if  the  muscular 
fibres  of  the  stomach  completely  close  this  incision  after  the  substance 
has  been  extracted  notiiing  further  need  be  done.  The  viscus  is  released 
and  the  external  wound  sewn  up.  Otherwise  the  wound  in  the  stomach 
must  be  united  witli  a  line  continuous  suture.  When  a  permanent  fistula 
is  to  be  formed  (gastrostomy)  the  stomach  is  drawn  into  the  wound, 
fixed  by  interrupted  sutures,  opened  to  the  extent  of  about  an  incli,  and 
then  the  margin  of  the  divided  mucous  membrane  carefully  attached  to 
the  skin  along  the  whole  extent  of  the  opening. 

Other  operators  (as  Sedillot  and  Lowe)  have  made  a  crucial  incision. 
But  on  the  whole  the  best  incision  seems  that  used  by  Mr.  Bryant  and 
Dr.  Maury — ''curvilinear,  the  convexity  presenting  towards  the  median 
line,  commenced  at  the  sternal  extremity  of  the  seventh  intercostal  space, 
and  carried  downwards  and  outwards  for  nearly  four  inches,  exposing 
the  sheath  of  the  rectus  muscle."  This  seems  to  give  readier  access  to 
the  stomach,  and  to  involve  less  tension  on  the  sutures  than  the  vertical 
incision  in  common  use. 

After  the  operation  it  is  well  to  leave  the  parts  entirely  alone  as  far  as 
may  be,  and  therefore  to  support  the  patient  b^^  nutrient  enemata  as  long 
as  possible,  in  order  that  after  the  removal  of  a  foreign  sulistauce  the 
wound  in  tlie  stomach  may  heal ;  or,  in  the  formation  of  a  fistula,  that 
the  edges  of  the  skin  and  mucous  membrane  may  unite  before  any  food 
is  introduced  into  the  stomach.  And  this  forms  another  argument  for 
the  early  performance  of  the  operation,  since  if  the  patient  is  very  much 
exhausted  it  may  be  absolutel^^  necessarj'^  to  feed  him  by  the  stomach  at 
once. 


CHAPTER   XIII. 

INJURIES    OF    THE    PELVIS. 

Contusions  of  the  walls  of  the  pelvis  are  very  common  from  the  pas- 
sage of  carriage-wheels  over  the  body,  from  crushes  of  any  kind,  kicks, 
etc.,  and  very  large  blood-tumors  are  often  seen  in  the  buttock  under  such 
circumstances.  Many  of  the  recorded  cases  of  gluteal  aneurism  have 
been  caused  by  rupture  or  contusion  of  the  arter}^  against  the  bone  on 
which  it  lies.  And  even  when  the  patient  escapes  without  any  serious  ill 
conse(}ucnces  at  the  time,  yet  disease  of  the  bones  may  be  subsequently 
developed — a  malady  which  is  only  too  frequently  fatal.  Such  injuries 
should  l)e  looked  u[)on  with  an  amount  of  care  proportioned  to  the  vio- 
lence indicted;  and  remembering  the  frequency  witii  which  mistakes  have 
been  committed,  in  taking  an  old  blood-tumor,  or,  still  more  unfortunately, 
a  traumatic  aneurism,'  for  an  abscess,  all  possible  care  should  be  given 

*  See  a  paper  on  the  Diagnosis  of  Aneurism,  in  St.  George's  Hospital  Reports,  vol. 
vii,  and  especially  the  case  quoted  on  p.  18L 


FRACTURES    OF    PELVIS. 


241 


to  the  i)hysioal  examination  of  tumors  in  the  buttock  which  follow  after 
contusion.  Auscultation  and  exploratory  puncture  should  never  be  neg- 
lected in  cases  where  anj'  reasonable  doubt  can  exist.  It  must  be  remem- 
bered that  as  these  extravasations  are  below  the  gluteal  fascia  there  is 
rarely  any  sign  of  bruise  or  injury  in  the  skin. 

In  wounds  of  the  buttock  the  chief  point  is  to  determine  the  absence 
of  Ibreign  bodies.  I  have  seen  immense  i)ieces  of  glass  and  other  sub- 
stances imbedded  in  the  buttock  and  quite  overlooked.  In  deep  wounds 
which  penetrate  to  or  near 

the  great  sacro-sciatic  for-  Fk;.  -o. 

amen  and  implicate  tlie 
large  vessels  the  surgeon 
will  re(iuire  all  his  dexter- 
ity and  anatomical  knowl- 
edge in  order  to  secure  the 
gluteal,  sciatic,  or  other 
wounded  artery.^  Yet, 
however  difficult  or  sevei'e 
the  operation  may  be,  it  is 
urgentl}'  indicated,  in  order 
to  save  the  patient  fror. 
worse  dangers.  Possibly 
the  application  of  Lister's 
tourniquet  on  the  aorta 
may  render  the  dissection 
easier  and  less  danaerous. 


Fracture  of  the.  pelvis  is 
usually  a  very  grave  injury, 
less,  perhaps,  on  account 
of  the  danger  involved  in 
the  fracture  itself,  for  the 
bones  unite  readily,  than 
because  of  the  great  vio- 
lence by  which  it  is  usually 
produced  and  the  risk  of 
injury  to  the  pelvic  viscera. 
There  are  partial  fractures 
of  the  pelvis  or  fractures 
of  the  false  pelvis  which 
involve  little  or  no  danger. 
Such  is  the  fracture  of  the 
anterior  superior  spine,  or 
of  the  crest  of  the  ilium, 
in  its  neighborhood,  which 
we  meet  with  occaasionally 
as  the  result  of  direct  vio- 
lence. There  is  pain  in  the 
part,  and  if  only  the  spine 
is  detached  it  is  sometim 
oris  or   the  sartorius,  but 


Fracture  of  the  false  pelvis  irregularly  united.  The  fragments 
are  seen  to  be  a  good  deal  displaced,  and  at  one  part,  a,  is  a  per- 
foration traversing  the  entire  bone.  The  patient  survived  six 
weeks,  and  it  is  seen  that  the  fracture  is  completely,  though  not 
firmly,  consolidated.  Besides  this  fracture  of  the  false  pelvis 
there  was  also  fracture  through  the  horizontal  ramus  of  the 
pubes  and  ascending  ramus  of  the  ischium,  separating  from  the 
rest  of  the  bone  the  fragment  which  is  absent  in  the  drawing. 
These  fractures  were  not  united,  and  a  small  quantity  of  pus 
was  found  between  the  fragments.  The  patient,  a  girl  of  sev- 
enteen, had  sustained  other  severe  injuries,  and  died  of  jjyjemic 
iuflaniniation  of  the  lungs.  St.  George's  Hospital  Museum,  Ser. 
i.  No.  r-'2. 

es   drawn  down    by  the  tensor  vaginai   fem- 
more    commonly  there  is  no  such  displace- 


i  A  very  interesting  case  of  wound  of  the  sciatic  artery,  and  of  the  subsequent  lig- 
ature of  that  vessel,  is  recorded  by  Dr.  Campbell,  of  Montreal,  Lancet,  1862,  vol.  ii, 
p.  41. 

16 


242  INJURIES    OF    THE     PELVIS. 

meut.  Rest  is  all  that  is  necessar}',  and  the  fracture  will  give  rise  to  no 
serious  inconvenience.  Another  fracture,  the  result  of  greater  violence, 
such  as  the  crushing  of  the  body  against  a  wall,  is  that  which  traverses 
the  whole  length  of  the  false  pelvis  or  ala  of  the  ilium.  This  is  a  more 
dangerous  injur}'  than  the  former,  on  account  of  the  possibility  of  lesion 
of  the  intestines  which  lie  in  the  cavity.  I  remember  well  seeing  a  case 
in  which,  after  an  injury- presumably  of  this  kind  (for  its  exact  nature 
was  not  ascertained),  the  whole  of  the  freces  were  discharged  through  the 
outer  side  of  the  right  buttock,  evidently  from  a  bruise  or  partial  lacera- 
tion of  the  CKCum,  causing  afterwards  complete  perforation  of  that  intes- 
tine.' The  patient  ultimately  recovered  perfectly  in  all  respects.  As  the 
viscera  are  far  less  closely  connected  with  the  false  than  with  the  true 
pelvis,  such  complications  are  less  to  be  dreaded  in  fracture  of  the  former. 
Fractures  of  the  true  pelvis  are  commonl}'  double  or  multiple.  Very  often 
the  two  horizontal  rami  of  the  pubes  give  way,  and  the  ascending  rami 
of  the  ischium  may  be  simultaneously  fractured,  so  that  the  whole  of  the 
central  part  of  the  pelvis  is  loose,  or  the  girdle  is  broken  near  the  sacro- 
iliac joint  on  one  side,  and  on  the  opposite  end  of  the  diagonal  axis  of  the 
pelvis  ov  the  other.  But  any  kind  of  multiple  fracture  may  take  place, 
and  on  the  other  hand  single  fractures,  as  of  one  pubic  ramus  or  of  the 
ascending  ramus  of  tlie  ischium  on  one  side,  from  limited  violence,  are 
not  uncommon,  and  in  these  the  entire  pelvis  girdle  can  hardly  be  said 
to  be  broken.  The  s3'mptoms  are  usually  unmistakable.  In  the  com- 
plete fracture  the  patient  cannot  stand,  and  can  hardly  make  any  move- 
ment without  extreme  pain  ;  displacement  is  eas}'  to  ascertain  by  exami- 
nation from  the  rectum  and  vagina  or  from  the  outside,  and  crepitus  can 
be  elicited  b}'  grasping  the  two  iliac  spines  and  making  attempts  at  rota- 
tion. It  is  well  not  to  carry  these  passive  movements  too  far,  remember- 
ing the  serious  consequences  which  may  ensue  from  the  displacement  of 
a  pointed  fragment.  In  the  more  limited  fractures  the  symptoms  are  of 
course  less  striking,  but  there  is  seldom  an}'  difficulty  in  making  the  diag- 
nosis. 

The  prognosis  will  depend  in  a  great  measure  on  the  presence  or  ab- 
sence of  visceral  lesion.  The  rectum,  bladder,  urethra,  small  intestine, 
vagina,  and  perhaps  even  the  uterus,  may  be  wounded  by  a  displaced 
fragment,  or  the  bladder,  if  full,  may  be  ruptured  by  the  shock.'-  In  the 
case  of  the  bladder,  which  is  the  viscus  most  commonly  injured,  the  lesion 
will  be  testified  by  blood  in  the  water,  sometimes  by  entire  inability  to 
pass  water  and  the  other  symptoms  of  complete  rupture.  The  small 
intestine  is  only  implicated  in  very  extensive  injuries  which  commonly 
prove  rapidly  fatal.  In  the  rectum  or  vagina  the  displaced  fragment  can 
be  generally  felt,  and  there  will  be  bleeding  from  the  part. 

Tlie  treatment  consists  merely  in  complete  rest.  In  the  case  of  cliil- 
dren  or  very  restless  adults  the  legs  should  be  tied  together,  or  the  pa- 
tient's movements  confined  by  a  broad  band  pinned  to  the  bed.  The 
body  slioidd  be  so  padded  as  to  give  the  patient  comfcjrtable  support  in 
an  easy  position.  If  displaced  fragments  can  be  felt  from  the  liowel  or 
vagina  they  must  be  replaced  if  possil)le,  for  which  purpose  an  auicsthetic 
is  to  be  given.     Nothing  further  is  required  beyond  attention  to  the  state 


'  Fig.  70  will  illustrato  the  possibility  of  sucli  lesion  of  the  intestine,  by  the  con- 
sidoriible  disphiccment  of  the  fnigments  of  the  ilium,  and  also  the  possibility  of  the 
discharge  of  ficces  through  the  bone,  by  the  large  p(;rforation  in  it  marked  a. 

'■'  In  rare  cases  some  of  the  large  nerves  may  be  injured.  The  Museum  of  St. 
George's  Hospital  contains  a  specimen  (Ser.  i,  No.  119)  of  fracture  of  the  ramus  of 
the  pubes,  in  which  the  obturator  nerve  was  injured.     The  patient  died  of  tetanus. 


FRACTURE  OF  THE  ACETABULUM. 


243 


of  tlie  bowels,  catlieterism  if  necessary,  and  a  watchful  vigilance  as  to 
the  formation  of  matter,  wliich  should  be  at  once  evacuated.  Probably 
in  about  six  weeks'  or  two  months,  if  all  goes  well,  the  patient  will  have 
recovered  tlie  power  of  standing,  and  when  this  is  the  case,  but  not  be- 
fore, he  ma\'  be  allowed  to  leave  his  l)ed.  It  is  much  better  to  keep  liim 
in  bed  longer  than  may  be  absolutely  necessary,  rather  than  to  risk  any 
relapse  by  too  early  disturbing  the  injured  parts. 

Dislocation  of  the  Pelvis. — There  are  various  other  fractures  wliich  are 
more  rarely  met  witli,  and  to  which  our  space  will  only  permit  a  ver}-^ 
short  reference.  Sometimes  the  line  of  fracture  traverses  the  pubic 
symphisis  (Fig.  H),  i.  c,  in  strictness  of  speech,  the  two  ossa  pubis  are 

Fig.  71. 


Corapoimd  comminuted  fracture  of  the  pelvis.  The  patient,  a  boy  set.  5,  died  next  day,  having  re- 
ceived other  severe  injuries,  a  a  shows  a  separation  of  the  symphysis  puhis,  whicli  communicated  with 
a  deep  wound  passing  down  on  the  right  side  of  the  bhidder,  b  (which  was  extensively  separated  from 
its  connections  on  the  right  side,  but  was  not  lacerated),  to  the  front  of  the  rectum,  c.  The  sphincter 
ani  was  partly  torn  on  its  anterior  aspect,  and  there  was  bleeding  from  the  anus;  but  the  bowel  was 
not  further  injured.  The  right  pubic  ramus  is  seen  to  be  comminuted,  separated  from  the  ilium,  and 
fractured  at  the  crest  of  the  pubes.  There  was  also  partial  separation  of  one  sacro-iliac  synchondrosis. 
— St.  George's  Hospital  Museum,  Ser.  i,  No.  1196. 

dislocated  from  each  other ;  and  it  seems  that  dislocation  more  or  less 
complete  of  the  sacro-iliac  joint  may  also  iiajipen,  though  only  as  a  com- 
plication of  more  extensive  injury.  As  in  the  analogous  case  of  the 
spine,  the  surgical  considerations  applicable  to  these  dislocations  differ 
in  no  respect  from  those  of  fracture  in  their  immediate  neighborhood, 
witli  wliich,  indeed,  they  are  usually  associated. 

F7-acture  of  the  Acetabulum. — Again,  fracture  maj^  originate  in  the 
acetabulum.  It  is  not  rare  for  an  extensive  fracture,  starting  from  any 
part  of  the  pelvis,  to  traverse  tiie  acetabulum,  and  such  fractures,  as  in 
two  beautiful  specimens  figured  by  Mr.  Birkett,-  may  unite  quite  kindly, 
thougli  probably  not  without  shortening  of  the  affected  limb.  But  the 
injuries  wliicli  are  described  as  fractures  of  the  acetabulum  are  twofold. 
One  is  a  fracture  of  some  part  of  the  lip  of  the  acetabulum,  and  this  is 
believed  to  occur  either  with  or  without  dislocation.     I  saw  a  case  once 


1  Fig.  70  shows  how  far  repair  may  have  advanced  in  .six  weeks. 

2  Syst.  of  Surg.,  vol.  ii,  pp.  711,  712,  2d  ed. 


244  INJURIES    OF    THE    PELVIS. 

of  dorsal  dislocation  in  which  all  the  symptoms  were  strongly  confirma- 
tor}'  of  the  diagnosis  of  fracture  of  the  acetabnlnm.  The  dislocation 
was  reduced  without  ditlicnlty,  and  nothing  peculiar  was  noticed,  but  on 
visiting  the  patient  next  day  the  surgeon  was  snrprised  to  find  that  it 
had  been  reproduced.  It  was  again  reduced,  but  the  reduction  was  found 
to  be  quite  insecure,  for  it  slipped  out  as  easily  as  it  was  put  in.  And 
now  it  was  thought  that  crepitus  could  be  detected.  The  limb  was  put 
up  as  carefully  as  possible,  but  I  believe  that  some  deformity  persisted. 
Fracture  of  the  lip  of  the  acetabulum  without  dislocation  was  believed 
by  Mr.  Benjamin  Travers,  Jun.,^  to  be  the  injury  in  some  of  those  cases 
in  which,  without  any  proof  of  fracture  of  the  neck  of  the  femur,  the 
upper  end  of  the  bone  becomes  afterwards  changed  in  shape,  so  that 
shortening  gradually  comes  on  ;  but  the  truth  of  this  opinion  has  not  as 
yet  been  proved.  One  of  Mr.  Travers's  cases  was  obviousl}^  an  instance 
of  chronic  rheumatic  arthritis  complicated  with  a  contusion.  The  ace- 
tabulum is  sometimes  driven  in  by  the  forcible  impaction  of  the  head  of 
the  femur  in  falls  on  the  trochanter,  and  this  impaction  in  a  celebrated 
case  related  by  the  late  Mr.  Moore  {Med.-Chir.  Trana.^  vol.  xxxiv)  had 
been  so  complete  that  the  whole  of  the  head  of  the  femur  had  passed 
into  the  inside  of  the  pelvis  ;  yet  the  patient  recovered.  A  few  similar 
cases  are  recorded,  though  none,  as  far  as  I  know,  in  which  the  impac- 
tion was  so  complete  as  this.  The  diagnosis  from  fracture  of  the  neck 
of  the  femur  is  very  difficult.  The  only  case  which  I  have  myself  seen 
was  taken  during  life  for  an  impacted  fracture  of  the  cervix  femoris ;  but 
it  is  fair  to  add  that  the  surgeon  under  whose  care  the  patient  was  thought 
it  better  to  abstain  from  anj^  rigorous  examination.*  If  the  head  of  the 
femur  were  completely  wedged  into  the  pelvis,  as  in  Mr.  Moore's  case,  I 
presume  that  under  chloroform  the  complete  iraraobility  of  the  femur  and 
the  absence  of  any  sign  of  dislocation  would  enable  the  surgeon  to  make 
at  any  rate  a  conjectural  diagnosis  ;  and  if  the  impaction  were  incomplete 
possibly  crepitus  might  be  obtained,  and  might  be  felt  also  in  other  parts 
of  the  pelvis,  but  I  am  not  aware  that  any  case  of  the  kind  has  ever  been 
minutely  examined,  nor  is  it,  perhaps,  justifiable  to  do  so.  Hence  the 
diagnosis  is  as  a  rule  only  conjectural.  As  the  treatment  is  exactly  the 
same  as  for  impacted  fracture  of  the  cervix  femoris,  this  is  a  matter  of 
no  importance. 

Fractui^e  and  Dialocation  of  Coccyx. — Lastly,  the  coccyx  ma_y  be  frac- 
tured or  dislocated.  This  is  commonly  the  result  of  direct  violence, 
though  it  is  said  to  have  taken  place  also  in  parturition.  The  pain  in  the 
part,  felt  especially  in  sitting,  and  the  results  of  exploration  from  the 
skin  and  from  the  bowel,  will  easily'  settle  the  diagnosis.  Reduction  can 
be  accomplished  by  pressure  and  counter-pressure  from  the  skin  and  rec- 
tum, and  the  patient  must  be  kept  at  rest  till  movement  is  no  longer 
painful. 

Rupture  of  the  Bladder. — One  of  the  most  formidable  consequences  of 
contusion  of  the  pelvis  or  lower  part  of  the  alxlomen  is  rupture  of  the 
bladder.  This  occurs  in  both  sexes,  but  is  much  more  common  in  the 
male.  The  bladder  ma}'  also  l)e  perforated  l)y  one  of  the  fragments  in 
fracture  of  the  pelvis,  or  may  be  ruptured  in  fracture  of  the  })elvis  with- 
out any  perforation.  The  symptoms  of  rupture  of  the  bladder,  when  un- 
complicated by  fracture,  are  generally  quite  unmistakable.     The  patient 

'  Further  Observutions  in  Surgery,  1860,  p.  27. 

2  The  prepariition  is  in  the  Museum  of  St.  George's  Hospital,  Sor.  i,  No.  123. 


RUPTURE  OF  THE  BLADDER  245 

loses  at  once  all  power  of  exj)elling  urine,  and  when  the  catlieter  is  passed, 
which  is  unattended  with  any  difliculty,  the  bladder  is  found  perfectly 
empty,  or  only  a  few  droi)s  of  blood}'  fluid  are  drawn  off.  There  is  fre- 
quently severe  pain  and  collapse,  but  often  also  there  is  no  collapse  and 
but  little  pain.'  Sooner  or  later,  however,  the  usual  symptoms  of  perito- 
nitis will  come  on,  and  then  the  patient  will  probably  sink. 

Two  or  three  questions  of  interest  present  themselves  in  connection 
with  the  subject  of  traumatic  rupture  of  the  bladder.  First,  as  to  the 
diagnosis.  This,  as  I  said  above,  is  usually  unmistakable.  After  a 
severe  blow  the  patient  immediately  loses  all  power  of  passing  water.  It 
may  be  merely  retention  from  shock,  following  on  the  contusion  ;  and 
temporary  retention  from  a  blow  on  the  abdomen  is  common,  as  it  is  also 
after  surgical  operations  on  the  abdomen.  But  then  the  catheter  will 
draw  off  a  quantity  of  urine  proportioned  to  the  period  of  retention  ;  and 
this  urine  will  be  free  from  blood,  unless  the  kidney  is  bruised.  Or  it 
may  be  a  case  of  laceration  of  the  urethra,  but  then  there  will  be  consid- 
erable difficulty  in  introducing  the  catheter ;  and  if  the  catheter  can  be 
passed  the  bladder  will  be  found  full  of  healthy  urine.  There  are,  how- 
ever, some  cases  in  which  the  exact  nature  of  the  injury  remains  obscure. 
They  are  chiefly  those  in  which  the  laceration  affects  the  extra-peritoneal 
portion  of  the  bladder,  and  where  the  urine,  not  finding  so  free  an  exit  as 
it  does  when  the  rupture  passes  into  the  peritoneal  cavity,  the  bladder 
preserves  some  power  of  retaining,  if  not  of  expelling,  the  urine.  But 
there  are  other  cases  in  which  somewhat  similar  symptoms  exist,  though 
the  laceration  extends  into  the  peritoneum.'^  In  one  such  case  I  sus- 
pected that  the  laceration  had  at  first  been  incomplete,  and  that  the  rent 
afterwards  gave  way ;  but  others  are  not  susceptible  of  this  explanation. 
The  complete  discussion  of  the  subject  would  lead  us  too  far  in  treating 
of  what  are,  after  all,  very  exceptional  injuries.  Another  very  interest- 
ing question  is  the  possibility  of  recovery  after  traumatic  rupture  of  the 
bladder;  and  this  is  obviously  connected  with  the  situation  of  the  rup- 
ture. If  the  rupture  be  entirely  extra-peritoneal  there  is  no  intelligible 
reason  why  recovery  should  not  ensue  ;  and  one  case  is  recorded  in  which 
this  injury,  complicated  with  fracture  of  the  pelvis,  terminated  in  recovery.^ 
But,  as  a  general  rule,  in  rupture  from  contusion  the  bladder  gives  way 
at  its  upper  part,  and  the  rent  extends  freely  into  the  peritoneal  cavity. 
Is  such  an  injury  necessarily  fatal?  I  confess  that  I  think  not.  If,  in- 
deed, we  believe  that  the  urine  has  some  necessarily^  poisonous  properties, 
its  free  admission  into  the  peritoneal  cavity  must,  of  course,  prove  fatal. 
But  this  seems  rather  assumed  from  the  analogy  of  the  effects  of  extrava- 
sation of  urine  in  stricture  than  proved  by  observation  of  cases  of  rup- 
tured bladder.  I  have  already  refei'red  to  a  case  in  which  there  were  no 
symptoms  of  any  urgency,  though  the  urine  had  been  admitted  to  the 
peritoneal  cavity  for  a  period  of  thirty-six  hours  at  least.     And  I  may  re- 


1  I  well  remember  the  case  of  a  man  who  applied  at  St.  George's  Hospital  on  a 
Monday  morning,  having  received  a  rupture  of  the  bhidder  on  the  previous  Saturday 
evening  from  a  blow  or  fall  when  fighting.  He  walked  to  the  hospital  and  displayed 
no  distress  of  any  sort,  except  some  pain  in  the  part  which  had  been  struck,  though 
on  post-mortem  examination  the  bladder  was  found  extensively  lacerated  and  com- 
municating freely  with  the  peritoneal  cavity. 

2  See  a  very  characteristic  case  in  Le  Gros  Clark,  op.  cit.,  p.  333,  in  which  six  or 
eight  ounces  of  bloody  urine  were  drawn  ofi"  by  the  catheter,  and  the  patient  several 
times  passed  urine;  nevertheless  there  was  a  laceration  of  the  bladder  an  inch  in 
length  communicating  with  the  peritoneal  cavity. 

s^Khynd,  Path,  and  Prac.  Obs.  on  Stricture,  quoted  by  Birkett,  Syst.  of  Surg..,  vol. 
ii,  p.  717. 


24G  INJURIES    OF    THE    PELVIS. 

mark,  tliat  though  the  extravasation  of  putrefying  urine  will  rapidly  de- 
stroy the  cellular  tissue,  3'et  the  constant  exposure  of  transplanted  flaps  in 
the  operation  for  extroversion  of  the  bladder  to  the  contact  of  healthy 
urine  is  not  inconsistent  with  their  nuti'ition  and  rapid  union.  I  am  glad 
to  be  able  to  refer  to  the  high  authority  of  Mr.  Le  Gros  Clark  in  support 
of  the  doctrine  "  that  in  some  instances  the  presence  of  urine  seems  to  be 
tolerated  almost  passively  by  the  serous  membrane,"  and  that  ^  it  seems 
not  improbable  that  urine  may  be  absorbed  by  the  peritoneum"  [op.  cit., 
p.  341).  If  we  lielieve  this  it  seems  reasonable  to  take  a  somewhat  more 
hopeful  view  of  this  injury  than  has  prevailed  as  yet,  and  to  inquire 
whether  something  might  not  be  done  for  its  relief.  The  usual  (practice 
is  to  subdue  the  pain  b}'  opium,  and  to  draw  off  the  water,  if  possible,  as 
it  comes  into  the  bladder  l\v  tying  in  a  soft  catheter,  the  eye  of  which  is 
believed  only  just  to  lodge  within  the  viscus.  But  this  practice  has  ob- 
viously no  curative  efl'ect,  and  the  bladder  in  these  cases  is  usually  so 
collapsed  that  it  is  impossible  to  be  sure  that  the  catheter  is  not  lodged 
in  the  peritoneal  cavity,  in  wliich  case  it  would  effectually  prevent  re- 
covery. Mr.  Bryant'  proposes  to  make  a  free  incision  through  the  peri- 
neum into  the  bladder,  so  as  to  give  a  depending  exit  for  the  urine  as  it 
reaches  that  viscus  ;  but  he  does  not  say  that  the  idea  has  been  put  into 
practice.  It  has  occurred  to  me  whether  it  would  be  justifiable,  when  the 
laceration  clearlj-  involves  the  peritoneal  cavity  (which  could  be  easily 
ascertained  by  examination  with  a  long  staff  or  catheter),  to  cut  freely 
into  the  abdomen,  draw  up  the  bladder,  unite  the  wound  in  it  with  silver 
or  carbolized  gut  sutures,  wash  out  the  peritoneum,  and  close  the  open- 
ing, leaving  a  catheter  in  the  bladder  to  obviate  any  distension  of  the 
viscus,  which  might  reopen  the  wound. 

Rupture  of  the  Urethra. — Another  ver}' formidable  lesion  in  contusion 
of  the  pelvis  is  laceration  of  the  urethra,  which,  though  seldom  directly 
fatal,  involves  often  the  most  formidable  kind  of  stricture,  and  thus  fre- 
quently proves  fatal  indirectly  or  condemns  the  patient  to  a  life  of  misery. 
The  injury  occurs  from  a  fall,  blow  or  kick,  on  the  perineum,  by  which 
the  urethra  is  caught  between  the  contusing  force  and  the  pubic  arch, 
and  is  lacerated  just  in  front  of  the  prostate  gland.  The  laceration  may 
be  total — and  probably  it  is  so  generall}' — but  in  some  cases  a  portion  of 
the  tube  remains  entire,  as  I  have  known  verified  by  dissection.  There 
is  often  some  bruising  in  the  perineum,  though  this  is  by  no  means  nec- 
essarily the  case.  If  the  patient  has  been  neglected  the  urine  may  be 
extravasated,  and  after  a  time  the  skin  will  slough — and  I  have  known 
this  sloughing  assume  considerable  propoitions — but  usually  either  the 
patient  passes  no  water  for  some  time  after  the  injury,  or  it  produces  no 
deleterious  effect,  for  sucii  inflammation  and  slougiiing  are  not  very  com- 
mon. The  passage  of  a  catheter  reveals  at  once  tiie  nature  of  the  injury. 
The  point  of  the  instrument  passes  into  a  cavity  at  the  part  mentioned 
{i.  e.,  just  below  the  pul)es) ;  and  this  cavity  is  often  of  large  size,  con- 
taining a  good  deal  of  bloody,  urinous  fluid.  It  is  sometimes  possible  to 
pass  the  catheter  into  the  posterior  end  of  the  urethra  and  reach  the 
bladder;  and  when  this  is  done  healthy  urine  is  drawn  ofl".  The  instru- 
ment may  then  be  tied  in,  and  the  surgeon  may  wait  for  any  subsequent 
inflammation  or  efli'usion,  when  free  incisions  are  to  be  made.  Usually, 
however,  it  is  found  impossible  to  reach  the  bladder  tiius.  The  patient 
must  then  be  anicsthetized,  put  up  in  the  lithotomy  position,  and  an  in- 


'  Practice  of  Surgery,  p.  306. 


INJURIES    OF    PERINEUM    AND    MALE    ORGANS.  247 

eision  nuist  be  made  through  the  whole  raphe  of  the  perineum,  extending 
freely  into  the  ahovementioned  cavity.  If  other  i)arts  of  the  perineum 
are  swollen  and  inflamed  incisions  ought  to  be  made  into  them.  As  to 
passing  a  catheter  into  the  bladder  the  views  of  surgeons  difli'er.  A  free 
incision  into  the  perineum  is  doubtless  all  that  is  necessary  for  the  mo- 
ment. The  urine  will  escape  through  the  wound,  and  the  patient — who 
is  generally  a  lad  or  a  healthy  young  man — will  in  all  jjrobability  recover. 
As  the  parts  consolidate  it  will  become  possible  to  pass  the  catheter,  and 
for  a  time  all  will  be  well.  On  the  other  hand,  the  retention  of  a  catheter 
in  the  bladder  may  occasion  a  good  deal  of  irritation,  and  it  may  be  nec- 
essary on  that  account  afterwards  to  withdraw  it.  All  this  I  admit;  and 
on  these  grounds  many  of  the  best  authorities  dissuade  any  attempt  to 
reach  the  bladder  and  leave  a  catheter  in  it.  But  it  seems  to  me  that  if 
the  catheter  can  l)e  passed  at  first,  and  if  the  patient  can  bear  it  to  be  left 
in  the  bladder  (which  I  know  by  ex|)erience  that  he  very  often  can),  the 
wound  in  the  urethia  unites  much  more  kindly,  and  with  far  less  tendency 
to  tiiat  sul)sequent  cicatricial  contraction  which  is  so  painful  a  sequela  of 
these  contusions.  In  any  case  the  patient  must  be  warned  that  it  is  only 
by  the  constant  passage  of  the  catheter  after  recovery,  and  that  for  an 
indelinite  period,  that  he  can  hope  to  be  free  from  the  painful  conse- 
quences of  cicatricial  stricture,  which  is  the  worst  form  of  stricture, 
rapidly  contracting  till  the  passage  is  almost  closed;  peculiarly  liable  to 
be  complicated  with  fistula  in  perinreo,  and  often  so  tight  and  irritable  as 
to  cause  much  difficult}-  and  pain  in  passing  the  instrument.  When  this 
is  the  case  the  best  counsels  of  the  surgeon  are  generally  vain,  and  the 
patient  will  not  submit  to  the  necessary  treatment  till  too  late.  Further 
observations  on  the  treatment  of  cicatricial  stricture  will  be  found  in  the 
section  on  Stricture. 

Injuries  of  the  Perineum  and  Male  Organs. — Contusions  and  wounds 
of  the  scrotum  are  comparativel}'  common.  Extravasation  produces  a 
large  ecchymosis,  the  color  of  which  is  generally'  perfectly  black'.  But  it 
is  rarely  followed  by  consequences  which  can  be  regarded  as  at  all  serious, 
unless  it  is  complicated  by  rupture  of  the  urethra  and  extravasation  of 
urine,  when  there  may  be  extensive  sloughing.  Again,  wounds  of  the 
scrotum  are  sometimes  lacerated  to  a  very  great  degree.  The  whole 
scrotum  may  be  torn  off,  and  the  exposed  testicle  or  testicles  may  either 
be  implicated  in  the  injury  or  not.  There  are  also  wounds  inflicted  in 
attempts  at  self-mutilation  in  which  the  parts  may  be  very  freely  removed. 
I  was  once  called  upon  to  treat  a  lunatic  who  had  completely  removed 
the  whole  of  the  generative  organs — penis,  scrotum,  and  both  testicles' — 
leaving  only  about  a  quarter  of  an  inch  of  the  penis.  Other  injuries  of 
the  penis  are  rare,  on  account  of  its  mobility  antl  usual  flaccid  condition. 
All  such  wounds  are  to  be  ti'eated  on  general  principles.  They  are  re- 
markably prone  to  rapid  union  and  complete  repair.  It  is  singular  to 
observe  how  completely  the  new  tissue  will  cover  the  exposed  testicles, 
and  how  well  the  cicatrix  will  replace  the  lacerated  and  removed  scrotum. 
The  testicle,  though  so  exquisitely  sensitive  to  contusion  or  pressure,  is 
singularly  indifferent  to  wounds,  and  has  often  been  punctured  b}'  mistake 
in  the  operation  for  hydrocele,  or  incised  in  treating  orchitis,  with  perfect 
impunity.  In  the  instance  above  referred  to  nothing  was  necessaiy  except 
to  tie  one  of  the  spermatic  arteries,  the  other  having  ceased  to  bleed,  and 
the  patient  recovered  rapidly  under  the  use  of  simple  water-dressing. 

'  The  parts  are  preserved  in  the  Museum  of  St.  George's  Hospital,  ser.  xiii,  No.  1. 


248  IX  JURIES  OF  THE  PELVIS. 

But  whenever  llie  uretlira  is  divided  it  is  necessary  either  to  keep  a 
catheter  in  the  bladder  while  it  is  healing,  or  to  i)ass  the  instrument  fre- 
quently ;  and  if  the  penis  is  cut  off  the  same  precaution  should  be  adopted 
as  after  amputation  of  the  organ,  viz.,  to  keep  the  urethra  permanently 
open  by  slitting  it  up  and  attaciiing  the  mucous  membrane  to  the  skin 
(see  Amputation  of  the  Penis).  The  most  troublesome  cases  are  those 
of  wounds  of  the  corpora  cavernosa,  which  are  apt  to  be  followed  by  very 
distressing  erections  and  by  deformity  of  the  organ.  All  wounds  of  the 
male  organs  of  generation  require  very  careful  adaptation  by  means  of 
sutures.  And  in  wounds  of  the  scrotum  the  extremely  retractile  nature 
of  the  dartos  should  be  remembered.  The  testicles  ma}^  be  most  freely 
exposed,  and  the  surgeon  be  tempted  to  believe  that  the  scrotum  has  been 
almost  torn  off,  yet  if  the  part  be  relaxed  by  the  application  of  warmth 
and  moisture  for  an  hour  or  two  he  may  find  that  there  is  really  little  if 
any  loss  of  tissue,  and  that  the  scrotum  can  be  perfectly  adjusted  ;  and 
iu  such  injuries  if  the  spermatic  cord  is  severed  Mr.  Birkett  believes  that 
its  repair  is  not  impossible,  if  the  ends  of  the  vas  deferens  are  united  by 
suture.     At  any  rate  the  attempt  seems  worth  making. 

The  painful  consequences  of  contusion  of  the  testicles  are  best  combated 
by  complete  rest,  supporting  the  testicles  in  some  soft  substance,  with 
warmth  and  moisture.  If  the  patient  suffers  severely  morphia  should  be 
injected  subcutaneously. 

Ligature  round  the  Penis. — Another  injury  which  we  meet  with  some- 
times is  that  in  which  children  in  play,  or  sometimes  in  fright  from  having 
been  beaten  for  wetting  the  bed,  tie  a  string  tight  round  the  penis.  Tlie 
nature  of  the  case  is  known  at  once  by  the  swelling  of  the  front  part  of 
the  organ,  and  the  deep  groove  seen  behind  the  swollen  part.  Auffisthesia 
should  be  at  once  induced,  and  the  string  carefully  divided  on  the  dorsal 
aspect  of  the  penis  and  removed.  If  this  is  not  done  I  have  seen  the 
urethra,  and  even  almost  the  whole  penis,  cut  through  by  the  ligature, 
causing  irreparable  and  most  painful  deformit3\ 

Injuries  of  the  External  Female  Organs. — Injuries  of  the  labia  and 
female  perineum  from  blows  and  kicks  are  common  enough.  The  ecchy- 
mosis,  as  in  the  scrotum,  is  usually  abundant  and  very  dark-colored. 
The  skin  may  be  more  or  less  lacerated,  and  sometimes  the  perineum 
may  be  slightly  torn,  but  it  is  very  rare  for  an}'  serious  laceration  of  the 
perineum  to-be  caused  by  a  wound.'  Nor  are  the  consequences  of  con- 
tusion usually  serious.  If  neglected,  abscess  may  ensue,  so  that  rest  is 
to  be  enjoined,  and  the  application  of  an  icebag  or  evaporating  'lotion  is 
generally  advisable  at  first,  in  order  to  check  the  extravasation.  After- 
wards warm  fermentation  is  more  soothing  and  grateful. 

Wounds  of  tlie  vulva  may  involve  the  vagina  to  a  greater  or  less  de- 
gree, or  may  pass  into  the  rectum  or  bladder,  or  the  vagina  may  be  torn 
in  coitu  ;■  but  the  vagina  is  more  often  wounded  by  the  unskilful  use  of 
instruments  in  delivery,  or  b}'  bungling  attempts  to  procure  al)ortion.  The 
latter  cases  hardly  fall  within  the  surgeon's  province.  The  main  point  to 
bear  in  mind  in  the  treatment  of  wounds  of  the  vagina  is  the  probability 
of  contraction  from  cicatrizatioJi,  and  the  great  difficulty  and  |)ain  which 
this  will  produce  in  sexual  intercourse.     So  that  all  possible  care  should 

1  1  do  not  hero  spciik  of  injuries  to  the  external  parts  in  criminal  assaults,  as  this 
subject  is  best  treated  along  with  the  questions  of  medical  jurisprudence.  The  surgi- 
cal injuries  so  inflicted  ar(;  trivial. 

*  St.  George's  Hospital  Museum,  ser.  xiv,  No.  108. 


FOREIGN    BODIES    IN    BLADDER.  249 

be  used  to  maintain  dilatation  of  the  vagina  durino-  the  union  of  the  wound, 
and  for  some  time  afterwards. 

The  nnimpregnated  uterus  is  so  small,  so  hard,  so  movable,  and  in  so 
remote  a  situation  that  it  can  hardly  be  wounded  except  in  complicated 
injuries  in  which  this  would  be  quite  a  subordinate  feature.  And  the  in- 
juries of  the  pregnant  uterus  seem  better  left  to  works  on  obstetrics,  since 
they  could  hardl}-  be  treated  of  adequately  here.  They  are  rarely  the 
result  of  mere  accident,  but  constantly  occur  in  criminal  attempts  to  pro- 
duce abortion,  and  sometimes  in  unfortunate  instrumental  delivery,  with 
or  without  want  of  skill.  For  a  comi)rehensive  account  of  the  surgical 
aspects  of  these  cases  the  reader  is  referred  to  the  account  by  Mr.  Birkett 
and  Dr.  Braxton  Hicks  in  tiie  Syst.  of  Surg.^  second  edition,  vol.  ii,  p.  741 
and  seq. 

Either  the  rectum  or  the  bladder  may  be  penetrated  by  a  wound.  In 
the  male  sex  the  bladder  can  only  be  wounded  through  the  abdominal 
wall  or  the  rectum,  but  in  the  female  it  may  be  punctured  through  the 
vagina.'  In  all  such  cases  as  those  last  mentioned  the  greatest  care 
should  be  taken  to  sew  up  the  wound  at  once,  and  keep  a  catheter  in  the 
bladder,  when  the  wound  will  probaI)ly  heal,  if  its  edges  are  clean  cut.  In 
stabs  of  the  bladder  from  the  abdomen  the  risk  of  extravasation  of  urine 
is  great,  and  they  are  very  often  fatal,  and  this  danger  is,  of  course, 
greatly  increased  when  the  peritoneal  cavity  is  also  implicated,  I  think 
it  is  usually  desirable  in  wounds  of  the  bladder  to  keep  the  viscus  emptied 
by  means  of  a  catheter  tied  in,  though  on  this  subject  the  surgeon  must 
use  his  own  discretion,  remembering  the  risk  of  lodging  the  point  of  the 
instrument  in  the  wound.  In  other  respects  no  treatment  can  be  applied 
except  that  which  may  be  demanded  by  the  symptoms. 

Wounds  of  the  rectmn  are  produced  usually  by  falling  on  a  stake  or 
railing.  They  are  not  generally  fatal,  and  if  not  fatal  they  lead  to  no 
serious  consequence.  I  am  not  aware  that  any  case  is  recorded  in  which 
contraction  of  the  bowel  has  been  thus  produced.  But  when  the  stake 
or  other  weapon  has  passed  far  in  it  may  lacerate  the  peritoneal  cavity, 
or  the  great  vessels  in  the  pelvis  or  the  bladder.  The  first-named  injury 
may  be  regarded  as  inevitably  fatal,  and  the  second  will  probably  be  so. 
Of  the  third  two  cases  are  recorded,'^  one  of  which  survived.  No  special 
treatment  can  be  adopted  in  any  of  these  forms  of  injury. 

Foreign  Bodies  in  the  Bladder. — Foreign  bodies  may  be  introduced  into 
the  male  or  female  urethra  or  bladder,  into  the  vagina  or  rectum.  They 
may  also  lodge  in  any  of  these  situations  in  cases  of  wounds,  but  this  is 
most  common  in  gunshot  wounds  ;  and  as  the  surgical  considerations  are 
the  same  in  all  such  cases  the  reader  is  referred  on  that  head  to  the  chap- 
ter on  Gunshot  Wounds. 

Foreign  bodies  lodged  in  the  male  urethra  may  commonly  be  extracted 
with  the  forceps,  since  they  lie  generally  very  far  forward,  and  must  be 
smooth  and  rounded,  or  they  would  not  be  introduced.  But  in  some  cases 
fragments  of  bougies  or  of  other  substances  introduced  may  break  off  in 
the  deeper  parts  of  the   urethra  beyond  reach  of  the  forceps.     The  best 

^  In  the  section  on  vesico-vaginal  fistula  will  be  found  a  reference  to  a  singular  case, 
in  which  that  infirmity  was  caused  by  the  passage  of  a  pistol-bullet  from  the  vulva 
through  the  vagina  into  the  bladder. 

2  By  Mr.  Prescott  Hewett,  Path.  Soc.  Trans  ,  vol.  i,  p.  152 ;  and  by  Mr.  Buee,  of 
Slough,  Syst.  of  Surg.,  vol.  ii,  p.  722. 


250  INJURIES    OF    THE    UPPER    EXTREMITY. 

plan  then  is  to  try  and  pnsh  the  substance  back  into  the  bladder,  and 
break  it  to  pieces,  or,  if  small,  remove  it  entire  with  the  lithotrite.  If  this 
is  impossible  tlie  foreign  body  must  be  cut  down  upon  from  the  middle 
line  of  tiie  perineum  and  extracted.  Of  the  foreign  substances  which  are 
lodged  in  the  male  bladder  a  fragment  of  an  old  worn-out  bougie  or  gum- 
catheter  is  by  far  the  most  common,  and  these  can  usually  be  caught  in 
a  lithotrite,  and  if  shiall  extracted  entire,  while  if  of  large  size  they  can  be 
cut  to  pieces  and  will  pass  of  themselves.  If  the  substance  cannot  be 
caught,  or  is  too  hard  or  too  large  to  bi'eak,  it  must  be  extracted  b}'  lith- 
otomy, and  lithotomy  in  such  cases  is  far  more  successful  than  in  cases 
of  stone,  since  the  urinary  organs  are  probably  healthy.  One  of  the  most 
troublesome  foreign  bodies  to  deal  with  is  a  hairpin  in  the  female  bladder. 
It  is  not  at  all  uncommon  fortliepin  to  be  passed  up  the  urethra,  of  course 
with  its  bend  towards  the  bladder,  and  then  to  slip  into  the  bladder  and 
expand,  its  points  sticking  into  the  mucous  membrane,  and  awkward  at- 
tempts at  extraction  will  aggravate  the  mischief.  The  best  treatment  is 
to  dilate  the  urethra  sutHciently  to  introduce  the  finger,  when  tlie  foreign 
substance  may  be  dislodged,  or  be  drawn  down  b}'  a  hook  passed  round 
its  bent  end,  or  its  two  points  may  be  brought  together  and  a  tube  or 
forceps  applied  round  them. 

Foreign  bodies  are  sometimes  passed  into  the  vagina,  and  the  patient 
is  unable  to  extract  them,  and  will  not  appl)^  for  relief  till  they  have  occa- 
sioned much  mischief  I  once  saw  a  case  in  which  the  end  of  a  phial  was 
lodged  in  the  vagina  and  had  made  its  way  by  ulceration  into  the  bladder, 
causing  a  most  formidable  and  perfectly  incurable  form  of  vesico-vaginal 
fistula.  It  is  not  uncommon  for  the  string  of  a  pessar}^  to  break,  and  the 
substance  to  be  left  in  the  vagina  till  it  becomes  very  foul  and  offensive. 
All  such  foreign  bodies  should  be  removed  at  the  earliest  possible  mo- 
ment, under  anaesthesia  if  necessary. 

Foreign  bodies  in  the  rectum  ma}'  be  of  very  large  size,  but  there  is  no 
difticnlty  whatever  in  extracting  them  under  chloroform  after  dilatation 
of  the  anus  :  or  if  the  surgeon  judges  it  better  they  may  be  broken  up,  as 
is  usually  done  in  the  hardened  lumps  of  fneces  which  sometimes  obstruct 
the  lower  part  of  the  bowel.  This  can  be  effected  with  the  handle  of  a 
spoon  or  with  a  lithotomy  scoop.  Harder  substances  may  require  a  strong 
pair  of  forceps,  or  even  cutting  pliers.  But  in  all  cases  the  extraction  of 
sharp-pointed  fragments  at  once  is  imperative. 


CHAPTEE   XIV. 

IN.IUJUES  OF  THE  UPPER  EXTREMITY. 

All  injuries  of  the  shoulder,  arm,  forearm,  or  hand  are  less  serious 
than  the  similar  injuries  of  the  hip,  tliigii,  leg,  or  foot.  The  main  rea- 
son of  this  is  no  douI)t  the  freer  su|)ply  of  blood  to  the  part;  but  even 
irrespective  of  this  there  is  a  specific  difference  in  the  effects  of  disease 


WOUNDS    OF    PALMAR    ARCH.  251 

on  the  two  limbs  respectively.  Thus  gangrene  of  tlie  arm  is  of  far  less 
consequence  than  of  the  leg,  and  a  wound  implicating  the  shoulder  does 
not  involve  anything  like  the  same  danger  to  life  as  one  of  the  hip. 

Again,  the  fact  that  injuries  of  the  upper  extremity  do  not  necessitate 
confinement  to  bed  or  to  the  house  renders  them  in  many  respects  less 
depressing  than  those  of  the  lower. 

From  tliese  and  sucli  like  considerations  it  results  that  the  surgeon 
may  venture  on  attempts  to  preserve  the  upper  limb  in  traumatic  inju- 
ries, or  in  lesions  from  disease,  which  in  the  lower  limb  would  impera- 
tively call  for  the  removal  of  the  diseased  part ;  that  when  the  diseased 
part  must  be  removed  he  may  venture  on  operations  of  excision  or  resec- 
tion which  would  not  be  justifiable  in  the  lower  limb ;  and  that  even 
when  he  knows  the  parts  to  be  damaged  beyond  the  possibility  of  repair 
he  may  often  think  it  the  best  course  to  wait  for  gangrene  rather  tlian 
remove  any  part  which  might  ultimately  recover  itself. 

And  for  the  same  reason  minor  injuries  are  susceptible  of  more  active 
treatment  in  the  upper  extremity,  because  the  surgeon  is  less  apprehen- 
sive of  the  occurrence  of  suppuration  from  too  early  use  of  the  part,  or 
from  friction  or  passive  motion,  and  less  apprehensive  also  of  its  results 
if  it  does  occur. 

Foreign  bodies  (thorns,  needles,  etc.)  often  lodge  in  the  psdm.  They 
are  frequently  hard  to  detect,  since  a  piece  of  indurated  tissue  may  be 
mistaken  for  the  end  of  the  needle.  Unless  the  patient  is  suffering  much 
inconvenience,  it  is  a  good  rule  not  to  cut  down  on  a  supposed  needle  in 
the  hand  or  foot  without  being  able  to  feel  both  its  ends. 

Wounds  of  either  jM  I  mar  arch  are  frequently  troublesome  in  their  treat- 
ment and  dangerous  in  their  results,  in  consequence  of  the  very  free 
anastomosis  which  takes  place  between  the  two  arteries  which  form  either 
arch.  The  superficial  arch,  it  is  true,  is  much  less  deeply  situated,  and, 
when  wounded,  it  can  be  reached  and  secured,  without  wounding  any 
other  Important  structure,  provided  the  patient  be  seen  soon  after  the 
injury  ;  but  then,  ver}^  frequently  this  is  not  the  case  ;  on  the  contrary, 
the  parts  have  become  so  infiltrated  with  blood  that  it  is  impossible  to 
find  tiie  bleeding  orifice.  And  when  the  deep  palmar  arch  is  wounded  its 
position  beneath  the  great  nerves  and  tendons  renders  it  almost  impossi- 
ble to  tie  it  without  very  serious  injury  to  the  structure  and  functions  of 
the  hand,  even  irrespective  of  any  infiltration  of  blood. 

In  tliese  injuries  the  first  object  of  the  surgeon  is  to  stop  the  bleeding 
long  enough  to  allow  the  wound  in  the  artery  to  close,  and  this  can  gen- 
erally be  done  b}'  careful  pressure  witli  pad  and  bandage,'  assisted  by  the 
raised  position  of  the  hand,  or  by  acute  flexion  of  the  elbow,  whereby  the 
brachial  artery  is  compressed  against  the  coronoid  process,  or  by  grad- 
uated pressure  on  the  radial  and  ulnar  arteries,  or  by  a  combination  of 
the  last  with  one  of  the  two  former  methods.  Such  compresses,  when 
once  applied,  should  not  be  moved  for  several  days  unless  from  absolute 
necessity. 

Professor  Yanzetti  has  lately  suggested  a  method  which  he  calls  "  unci- 
pression,"  i.e.^  the  pressure  of  a  single  or  double  hook  on  either  lip  of 
the  wound,  as  described  on  p.  125,  which  seems  especially  suitable  for 
these  wounds  of  the  palm,  since  it  makes  constant  pressure  on  the  bleed- 
ing orifice,  without  giving  pain  or  producing  either  oedema  or  sloughing, 

1  A  good  way  of  securing  these  pads  is  to  make  pressure  on  them  with  a  splint  in 
front,  which  is  connected  with  and  supported  by  another  splint  behind  the  hand. 


252 


INJURIES    OF    THE    UPPER    EXTREMITY. 


Fig.  72. 


\Yhicli  often  necessitates  the  removal  of  the  compresses  applied  to  the 
wound. 

If  the  bleeding  cannot  be  thus  suppressed  by  pressure  in  and  above 
the  wounds  two  courses  are  open — viz.,  either  to  tie  both  arteries  of  the 
forearm  just  above  the  wrist,  or  to  tie  the  bracliial  artery  at  once.  Like 
all  operations  in  which  an  artery  is  tied  higher  up  in  order  to  stop 
hferaorrhage  from  a  wound  below,  both  these  methods  of  treatment  are 
uncertain.  The  weight  of  authority  seems,  however,  to  be  in  favor  of  the 
ligature  of  the  brachial  at  once,  rather  than  that  of  the  two  arteries  of 

the  forearm.  Ijigature  of 
one  of  the  latter  without 
the  other  appears  nuga- 
tory. In  some  cases  it  has 
been  deemed  necessary  to 
amputate  the  hand  in  order 
to  save  the  patient  from 
death  by  haemorrhage;  but 
I  would  repeat  that  care- 
ful plugging  and  pressure 
on  the  wound,  immediately 
after  the  injury,  will  genei*- 
ally  stop  the  haemorrhage, 
and  render  all  ligature  of 
the  arteries  unnecessary. 


Fractures  of  the  Clavi- 
cle.— The  clavicle  may  be 
fractured  in  any  part  of  its 
extent,  but  the  middle  of 
the  bone  is  that  in  which 
fracture  is  by  far  the  most 
common.  The  accident  al- 
most always  takes  place 
from  indirect  violence,  i.  e., 
from  a  fall  on  the  hand  or 
on  the  point  of  the  shoul- 
der. The  common  fracture 
of  the  clavicle  is  easily 
recognized  in  most  cases 
from  the  characteristic  dis- 
placement. The  bone  gives 
wa.y  at  its  most  curved  part.  The  outer  fragment,  to  whicli  the  whole 
weight  of  tlie  arm  is  now  connected,  falls  downwards,  and  is  possibly 
drawn  down  also  by  the  muscles  which  pass  from  it  to  the  arm.  It  is 
also  almost  always  tucked  inwards  below  the  outer  fragment  by  the  action 
of  the  flaps  of  the  axilla,  or  by  the  impulse  of  the  fall,  or  by  both.  The 
inner  fragment  is  believed  by  some  surgeons  to  be  raised  by  the  sterno- 
niastoid  muscle,  l)ut  this  seems  unlikely,  as  the  attachment  of  the  rhom- 
boid ligament  is  sufllcient  to  prevent  any  such  disi)lacement.'  No  doubt, 
however,  the  displacement  in  this,  as  in  all  other  fractures,  depends  a 
good  deal  on  the  direction  of  tlie  line  of  fracture,  and  accordingly  we  see 
specimens  in  whicli  the  outer  fragment  lies  on  the  same  level,  in  front  or 
behind  the  inner,  and  even  above  it. 

1  See,  however,  a  case  related  by  Mr.  Hulko,  in  which  the  sternal  fragment  was 
raised  up  at  an  angle  of  46°.     Syst.  of  Surg.,  vol.  ii,  j).  7G6. 


Diagram  of  the  common  fractures  of  the  clavicle  (after 
Hind,  raoclifled).  st,  sterno-raastoid  muscle,  r  p  p,  pecto- 
ralis  major  muscle,  p  m,  pectoralis  minor  muscle,  s,  subcla- 
vius  muscle,  l,  latissinius  dorsi  muscle,  c,  conoid  ligament. 
T,  trapezoid  ligament,  c  h,  coraco-liumeral  ligament,  it, 
rhomboid  ligament.  A  fracture  is  shown  in  the  usual  posi- 
tion, and  with  the  usiiar  displacement — the  outer  fragment 
downwards  and  inwards — and  the  muscles  are  shown  to  which 
that  displacement  is  generally  attributed.  Another  fracture 
is  shown  between  the  conoid  and  trapezoid  ligaments,  and  this 
fracture  is  shown  as  not  being  displaced,  according  to  the  gen- 
eral opinion. 


FRACTURf^S  OF  THE  CLAVICLE. 


253 


This  fracture  is  very  rarely  coniponnd,  and  it  is  very  rare  for  any  seri- 
ous complications  to  accompany  it.  But  tiie  nerves  of  tiie  brachial  jjlexus, 
or  one  of  the  large  bloodvessels  may  be  injured.  There  is  a  si)ecinien  in 
the  Museum  of  St.  George's  Hospital,  showing  the  internal  jugular  vein 
punctured  by  a  fragment  of  the  clavicle,  and  Sir  Robert  Peel's  deatli  was 


Fig.  73. 


Fig.  74. 


Bandage  for  fractured  clavicle  comraenced. 


Bandage  for  fractured  clavicle  complete. 


produced  by  a  somewhat  similar  injury.  In  some  very  rare  cases  of 
direct  violence  both  clavicles  are  fractured  simultaneously. 

The  fracture  is  susceptible  of  very  complete  repair,  and  in  cases  where 
there  has  been  no  displacement  this  will  be  unaccompanied  by  any  de- 
formity ;  usually',  however,  considerable  displacement  remains  during 
life,  though  it  entails  no  ill  effects  l)eyond  the  slight  disfigurement.  The 
periosteum  appears  to  be  often  untorn,  especially  in  early  life,  and  pos- 
sibly in  some  of  these  cases  the  fracture  may  have  been  incomplete,  or  of 
the  "green-stick"  variety,  as  shown  in  the  figure  on  page  138. 

The  method  of  union  is  often  by  an  exuberant  or  provisional  callus. 
The  period  of  union  is  from  three  to  four  weeks,  after  which  no  apparatus 
is  necessary,  though  it  is  prudent  for  the  patient  to  carr}'  his  arm  in  a 
sling  for  a  time.  The  number  of  ditferent  contrivances  for  the  treatment 
of  fractured  clavicle  testifies  to  the  difficulty  of  keeping  the  bones  in 
contact,  and,  in  fact,  it  is  always  proper  to  prepare  the  patient's  mind  for 
the  continuance  of  deformity.  The  old  plan  attempts  to  fulfil  three  indi- 
cations :  1.  Reduction  is  eS'ected  by  drawing  both  shoulders  backwards, 
and  raising  the  affected  shoulder  b}^  the  hand  in  the  axilla,  the  surgeon 


254  INJURIES    OF    THE     UPPErf'  EXTREMITT. 

standing  behind  the  patient,  and  pressing  his  knee  betvveen  the  scapulae. 
To  remedy  the  disphxcement  of  the  outer  fragment  inwards  tlie  shoulders 
are  then  kept  hack  by  a  fignre-of-8  bandage  encircling  both  axillae 
and  crossing  behind.  2.  Before  applying  the  bandage  a  thick  pad  is 
placed  in  the  axilla,  in  order  to  raise  the  shoulders  and  prevent  the  dis- 
placement of  the  outer  fragment  downwards.  3.  Next,  in  order  to  ob- 
viate the  tendency  to  loosening  of  these  bandages,  the  arm  and  hand  are 
encircled  and  bound  to  the  chest  by  a  broad  bandage,  which  also  fixes 
the  scapuUv.  All  the  turns  of  the  bandage  should  be  stitched  together, 
or  painted  lightl}'  with  starch.  This  apparatus,  however,  can  never  be 
kept  satisfactorily  in  position,  and  many  surgeons  object  (and,  I  think, 
with  reason)  to  the  figure-of-8  bandage  as  liable  to  press  on  the  outer 
fragment  and  displace  it.  A  good  and  convenient  plan  is  to  put  a  short 
crutch  into  tiie  axilla,  which  is  fixed  bv  a  strap  going  across  the  opposite 
shoulder,  and  another  round  the  body,  and  to  carry  the  arm  in  a  sling. 
Some  surgeons  recommend  that  the  hand  should  be  raised  and  bandaged 
on  to  the  opposite  shoulder  ; '  others  again  teach  that  the  arm  should  be 
extended  vertically  downwards  and  bandaged  to  the  body.'^  These  dia- 
metrically opposite  views  show  the  difficult  and  unsatisfactory  nature  of  the 
treatment  as  far  as  remedying  the  deformity  is  concerned.  It  is  said  that 
complete  success  may  be  obtained  b}'  perfectly  reducing  the  fracture,  and 
keeping  the  patient  at  perfect  rest  in  the  supine  horizontal  posture,  any 
accidental  fresh  displacement  being  at  once  remedied.  But  very  few 
persons,  excei)t  young  ladies  careful  of  the  future  appearance  of  the 
neck,  could  be  persuaded  to  submit  to  such  an  irksome  treatment  in  order 
to  avoid  the  very  trifling  deformity  left  by  the  fracture,  since  no  real 
inconvenience  results  from  it. 

Fracture  of  the  internal  end  of  the  clavicle  is  not  a  common  injury.  It 
generally  takes  place  about  an  inch  from  the  end  of  the  bone,  and  is 
accompanied  by  a  well-marked  displacement  of  the  outer  fragment  down- 
wards and  forwards  in  front  of  the  sternum,  which  has  often  been  con- 
founded with  dislocation."  The  treatment  appears  to  be  usuall}-  unsuc- 
cessful in  the  same  sense  as  in  the  common  fracture,  that  is  to  sa}^,  that 
the  displacement  remains,  but  no  serious  loss  of  motion  results.  This 
fracture,  of  course,  lies  external  to  the  attachment  of  the  rhomboid  liga- 
ment. The  occurrence  of  fracture  internal  to  this  ligament  has  not  as 
yet  been  proved  ;  its  fibres  would  probably  prevent  an}^  extensive  dis- 
placement, though  some  movement  of  the  inner  fragment  forwards  would 
still,  according  to  Professor  Smith,  be  possible. 

Fracture  of  the  acromial  end  is  a  much  more  common  injury,  and  is 
often  accompanied  by  very  great  deformity,  the  effect  of  the  mobility  of 
the  scapula,  which,  being  now  deprived  of  the  natural  support  of  the 
clavicle,  carries  the  outer  fragment  inwards,  so  that  it  makes  almost  a 
right  angle  with  the  inner,  and  in  sOrae  cases  (as  in  that  figured  by  Pro- 

'   Bryant,  Practice  of  Surgery,  p.  928. 

2  Gordon,  Dublin  Qiiiirtcrly  .Journal,  vol.  xviii,  November,  1859,  p  480.  I  would 
recommend  tlii.s  .short  paper  to  the  reader'.s  peru-sal,  as  it  gives  a  different  view  of  the 
cause  of  the  deformity  from  that  which  i.s  usually  adopted.  I  have  not  space  here  to 
argue  the  question,  and  1  liave  no  experience;  of  the  results  of  Professor  Gordon's 
treatment,  but  his  opinions  are  entitled  to  the  most  respectful  attention.  I  agree,  at 
any  rate,  so  far  with  Mr.  Gordon's  views  that  I  believe  Iho,  eftect  of  the  rotation  of 
the  scapula  upon  the  position  of  the  outer  fragment  in  this  fracture  is  usually  too 
mucli  overlooked,  though  I  confess  tliat  his  theory  seems  to  me  to  give  too  exclusive 
prominence  to  the  action  of  the  muscles. 

'  On  this  head  see  a  paper  by  Dr.  K.  W.  Smith,  Dublin  Quarterly  Journal,  August, 
1870. 


FRACTURES    OF    THE    CLAVICLE. 


255 


lessor  R.W.  Smith,  On  Fractures  and  Didocalions,  p.  219)  tlie  sternal 
fragment  is  much  elevated,  while  the  shoulder  is  drawn  inwards  and  for- 
wards, thus  adding  greatly  to  the  deformity. 


Fracture  of  the  sternal  end  of  the  clavicle,  seven  days  before  death.  The  situation  of  the  joint  is 
shown ;  the  fracture  is  about  an  inch  from  the  joint.  There  is  a  large  blood-clot  between  the  fragments. 
The  outer  fragment  is  pointing  directly  forwards,  i.  e.,  its  point  pressed  against  the  skin.— Museum  of 
St.  George's  Hospital,  Ser.  i,  No.  77. 


On  the  other  hand,  when  the  fracture  happens  to  occur  just  in  the  in- 
terval between  the  conoid  and  trapezoid  ligaments  there  may  be  little  or 
no  displacement;  at  least  such  is  the  common  impression  (as  shown  in 
Fig.  72).     Dr.  Gordon,  of  Belfast  {op.  ciL,  p.  478),  thinks  this  impression 


Fig.  76. 


A  recent  comminuted  fracture  of  the  left  clavicle,  from  a  case  in  which  death  was  produced  by  other 
injuries  in  a  few  hours,  o,  superior,  and  b,  inferior  view.  The  external  fragment  has  become  placed 
below  the  inner  one,  and  is  at  the  same  time  directed  forwards,  so  that  the  two  fragments  form  nearly 
a  right  angle  with  each  other.  Two  pieces  of  the  inner  fragment  have  been  detached  and  are  lying 
above  it,  as  seen  in  a.  Fig.  6  shows  how  the  outer  fragment  has  passed  below  the  inner.  The  fracture 
is  situated  between  the  coraco-clavicular  ligaments  and  the  acromial  joint. — From  a  case  by  Mr.  Canton, 
in  Path.  Trans.,  vol.  xii,  p.  161. 

incorrect,  and  believes  that  fracture  between  the  conoid  and  trapezoid 
ligaments  produces  the  same  deformity  as  any  other  fracture  of  the  outer 
end  of  the  bone ;  in  other  words,  he  does  not  believe  that  these  ligaments 
have  any  effect  in  resisting  displacement. 

All  these  fractures  are  to  be  treated  on  the  same  principle  as  the  com- 


256  INJURIES    OF    THE    UPPER    EXTREMITY. 

moil  rracture  of  the  clavicle,  ?'.  c,  to  fix  the  shoulder  in  the  position  best 
adapted  to  })reveiit  the  displacement  characteristic  of  each  ;  but  the  diffi- 
culty of  keeping  the  scapula  fixed  is  a  great  obstacle  to  complete  success. 
This  may  be  c()iiil)ated  b3'  fixing  a  pad  on  the  scapula  below  its  spine  and 
strapping  it  tiglitly  to  the  chest;  but  when  the  tendency  to  displacement 
is  considerable  the  success  of  any  plan  will  not  be  great  while  the  patient 
is  allowed  to  move  about. 

Fracture  of  the  Scainda. — Fracture  of  the  body  of  the  scapula  is  usu- 
ally the  result  of  direct  violence :  the  passage  of  a  carriage  over  the  l)ody 
or  a  crush  against  some  obstacle.  It  is  usuall}'  easy  of  detection,  for  it 
generally  passes  through  the  spine  of  the  l)one,  and  in  passing  the  finger 
along  the  spine  the  broken  part  can  be  reached  at  once,  or,  the  shoulder 
being  grasped  in  one  hand  and  the  lower  angle  of  the  scapula  in  the 
other,  the  crepitus  will  be  elicited.  The  fracture,  if  not  complicated  with 
other  injuries — which,  however,  is  very  often  the  case — will  not  in  all 
probabilit}'  lead  to  any  evil  consequences.  Should  any  displacement 
exist  the  parts  must  be  manipulated  into  position,  but  this  is  not  gener- 
all}^  necessary,  since  the  broad  muscles  attached  to  the  bone  prevent 
any  change  in  the  relative  position  of  the  fragments.  After  reduction 
all  that  can  be  done  is  to  apply  a  broad  rib-roller,  and  even  if  the  frac- 
ture consolidates  irregularly  no  harm  will  result.  In  three  or  four  weeks 
the  patient  ma}'  be  allowed  the  free  use  of  his  arm. 

Fraclare  of  the  neck  of  the  scajnda  may,  as  it  appears,  involve  either 
the  anatomical  or  the  surgical  neck  of  the  bone,  the  former  being  the 
constriction  around  the  glenoid  cavity  external  to  the  root  of  the  cora- 
coid  process,  the  latter  the  part  by  which  the  glenoid  fossa  and  coracoid 
process  are  connected  to  the  body  of  the  bone.  Fracture,  therefore, 
through  the  anatomical  neck  would  separate  only  the  glenoid  process 
from  the  rest  of  the  bone,  while  fracture  through  the  surgical  neck  would 
separate  the  coracoid  process  also  from  the  scapula  and  render  it  mov- 
able. The  subject  of  fracture  of  the  neck  of  the  scapula  is  one  on  which 
much  difference  of  opinion  has  prevailed,  and  which  is  still  unsettled. 
Sir  A.  Cooper  described  it  as  an  injury  which  often  simulates  dislocation 
of  the  humerus  into  the  axilla,'  and  his  description  is  expressly  applied 
to  fractures  of  the  surgical  neck  of  the  bone,  since  he  points  out  carefully 
that  "  the  coracoid  process  being  attached  to  the  glenoid  cavity,  and 
being  l)roken  off  with  it,  the  crepitus  [of  the  fracture]  is  communicated 
through  the  medium  of  this  process,"  and  the  ^eat  of  the  supposed  frac- 
ture is  marked  in  one  of  his  figures.  Other  surgeons  have  explained 
differently  tiie  injury  which  Cooper  classed  as  fracture  of  the  neck  of  tlie 
scapula,  some  believing  tliat  the  real  lesion  was  a  dislocation  in  which  a 
portion  of  the  glenoid  [)rocess  was  fractured,'^  others  that  it  was  a  frac- 
ture of  the  head  of  the  humerus.''  I3ut  neither  of  these  explanations 
seems  to  me  at  all  consistent  with  Sir  Astley's  very  clear  description  of 
the  symptoms  as  observed  by  him  ;  and  although  there  is  no  dissection 
in  existence,  from  a  case  of  this  kind,  which  can  show  on  what  precise 
injury  the  symptoms  have  depended,  yet  as  tliere  are  certainly  specimens 


'  Cooper,  On  Dislocations  and  on  Fractures,  2d  ed.,  1823,  p.  454. 

2  Malgaigne,  Traite  des  Fractures  et  des  Luxations,  vol.  ii,  p.  651. 

''  Mr.  South,  CheHus  (vol.  i,  p.  549),  says  that  this  has  been  proved  to  be  so;  but 
if  so  Sir  A.  Cooper  must  have  utterly  misstated  the  symptoms  of  the  ease  which  he 
described. 


FRACTURES    OF    THE    SCAPULA.  257 

in  existence  of  fracture  of  tlie  surgical  neck  of  tlie  scapula,'  and  as  it 
seems  certain  that  such  a  fracture  miorjit  produce  tlie  symptoms  described 
by  Sir  A.  Cooper,  I  see  no  reason  for  denying  the  accuracy  of  his  diag- 
nosis, though  the  fact  that  the  injury  can  hardly  prove  fatal  renders  the 
anatomical  proof  of  it  hitlierto  deficient.  The  reader  may  consult  a  very 
interesting  paper  by  Dr.  Lotzbeck,  of  Munich,  on  tliis  subject,'  in  which 
the  symptoms  due  to  both  of  these  varieties  of  fracture  of  the  neck  of 
the  scapula  are  described,  though  only  from  the  living  subject,  and  the 
various  opinions  which  have  been  expressed  on  the  question  are  discussed. 
The  symptoms  in  one  of  the  cases  there  described  ''  much  resembled  dis- 
location ;  the  arm  was  lengthened  one  inch,  drawn  away  from  the  side, 
and  the  acromion  prominent;  but  the  injury  was  easily  distinguished 
from  dislocation  by  the  fact  that  the  coracoid  process  was  also  displaced, 
and  moved  with  the  arm  in  passive  motion  ;  that  such  movements  were 
perfectly  easy  to  produce,  though  very  painful;  the  length  of  the  arm 
was  at  once  restored  and  crepitus  obtained  ;  and  finally  an  irregular  frag- 
ment of  bone  was  felt  in  the  axilla."  Dr.  Lotzbeck  also  met  with  another 
case  in  which  the  symptoms  were  very  similar,  only  that  the  coracoid 
process  was  not  movable,  and  which  he  therefore  believed  to  be  a  frac- 
ture through  the  anatomical  neck  of  the  bone.  In  both  cases  tlie  dis- 
placement was  reduced  and  good  motion  of  the  joint  obtained.  The 
diagnostic  signs  from  dislocation  are  the  ease  with  which  the  parts  can 
be  put  into  position,  the  production  of  crepitus,  and,  when  this  is  done, 
the  freedom  of  passive  motion — though  this  causes  much  pain— and  the 
sensation  of  a  bony  fragment  in  the  axilla.  It  must  nevertheless  be  ad- 
mitted that  the  injury  cannot  be  described  with  the  same  confidence  as 
one  whose  nature  has  been  conclusively  proved  by  dissection. 

Fracture  of  Coracoid  and  Acromion  Pr'ocesses. — Fracture  may  also 
occur  either  of  the  coracoid  or  of  the  acromion  processes  alone.  That  of 
the  coracoid  is  unquestionably  rare  as  a  separate  injury,  though,  as  a 
complication  of  dislocation,  it  is  known  to  occur,  and  is  perhaps  not 
extremelyuncommon.  The  fragment  is  described  as  being  drawn  down 
by  the  biceps  muscle,^  and  it  is  said  that  ligamentous  union  is  on  that 
account  common.  I  do  not  believe,  however,  that  enough  is  known  about 
the  injury  to  enable  us  to  judge  whether  this  is  generally  true.  The 
muscles  attached  to  the  coracoid  process  would  only  displace  the  frag- 
ment in  the  event  of  its  being  entirely  torn  away  from  the  periosteum, 
and  this  I  suppose  to  be  rare.  And  doubtless  the  statement  as  to  the 
frequency  of  ligamentous  union  in  this  fracture,  as  in  that  of  the  acro- 
mion, rests  in  a  great  measure  on  post-mortem  examinations,  in  which 
additamentary  bones  around  shoulders  affected  with  chronic  osteoarthritis 
have  been  mistaken  for  fragments  of  old  non-united  fractures.  If  frac- 
ture of  the  coracoid  process  is  met  with  uncom|)licated  withotlier  iujury, 
and  if  the  fragment  is  diplaced  (of  wliich  Mr.  Bryant  records  an  example 
under  his  own  care),  the  arm  should  be  bandaged  with  the  elbow  raised 
and  the  forearm  flexed,  so  as  to  relax  the  biceps  muscle,  and  the  parts 
kept  in  that  position  for  about  a  month. 

1  One  in  Guy's  Hospital  Museum  is  figured  in  Mr.  Bryant's  worlc,  p.  929;  another 
is  in  the  Museum  of  the  Royal  College  of  Surgeons. 

2  Deutsche  Klinik,  1867,  abstracted  in  the  New  Syd.  Soc.'s  Biennial  Retrospect  for 
1867-8,  p.  240.  ^      ,  . 

8  See  a  case  described  by  Mr.  South,  Med.-Chir.  Trans.,  vol.  xxii,  p.  100.  In  this 
case  the  fragment  was  pulled  down  by  the  short  head  of  the  biceps  muscle  as  far  as 
the  triangular  ligament  would  allow— about  half  an  inch  below  and  to  the  outer  side 
of  the  coracoid  process. 

17 


258  INJURIES    OF    THE    UPPER    EXTREMITY. 

Fiacture  of  the  acromion  is  easily  diagnosed  by  tracing  the  spine  of  the 
scapula  with  the  finger,  an  abrupt  drop  marking  the  seat  of  fracture.  The 
rnobilitv  of  the  fragment  and  the  dropping  of  the  point  of  the  shoulder 
will  suhieiently  prove  the  nature  of  the  case,  and  the  diagnosis  will  be 
confirmed  b}-  the  crepitus.  The  surgeon  will  also  notice  how  the  deformity 
disappears  on  raising  the  elbow  and  recurs  as  soon  as  the  elbow  is  allowed 
to  drop.  '•  In  the  treatment  of  this  accident,"  says  Sir  A.  Cooper,  "  the 
head  of  the  os  humeri  is  the  splint  which  is  employed  to  keep  the  acro- 
mion in  its  natural  situation;  and  with  this  view  the  elbow  is  raised  and 
the  arm  fixed."  He  also  points  out  the  unadvisability  of  either  putting  a 
pad  in  the  axilla  or  bandaging  the  elbow  too  closely  to  the  side,  since  by 
both  of  these  plans  the  head  of  the  humerus  is  thrown  outwards  and  the 
fragments  separated.  The  surgeon  should  raise  the  elbow  and  fix  it  in 
that  position,  which  places  the  bones  in  perfect  contact,  and  endeavor  to 
keep  them  thus  for  about  three  weeks;  but  it  is  somewhat  difficult  to 
keep  the  parts  quiet,  and  to  this  Sir  A.  Cooper  attributes  the  ligamentous 
union  of  fractured  acromion,  which  he  believes  to  be  common,  and  in  this 
belief  he  has  been  followed  by  most  authors  ;  but  in  this  case  also  there 
is  much  reason  to  believe  that  specimens  of  old  chronic  rheumatic  arthritis 
have  been  looked  upon  as  examples  of  ununited  fracture.^  At  the  same 
time  it  is  very  desirable  to  realize  the  probability  of  non-union  in  this 
fracture,  and  to  endeavor  to  guard  against  it. 

Fracturefi  of  the  humerus  are  divided  into  those  of  the  upper  end,  of 
the  sliaft,  and  of  the  lower  end.  Those  of  the  upper  end  of  the  humerus 
are:  1.  Fracture  of  tiie  anatomical  neck  (intra-capsular)  ;  2.  Of  the  sur- 
gical neck  (extra-capsular) ;  3.  Separation  of  the  epiphj'sis  ;  and  4.  Frac- 
ture of  the  great  tuberosity. 

Fracture  of  Anatomical  Neck. — 1.  Pure  uncomplicated  fracture  above 
the  tuberosities — i.  e.,  entirely  within  the  capsule — is  a  rare  injury,  and  its 
diagnosis  is  by  no  means  easy.  It  is  very  generally  accompanied  with 
impaction,  the  shaft  of  the  bone  being  sometimes  driven  into  the  upper 
fragment,  whilst  in  other  cases  the  head  of  the  bone  is  more  or  less  dis- 
placed and  driven  into  the  lower  fragment  (Fig.  78).  In  a  remarkable 
case  recorded  and  figured  by  Prof.  R.  W.  Smith  the  fractured  head  was 
entirely  reversed,  so  that  the  cartilaginous  surface  had  been  driven  into 
the  shaft,  while  the  fractured  cancellous  tissue  was  turned  upwards 
towards  tne  glenoid  cavity.  The  diagnosis  is  in  many  cases  mainly  nega- 
tive. Tliere  are  not  the  characteristic  symptoms  of  any  of  the  otlier  frac- 
tures to  be  presently  described,  nor  those  of  dislocation.  If  the  fracture 
be  firmly  impacted  no  crepitus  can  be  elicited,  but  some  change  of  shape 
of  the  upper  end  of  the  bone  may  be  made  out,  if  not  masked  by  the 
swelling.  If,  however,  the  fracture  be  not  impacted,  crepitus  will  be  made 
out;  and  the  surgeon  being  convinced  that  the  scapula  is  not  injured, 
and  that  the  injury  is  seated  above  the  surgical  neck,  and  is  not  of  the 
tuberosity  only,  must  conclude  that  it  is  an  intra-capsular  fracture.  Much 
caution,  however,  is  required  not  to  confound  the  pseudo-crepitus  of  elfu- 
sion  into  the  sheaths  of  the  tendons  with  the  real  crepitus  of  fracture. 
These  fractures  unite  solidly  by  bone  ;  in  fact  there  is  often  a  very  exu- 
berant production  of  stalactitic  bone,  especially  when  the  head  is  impacted 


'  Dr.  K.  Adams  says  that  in  chronic  arthritis  of  the  shoulder  the  acromion  is  often 
found  to  have;  undergone  a  solution  of  continuity  from  disease,  and  that  this  usually 
but  not  alwa3'S  occurs  at  the  line  of  the  epiphysis  (On  Chronic  Rheumatic  Arthritis, 
2d  ed.,  p.  102). 


FRACTURE    OF    NECK    OF    HUMERUS. 


259 


in  the  lower  fragment,  and  tlie  inflammation  which  produces  this  bony 
effusion  must  greatly  limit  the  movements  of  the  joint.  The  only  treat- 
ment which  can  be  adopted  is  to  remedy  any  tendency  to  displacement 
of  the  lower  fi-agment  inwards  which  may  be  present,  by  means  of  a  pad 


Fig.  77.— Recent  intra-capsular  fracture  of  the  left  liumerus,  seen  from  behind.  The  tuberosities  sep- 
arated from  the  head  and  shaft  are  divided  into  three  fragments  and  driven  outwards.  The  head, 
separated  from  the  anatomical  neck  of  the  bone,  is  partly  crushed.  The  shaft  is  driven  upwards,  and 
touches  the  lower  part  of  the  glenoid  cavity.  The  capsule  was  intact,  and  has  been  opened  in  the  dis- 
section to  show  the  fracture. — From  Malgaigne's  Atlas,  pi.  v,  Fig.  1. 

Fig.  78. — Bony  union  of  impacted  intra-capsular  fracture  of  the  humerus,  five  years  after  the  occur- 
rence of  the  accident. — From  Prof.  E.  W.  Smith,  On  Fractures,  p.  192. 

in  the  axilla,  and  to  support  the  arm  in  a  sling.  In  impacted  fracture  it 
is  neither  feasible  nor  desirable  to  disengage  the  fragments.  The  patient 
should  be  prepared  for  the  loss  of  motion  which  will  probably  ensue,  and 
passive  motion  should  be  employed  to  obviate  this  as  far  as  possible. 
Gentle  attempts  to  raise  the  shoulder  should  be  made  as  early  as  the 
patient  can  bear  them  after  the  first  three  weeks. 

2.  Extra-capsular  Fracture. — The  ordinary  fracture  of  the  neck  of  the 
humerus  is  the  extra-capsular,  or  the  fracture  through  the  surgical  neck, 
i.e.,  below  the  tuberosities.  The  arm  is  shortened;  the  lower  fragment 
can  be  felt  projecting  into  the  axilla,  whei'e  its  sharp,  ii-regular  outline 
can  easily  be  distinguished  from  the  globular  head  of  the  humerus;  the 
shoulder  has  not  the  pointed  outline  of  dislocation  ;  the  arm  is  much 
more  easily  movable,  and  when  its  length  is  restored  crepitus  will  be 
felt.  The  upper  fragment  is  usually  tilted  outwards  by  the  muscles  in- 
serted into  the  great  tuberosity  (Fig.  79) ;  the  displacement  of  the  lower 
fragment  inwards  and  upwards  is  due  partly  to  the  action  of  the  force, 
partly  to  that  of  the  flaps  of  the  axilla  and  tlae  muscles  which  {)ass  from 
the  scapula  to  the  humerus  below  the  fracture,  and  partly  to  the  direction 
of  the  line  of  fracture.  In  some  cases  the  lower  fragment  lies  "  ante- 
riorly externally,  and  even  posteriorly,"  as  shown  by  Malgaigne,  and  it 
may  be  impacted  in  the  tissue  of  the  upper  fragment. 


260 


INJURIES    OF    THE    UPPER    EXTREMITY. 


This  fracture  is  usually  treated  by  the  application  of  a  case  or  pad  .of 
leather  or  gutta  percha  moulded  to  the  outside  of  the  shoulder,  and  op- 
posed by  a  large  pad  in  the  axilla,  or  a  crutch  similar  to  that  used  for 
fracture  of  the  clavicle,  or  a  splint  about  two  feet  long  made  of  leather, 
bent  in  the  middle  to  an  acute  angle,  which  is  fitted  into  the  axilla,  while 
one  limb  of  the  splint  rests  upon  the  chest  and  the  other  supports  the 


Fig.  79. 


Fracture  of  the  surgical  neck  of  the  humerus,  with  complete  separation  of  the  fragments.  The  frac- 
ture occurred  in  an  old  man,  aet.  77,  who  died  twenty-six  days  after  the  fracture,  which  it  had  been 
impossible  to  reduce.  The  fracture  was  situated  below  the  tuberosities  and  capsular  ligament  (which 
latter  was  nowhere  opened),  and  about  an  inch  above  the  insertion  of  the  pectoralis  major.  The  de- 
tached fragment  was  separated  from  the  lower  fragment  and  buried  in  the  tissue  of  the  upper.  The 
upper  fragment,  free  from  any  adhesion,  had  been  drawn  up  by  the  supraspinatus,.and  probably  by  the 
other  scapular  muscles,  into  such  a  rotation  upwards  and  outwards  that  the  great  tuberosity  is  buried 
under  the  acromion.  In  other  words,  the  position  of  the  upper  fragment  corresponds  to  that  of  the  arm 
in  its  greatest  elevation,  and  that  of  the  lower  fragment  to  that  of  the  arm  In  its  greatest  depression. 
The  dotted  line  shows  the  position  that  the  lower  fragment  must  have  taken  in  order  to  bring  the  hu- 
merus into  a  line. — Malgaignc,  pi.  vi,  Fig.  3. 

inside  of  the  arm.  The  treatment  of  this  fracture  by  a  case  of  four 
straight  splints,  as  for  fracture  of  the  shaft,  is  very  ineffective,  since  all 
the  splints  will  probably  be  found  on  careful  examination  to  be  placed  on 
the  lower  fragment  only.  The  same  precautions  should  be  adopted  for 
avoiding  stiffness  of  the  joint  as  recommended  in  the  former  case ;  but 
some  loss  of  the  power  of  elevating  the  shoulder  is  a  very  common  result, 
and  is  usually  attributed  to  inflammatory  thickening  of  the  lower  portion 
of  the  capsule. 

I  have  described  these  fractures  separately  from  each  other,  as  purely 
intra-  or  extra-capsular,  but  in  practice  there  can  be  no  doubt  that  they 
are  often  mixed,  and  what  is  called  "  a  fracture  of  tlie  anatomical  neck  of 
the  humerus"  is  really  an  injury  in  which  the  greater  part  of  the  line  of 
fracture  is  external  to  the  capsule  ;  but  a  piece  has  been  comminuted,  or 
a  subordinate  line  of  fracture  has  run  upwards  into  the  joint.  This  is  so 
in  a  preparation  put  up  by  Sir  B.  Brodie  in  St.  George's  Hospital  Museum 
as  "  fracture  of  the  anatomical  neck,"  and  the  same  was  the  case  in  a 


FRACTURES    OF    THE    HUMERUS. 


261 


patient  latel_y  under  m}^  care,  who  presented  the  unusual  complication  of 
partial  rupture  and  obstruction  of  the  axillary  artery,  leading  to  gan- 
grene of  the  arm  and  necessitating  amputation  at  the  shoulder-joint. 

8.  Separation  of  the  upper  epiphysis  is  a  well-marked  accident,  ver}' 
clearly  described  by  R.  W.  Smith,  whose  description  I  had  an  oppor- 
tunity of  verifying  in  the  case  which  furnished  the  accompanying  figure 
(Fig.  80).  The  patient  is  a  young  person  belcw  the  age  of  20,  and  usu- 
ally much  )^ounger;  the  arm  is  neither  lengthened  nor  shortened;  the 
lower  fragment  projects  somewhat  inwards,  causing  "  a  striking  and 
abrupt  projection  situated  beneath  the  coracoid  process,"  which  Prof. 
Smith  calls  "the  most  remarkable  feature  of  this  injury;"  and  this  pro- 
jection has  not  the  sharp  outline  of  an  ordinary  fracture,  but  "  feels 
rounded,  and  its  superior  surface  is  smooth  and  slightly  convex."  When 
the  injury  is  recent  the  lower  fragment  can  be  brought  into  its  natural 
position,  and  then  the  prominence  will  be  obliterated  and  crepitus  can  be 
felt,  though  this  may  not  be  exactly  the  crepitus  of  fracture.  The  lesion 
may  be  treated  by  any  of  the  plans  which  are  used  in  other  injuries 
about  the  same  part,  but  the  projection 
will  probably  remain  permanently.    There  I'^ig.  sd. 

is,  however,  far  less  probability  of  loss  of 
motion  than  in  the  fractures  of  adult  life. 
The  line  of  fracture,  it  must  be  remem- 
bered, is  below  the  tuberosities,  and  the 
fracture  is  therefore  mainly,  if  not  en- 
tirely, extra-capsular.'  It  seems  to  unite 
usually  with  but  little  inflammation. 

4.  Fracture  of  the  great  tuberosity  is 
known  by  the  increased  width  of  the 
upper  end  of  the  bone,  and  the  presence 
of  a  bony  prominence  below  the  acromion, 
which  may  possibly  be  made  out  as  dis- 
tinct from  the  head  of  the  bone.  The 
acromion  is  somewhat  prominent,  though 
less  so  than  in  dislocation,  and  the  arm 
may  be  separated  from  the  side,  but  can 
easily  be  brought  back  to  it;  and  a  thor- 
ough examination  with  the  hand  in  the 
axilla  will  convince  the  surgeon  that  the 
head  of  the  bone  is  in  the  glenoid  cavity. 
There  are  cases,  however,  in  which  most 
probably  this  fracture  has  occurred  as  a 
complication  of  dislocation.  If  the  sep- 
aration be  extensive  and  complete  the 
union  may  be  ligamentous;  in  many  cases 
bony  union  seems  exuberant,  and  then 
considerable  loss  of  motion  will  follow. 
Beyond  keeping  the  parts  at  rest,  and  pressing  the  fragment  and  the 
head  of  the  bone  together  b}-  means  of  a  pad  in  the  axilla,  opposed  by 
a  cap  over  the  shoulder,  I  do  not  see  what  is  to  be  done  in  the  way  of 
treatment. 

Fracture  of  the  shaft  of  the  humerus  occurs  usually  somewhat  below 
the  middle,  though  any  part  of  the  bone  may  give  way.  It  is  caused  by 
any  kind  of  violence,  and  sometimes  by  muscular  action.^ 


''^''kkM^ 


Separation  of  the  upper  epiphysis  of 
Ihe  hunienis.  Taken  from  a  hoy  set.  15, 
under  my  care,  in  whom  the  diagnosis 
rested  only  on  the  symptoms  during  life. 
He  recovered,  witli,  I  helieve,  complete 
use  of  the  joint. — Holmes's  Dis.  of  Child- 
hood, 2d  ed.,  p.  249. 


1  R.  W.  Smith,  On  Fractures,  p.  203. 

^  In  this  latter  case,  however,  there  is  some  reason  for  suspecting  that  the  bone  maj' 


262 


INJURIES    OF    THE    UPPER    EXTREMITY. 


The  displacement  varies  witli  the  direction  of  the  line  of  fractnre  and 
other  circumstances.  Frequently  it  is  not  very  much  marked.  There  is 
seldom  any  difficulty  in  correcting  it,  or  in  procuring  union  without  de- 
formity. A  case  of  four  straight  splints  or  a  leather  or  gutta-percha 
splint,  must  be  applied  for  about  six  weeks,  when  the  fracture  will  be 
soundly  united.  Tiie  hand  is  to  be  carried  in  a  sling,  which  should  not 
be  long  enough  to  press  the  ell)ow  outwards. 

'  Fractui-es  of  the  loicer  end  of  the  humerus  may  be  divided  into  :  1. 
Simple  transverse  fracture  above  or  below  the  condyles  ;  2.  Fractures 
running  between  the  cond^yles  into  the  joint ;  3.  Fracture  of  either  con- 
dyle ;  and,  4.  Separation  of  the  epiphysis. 

1.  The  transverse  fracture  of  the  lower  end  of  the  humerus  is  of  inter- 
est, inasmuch  as  it  somewhat  resembles  dislocation.  Both  injuries  are 
common  in  youth.  In  the  fracture  the  lower  fragment  along  with  the 
forearm  is  usuall}'  carried  backwards,  producing  a  projection  behind  the 
joint,  and  a  prominence  of  the  triceps-  tendon,  as  in  dislocation  ;  and 
there  is  a  projection  in  front  near  the  bend  of  the  elbow,  as  in  dislocation. 
Here,  however,  the  resemblance  ceases.     In  the  fractnre  the  parts  can 

Fig.  81. 


Diagram  of  fracture  of 
lower  end  of  humerus,  a. 
Deltoid  ;  n.  Pectoralis  ma- 
jor ;  c.  Triceps  ;  D.  Biceps ; 
E.  Bracbialis  anticus. 


Diagram  of  dislocation 
backwards,  a.  The  bracbi- 
alis anticus  torn  by  the  dis- 
placed head  of  the  hume- 
rus ;  B.  The  biceps  ;  c.  The 
greater  sigmoid  cavity  of 
the  ulna  ;  D.  The  bicipital 
tuberosity  of  the  radius ;  K. 
The  end  of  the  humerus. 


Diagrammatical  representation  of  fracture  of  the  lower  end  of  the  liumerus,  contrasted  with  dislo- 
cation of  lioth  bones  of  the  forearm  backward.  The  figure  (from  Liston)  shows  the  general  featurss  of 
dislocation. 

commonly  be  reduced  and  crepitus  obtained.  The  projection  in  front  is 
seen  to  be  above  the  bend  of  the  ell)ow,  and  to  have  a  sharp  outline, 
whilst  in  dislocation  the  prominence  is  below  the  bend  of  the  ell)Ow,  and 
is  rounded.  But  the  most  unfailing  distinction  is,  that  the  measurement 
between  the  olecranon  and  internal  or  external  condyle  is  natural  in  the 
fracture,  wiiile  in  the  dislocation  it  is  much  increased.  However  great 
the  swelling  may  be,  one  or  other  of  the  condyles  can  almost  certainly  be 


be  diseased.  Thus,  a  sclioolrr.aster  in  slrikiiiii;  ii  boy  with  hi.s  cane  fractured  the  hu- 
merus. Some  weeks  afterwards  (the  fracture  havini;  in  the  meantime  united)  a  tu- 
mor showed  itself  at  the  seat  of  injury,  for  which  he  became  a  patient  at  St.  George's 
Hospital,  where  amputation  at  the  shoulder-joint  was  performed. 


FRACTURES    OF    THE    HUMERUS. 


263 


made  out.  In  some  cases,  especially  when  the  fracture  is  caused  by  a 
direct  blow,  the  displacement  of  the  lower  fragment  may  be  forwards,' in 
which  case  there  can  be  no  difficulty  in  diagnosis. 

The  separation  of  the  lower  epiphysis  of  the  humerus  is  difficult  to  dis- 
tinguish from  this  injury,  tliough  it  occurs  lower  down.  In  this  fracture 
either  the  whole  epiphysis— or,  as  Dr.  R.  W.  Smith  thinks,  only  the  part 
which  forms  the  trochlea  and  capitellum — is  separated  from  the  shaft  of 
the  bone  and  carried  backwards  with  the  forearm.  Prof.  Smith  describes' 
the  lower  epiphysis  of  the  humerus  as  being  placed  entirely  below  the 
condyles,  and  therefore  describes  the  separation  of  the  epiphysis  as  being 
necessarily  "  infra-condyloid."-  This  is  certainly  incorrect,  as  I  have  shown 
elsewhere,  and  as  the  annexed  figures  prove.  The  condyles  are  epiph3'ses 
as  well  as  the  trochlea  and  capitellum,  and  form  pieces,  tliough  detached 
pieces,  of  the  same  epiphysis,  as  is  correctly  descril)ed  in  the  ordinary 
anatomical  works.  At  the  same  time  it  is  quite  possible  that  in  separa- 
tions of  the  lower  epiphysis  only  the  part  which  belongs  to  tiie  trochlea 
and  capitellum  may  be  broken  off,  leaving  the  condyles  attached  to  the 
shaft  of  tiie  bone,  l)ut  I  am  not  aware  of  the  existence  of  any  preparation 
showing  this  form  of  fi'acture.  We  may  conclude,  then,  that  fracture  may 
occur  at  any  age,  through  the  lower  part  of  the  shaft  more  or  less  close 


Two  figures  to  show  the  position  of  the  epiphysial  line  in  the  lower  end  of  the  humerus,  a,  in  early- 
infancy,  B,  at  the  age  of  fifteen,  showing  that  in  early  life  all  the  part  which  afterwards  forms  the  con- 
dyles is  cartilaginous,  and  that  subsequently  the  condyles,  though  they  are  formed  distinct  from  the 
articular  end,  are  also  ephiphyses.  A  fracture  might,  therefore,  either  separate  them  from  the  shaft, 
along  with  the  epiphysis,  or,  on  the  other  hand,  separate  the  bullc  of  the  epiphysis,  and  leave  the  con- 
dyles attached  to  the  shaft.— From  Holmes's  Surgical  Dis.  of  Childhood,  pp.  251,  252. 

above  the  condyles;  and  at  early  periods  tlie  whole  epiphysis  maybe 
separated,  including  the  condyles,  or  only  its  infra-condyloid  i)art.  Thus 
there  would  be  three  forms  of  transverse  fracture  of  the  lower  end  of  the 
humerus:  1.  Supra-condyloid  ;  2.  Disjunction  of  the  entire  epiphysis; 
3.  Partial  disjunction,  or  infra-condyloid  fracture. 

Stated  shortly  the  signs  of  these  three  fractures  as  they  are  commonly 


^  See  a  preparation  in  the  Museum  of  St.  George's  Hospital,  Ser.  i,  No   97. 
*  Brit.  Med.  Jour.,  Aug.  17,  1867. 


264  INJURIES    OF    THE    UPPER    EXTREMITY. 

seen  would  be  as  follows  :  (a)  In  front  of  the  joint.  In  the  common 
fracture  of  the  lower  end  of  the  humerus  (displaced  backwards)  the  lower 
end  of  tlie  upper  fragment  projects  in  front  and  above  the  bend  of  the 
elbow  ;  so  it  does  in  the  other  tM'o  fractures,  but  in  the  infra-condyloid 
fracture  the  projecting  part  is  wider,  equal  in  breadth  to  that  of  the 
opposite  humerus  from  one  condyle  to  the  other;  and  if  the  swelling  is 
not  too  great  the  condyles  can  be  made  out  as  forming  a  part  of  it,  while 
in  the  disjunction  of  the  entire  epiphysis  the  condyles  will  remain  attached 
to  the  lower  fragment,  and  the  upper  fragment  will  therefore  be  higher 
and  less  broad.  (?>)  Turning  to  tlie  back  of  tlie  joint,  two  prominences 
are  seen,  one  external,  the  other  internal,  in  all  three  forms  of  fracture, 
as  well  as  in  dislocation.  In  all  tliese  injuries  the  two  prominences  are 
on  dirterent  vertical  levels,  the  internal  (which  in  all  of  them  is  formed 
by  the  displaced  olecranon)  being  the  higher.  The  external  prominence 
in  dislocation  is  formed  by  the  head  of  the  radius,  and  is  therefore  far 
more  remote  from  the  internal  than  it  is  in  any  of  the  fractures^  in  which 
it  is  formed  by  the  part  of  the  humerus  carried  backwards  with  the 
radius,  viz.,  the  capitellum  only  in  the  infra-condyloid  fracture,  the  capi- 
tellum  and  external  condyle  in  the  disjunction  of  the  entire  epiphysis, 
and  probably  some  part  of  the  external  condyloid  ridge  of  tlie  humerus, 
in  addition  to  the  condyle  in  the  common  supra-cond3'loid  fracture.  In 
all  four  forms  of  injury  the  forearm  is  generall}^  flexed,  and  the  hand 
midway  between  pronation  and  supination. 

The  other  fractures  which  communicate  with  tiie  elbow  are  often  com- 
minuted. Some  ai'e  of  a  T-shape,  consisting  of  a  transverse  branch  above 
the  condyles  and  a  vertical  one  between  them,  the  condyles  being  mova- 
ble on  each  other  with  crepitus,  and  the  end  of  the  bone  increased  in 
width.  Others  are  mere  linear  fractures  running  from  the  outer  or  inner 
side  of  the  bone  into  the  joint,  so  as  to  separate  tlie  external  or  internal 
condyle.  It  seems  that  the  prominent  extremity  of  the  latter  portion  of 
the  bone  may  be  separated  from  the  shaft  without  implicating  the  joint. 

The  treatment  of  all  tiiese  injuries  is  the  same.  The  elbow  must  be 
bent  to  something  above  a  right  angle,  so  that  if  anchylosis  should  unfor- 
tunatel}'  occur  the  hand  may  be  in  good  position.  This  position  ma}'  be 
maintained  by  an  angular  splint  in  the  bend  of  the  elbow  ;  or  if  there  is 
any  strong  tendency  to  displacement  of  the  lower  fragment  backwards 
the  angular  splint  may  be  applied  behind,  while  a  straight  splint  is  put 
in  front  of  the  arm  to  push  back  the  upper  fragment.  After  the  end  of 
three  weeks  passi\e  motion  must  l)e  sedulously  made,  the  splints  being 
removed  and  reai)plied  daily.  Dr.  Hamilton'^  even  recommends  the  total 
disuse  of  splints  after  the  first  seven  days  in  fractures  of  the  elbow,  and 
the  persevering  use  of  passive  motion  dull}',  remarking  that,  "though  at 
this  time  no  bony  union  has  taken  place,  yet  the  elfusions  have  somewhat 
steadied  the  fragments,  and  the  danger  of  displacement  is  lessened,  while 
the  prevention  of  anchylosis  demands  very  earl}'^  and  continued  motion." 
This,  however,  does  not  of  course  apply  to  IVactures  which  are  entirely 
above  the  cond3les,  but  only  to  those  in  wiiich  the  elbow-joint  is  clearly 
implicated. 

We  must  now  speak  of  fractures  of  the  forearm. 

Fracture  of  the  Olecranon. — The  olecranon  process  is  usually  fractured 

'  I'roCfKsor  Smith  says  that  in  dislocation  the  vertical  distance  between  the  two 
tumors  averafj;f,'S  one  and  a  half  inch,  while  in  infra-condyloid  fracture  it  seldom  ex- 
ceeds three-quarters  of  an  inch. 

*  On  Frnclurcs  and  Di.'ilocations,  p.  262. 


FRACTURES  OF  THE  OLECRANON. 


265 


by  a  fall  on  the  elbow,  and  sometimes  by  muscnlar  action.  The  fragment 
is  generally  drawn  npwards  by  the  triceps  muscle,  thougii  if  the  periosteum 
and  the  fibrous  expansion  around  the  bone  is  not  broken  tliere  may  be  no 
separation.  Bending  the  forearm  will  make  tlie  interval  more  distinct,  if 
there  is  any  difficulty  in  detecting  it,  which,  however,  is  rarely  the  case. 
The  loss  of  the  power  of  extending  the  forearm  is  sometimes  complete — 
more  commonly  the  patient  can  perform  this  action,  though  witli  pain 
and  difficulty.  Effusion  into  the  elbow-joint  generally  occurs  quickly,  for 
the  fracture  almost  always  implicates  the  joint.  It  is  said,  however,  that 
in  rare  cases  only  the  tip  of  the  process  is  broken  off  and  the  synovial 
membrane  left  intact. 

This  fracture  often  unites  by  ligament  only — but  also  by  bone — and 
then  frequently  with  obvious  evidence  of  inflammation  (Fig.  83).  The 
joint  is  often  left  with  hardly  a  trace  of 
injury  to  its  functions.  Tliis  will  neces- 
sarily depend  in  a  great  measure  on  the 
closeness  of  apposition  of  the  fragments, 
but  also  on  the  avoidance  of  subsequent 
inflammation,  and  it  is  to  these  two  indi- 
cations that  the  treatment  should  be  ad- 
dressed. The  first  thing  is  to  relax  the 
triceps  muscle  completely  by  putting  the 
arm  in  complete  extension  on  a  long  splint 
reaching  from  near  the  shoulder  to  the 
palm,  leaving  the  fracture  uncovered.  One 
of  the  plans  used  in  fracture  of  the  patella 
may  be  employed  here  also  to  draw  the 
movable  fragment  downwards.  Inflamma- 
tion must  be  combated  by  cold,  evaporating 
lotions,  and  leeches.  If,  however,  acute 
inflammation  nevertlieless  sets  in  and  per- 
sists, the  surgeon  must  not  allow  anchylosis 
to  occur  in  the  extended  position,  but 
should  examine  the  joint  under  chloroform, 
and  if  he  finds  that  adhesions  are  forming 
he  should  i)lace  it  at  an  appropriate  angle 
and  allow  it  to  anchylose  in  the  bent  posi- 
tion. In  ordinary  cases  the  splint  should  be  siderabie  interval,  a  large  mass  of  new- 
removed  after  a  "month,  and  passive  motion   ^y  ^o^^d  bone,  6,  extends  over  the  back 

,  1        1    •!  '^i  i  i  c      i.  of  the  olecranon,  and  forms  a  sort  of 

be  made  daily,  with  great  care  at  first,  so 
as  not  to  rupture  the  newly  formed  union. 

Compound  Fracture  of  the  Olecranon. — 
When  the  fracture  is  compound  it  is  per- 
haps   better,   if  the    wound    is    small  and 

uncomplicated,    to   treat    it    at    first    with    a    pltal,  of  which  there  is  no  history 

view  to  immediate  union  of  the  wound,  so 

as  to  convert  it  into  a  simple  fracture  and  preserve  the  motion  of  the 
joint;  but  if  there  is  considerable  laceration  and  the  joint  is  very  freely 
opened,  the  choice  lies  between  excision  and  anchylosis  in  the  flexed 
position.  The  former  would  be  indicated  if  there  is  reason  to  suspect 
the  presence  of  splinters  or  foreign  bodies  in  the  joint,  or  if  tlie  soft  parts 
are  much  torn,  but  in  most  cases  it  is,  I  think,  better  to  be  content  with 
anchylosis.  Should  much  suppuration  follow  and  the  bones  become  ex- 
tensively exposed  secondary  excision  can  at  any  time  be  practiced,  for 


Fracture  of  the  olecranon  united  by 
bone.  The  edges  of  the  fracture,  a,  a, 
are  united  by  bone  at  tlie  inner  side,  but 
at  the  outer  they  are  separated  by  a  con- 


splint  behind  the  fracture.  It  is  per- 
forated by  numerous  large  holes,  and 
separated  in  many  places  by  a  distinct 
interval  from  the  back  of  the  olecranon 
process. — From  a  specimen  (Ser.  i.  No. 
102)  in  the  Museum  of  St.  George's  Hos- 


266  INJURIES    OF    THE    UPPER    EXTREMITY. 

excision  of  the  elbow,  unlike  excision  of  the  knee,  may  be  performed  with 
success  in  the  acute  stages  of  inflammation, 

Frach(7'e  of  the  coi'onoid  proce.i^s  occurs  as  a  complication  of  dislocation 
of  the  elbow,  and  is  treated  of  under  that  head  (see  Fig.  98,  p.  282).  It 
is  also  spoken  of  as  a  separate  injury,  but  I  am  not  aware  that  its  exist- 
ence as  such  has  ever  been  proved  by  dissection.  It  is  said  to  unite 
usually  by  ligament,  in  consequence  of  the  displacement  of  the  fragment 
by  tlie  brachialis  anticus.  The  treatment  would,  therefore,  consist  in 
keeping  the  forearm  fixed  in  the  bent  position  for  about  three  weeks, 
should  this  injur}'  be  diagnosed. 

Fracture  of  the  upper  part  (head  or  neck)  of  the  radius  is  another  of 
the  proved  complications  of  dislocation  (q.  v.),  and  is  believed  liy  some 
authors  to  occur  independentl}',  but  without  anatomical  proof. 

The  most  common  fracture  of  the  central  part  of  the  forearm  is  that  in 
which  both  bones  are  broken,  which  usually  occurs  about  the  middle, 
though,  as  the  fracture  is  generally  caused  by  direct  violence,  any  i)art 
may  be  broken,  and  I  have  seen  cases  wliere  from  the  passage  of  a  wheel 
over  the  bod}^  the  bones  have  been  splintered  into  a  great  number  of  frag- 
ments. In  children  the  fracture  is  often  incomplete,  being  marked  by  a 
bending  of  the  bones,  with  no  crepitus,  the  upper  part  sharing  in  au}^ 
movement  impressed  on  the  lower  (see  Green-stick  Fracture,  p.  138). 
The  displacement  in  fracture  of  both  bones  of  the  forearm  is  often  very 
considerable  when  the  fracture  is  very  oblique  or  much  comminuted,  but 
there  is  not  in  general  any  serious  difflcult}'^  in  getting  the  bones  back 
into  position.  IS  or  is  the  treatment  generally  unsatisfactory'  even  in  some- 
what complicated  cases.  There  are,  however,  a  certain  number  in  which 
the  power  of  rotation  of  the  hand  is  more  or  less  lost,  a  result  wliich  is 
ascribed  by  Mr.  Flower^  (following  Lonsdale  in  this  particular)  to  the 
fact  that  the  two  portions  of  the  radius  have  been  put  up  in  ditferent  po- 
sitions as  regards  supination.  There  are  also  more  numerous  instances 
in  which  some  amount  of  deformity  is  left  after  union  but  without  au}' 
loss  of  motion.  The  indications  are  to  keep  the  fragments  from  falling 
together,  ?'.  e.,  to  ol)viate  an}'  tendency  of  the  fragment  of  the  radius  to 
point  towards  the  ulna,  or  vice  verad^  and  to  see  that  the  natural  line  of 
the  superficial  portions  of  both  bones  is  completely  restored.  For  the 
former  purpose  it  is  desirable  in  complicated  cases  to  place  a  graduated 
compress  in  the  intei'osseous  space.  With  regard  to  the  latter,  the  defect 
alluded  to  by  Lonsdale  and  Flower  of  putting  up  the  two  parts  of  the 
radius  in  different  positions  of  supination  is  most  surely  avoided  by  the 
completel}'  supine  position  of  the  whole  forearm.  This,  however,  is  more  , 
irksome  to  the  patient  tlian  the  half-supine  position.  The  latter  is  gener- 
ally adopted,  and  answers  well  for  all  ordinary  cases.  The  splints  in 
general  use  are  two  straiglit  well-padded  wooden  ones,  at  least  as  broad 
as  the  limb,  and  extending  from  tlie  elbow  to  tlie  wrist,  on  tlie  back  and 
front ;  or  a  pasteboard,  leather,  or  starched  case  may  be  applied  at  once. 
The  bones  should  be  kept  in  apposition  for  a  month,  care  being  taken  to 
give  passive  motion  to  tlie  fingers  if  they  seem  inclined  to  stitfen. 

Fraclure  of  Ulna  or  liadius  onbj. — The  ulna  or  radius  alone  may  be 
broken  in  its  centre.  The  ulna  can  only  be  thus  fractured  by  direct  vio- 
lence, and  this  is  also  the  cause  of  fracture  of  the  shall  of  the  radius  in 
almost  all  cases,  since  the  result  of  a  fall  on  the  hand  if  the  radius  gives 
wa}'  is  almost  always  Colles's  fracture.  Here  also  the  great  point  is  to 
see  that  the  fragments  do  not  fall  towards  the  other  bone,  and  for  this 


»  Syst.  of  Surg.,  vol.  ii,  p.  792. 


COLLES   S    FRACTURE. 


267 


purpose  to  thrust  tliein  out  if  uecessary  In-  a  pad  in  tlie  interosseous 
space.  Tiie  sound  bone,  acting  as  a  splint,  will  in  all  probability  prevent 
any  displacement,  and  no  lasting  effects  need  be  apprehended. 

Colles^s  fracture,^  or  fracture  of  the  radius  close  to  its  lower  end,  is  a 
very  frequent  consequence  of  falls  on  the  palm  of  the  hand,  especially  in 
old  persons.  It  is  one  of  the  few  fractures  which  are  believed  to  be  more 
common  among  women  than  men.  and  it  is  very  liable  to  be  followed  by 
a  considerable  amount  of  stiffness  of  the  wrist  and  fingers,  due  in  part, 
A'ery  likely,  to  a  tendency  to  rheumatism  in  the  patient.  The  radius  is 
broken  generally  about  an  inch  or  a  little  more  above  its  lower  end.  The 
displacement  which  usually  accompanies  this  injury,  and  which  is  so  char- 
acteristic of  it  that  it  enables  a  surgeon  to  recognize  it  at  a  glance,  is  well 
shown  in  the  accompanying  illustration,  taken  from  Prof.  Smith's  work. 

Fig.  84. 


CoUes's  fracture,  showing  the  most  common  deformity. — From  Professor  R.  W.  Smith, 
On  F"ractures,  p.  VST. 

The  lower  end  of  the  radius  carrying  the  hand  is  driven  backwards  and 
outwards,  causing  a  deviation  of  the  hand  from  the  axis  of  the  limb,  a 
prominence  of  the  styloid  process  of  the  ulna,  a  projection  on  the  back 
of  the  forearm  just  above  the  wrist,  and  a  corresponding  projection  on 
the  front  at  a  somewhat  higher  level  caused  by  the  flexor  tendons  being 
put  on  the  stretch  in  passing  over  the  upper  fragment.  The  power  of 
pronation  and  supination  is  lost.  If  the  hand  can  be  restored  to  its  nat- 
ural position  crepitus  will  be  felt  on  rotation.  The  line  of  fracture  is 
usually  nearly  transverse,  rarely  so  oblique  as  to  allow  of  verj'  great  dis- 
placement, which,  indeed,  is  iinpossible  so  long  as  the  ulna  and  the  inter- 
nal lateral  ligament  of  the  wrist-joint  remain  entire.  Much  difference  of 
opinion  prevails  as  to  whether  this  fracture  is  frequently  impacted  or  not. 
It  is  believed  to  be  so  by  most  English  and  French  authors,'^  and  the  ap- 
pearances of  fractures  which  have  been  long  united  with  some  amount  of 
displacement  certainly  resemble  exactly  those  of  impacted  fracture.  But 
the  Irish  surgeons,  and  notably  Prof.  R.  W.  Smith  and  Dr.  Gordon,  deny 
that  impaction  is  common  ;  and  they  attribute  the  appearances  referred 
to  not  to  penetration  of  the  lower  fragment  by  the  upper  at  the  moment 
of  the  accident,  but  to  subsequent  inflammation  which  has  produced  an 
irregular  callus  encircling  both  fragments.  There  is  no  doubt,  however, 
that  in  many  cases  there  is  an  almost  insuperable  difficulty  in  disengaging 
the  fragments,  v^hich  can  hardly  be  accounted  for  except  on  the  theory 
of  impaction,  and  for  myself  I  certainly  hold  the  general  view. 

'  Mr.  CoUes's  description  of  this  fracture  will  be  found  in  the  Ed.  Med.  und  Surg. 
Jour.,  April,  1814. 

2  The  testimony  of  eminent  pathologists  leaves  no  doubt,  to  say  the  least,  of  the 
occasio?tr/^  occurrence  of  impaction  of  the  upper  fragment  into  the  lower.  See  Cal- 
lender,  St.  Bartholomew's  Hospital  Reports,  vol.  i,  p.  283,  where  three  cases  are  re- 
lated in  which,  the  patient  dying  on  the  spot  from  other  injuries,  this  impaction  was 
found. 


268 


INJURIES    OF    THE    UPPER    EXTREMITY. 


The  treatment  is  very  often  not  entirel^y  successful  either  in  restoring 
the  shape  of  the  parts  or  the  movements  of  the  wrist  and  fingers,  though 
the  latter  may  be  trusted  to  improve  graduall3^  It  is  well  to  warn  the 
patient  of  this.  Several  plans  are  in  common  use.  Some  surgeons  use 
two  straight  splints,  anterior  and  posterior,  not  reaching  much  beyond 
the  wrist,  and  when  these  splints  are  used  the  surgeon  generally  draws 
the  hand  towards  the  ulnar  side  by  means  of  the  bandage  which  fixes  the 
splint  or  by  a  webbing  strap.  The  pistol-shaped  splint  is  a  very  common 
apparatus,  applied  either  to  the  front,  or,  as  is  perhaps  better,  to  the 
back  of  the  forearm  and  hand,  with  a  short  splint  on  the  palmar  aspect 
of  the  forearm. 

Dr.  Gordon'  teaches  that  in  this  fracture  both  the  fractured  ends  are 
displaced  forwards,  and  he  follows  Prof.  Smith  in  denying  the  existence 
of  impaction  as  a  common  condition.  The  means  by  which  he  proposes 
to  remed}^  the  displacement,  or  to  restore  the  natural  concavity  of  the 
radius  anteriorly,  consist  in  first  reducing  the  fracture  by  traction  on  the 
hand  and  pressure  on  the  fragments,  placing  the  hand  in  the  prone  posi- 
tion, then  appl3'ing  to  the  anterior  surface  of  the  forearm  a  splint  (Fig. 
85  a)  to  which  a  wooden  conical  or  triangular  piece  is  so  attached  that 
the  external  border  of  the  splint  projects  beyond  it ;  and  on  the  back  of 
the  forearm  a  straight  splint  (Fig.  85  b)  more  thickly  padded  over  the 
wrist  than  over  the  forearm.  The  splints  are  to  be  fixed  by  two  webbing 
straps,  not  bj^  bandage.  The  triangular  bevelled  end  of  the  anterior  radial 
splint  lifts  up  the  lower  end  of  the  upper  fragment  of  the  radius,  the 
pressure  made  by  the  straps  (which  is  thrown  entirely  on  the  ulnar  side 

of  the    limb    in    conse- 
Fi"-  ^^-  quence  of  the  projecting 

border  of  the  radial 
splint)  remedies  the  pro- 
jection of  the  ulna  in- 
wards, and  the  depres- 
sion of  the  hand  elevates 
the  lower  or  carpal  frag- 
ment and  raises  it  to  the 
level  of  the  upper  frag- 
ment. Those  who  have 
tried  this  plan  adequate- 
ly report  in  high  terms 
of  its  results,^  and  a 
somewhat  similar  plan 
is  said'^  to  have  been 
employed  by  Sir  P. 
Crampton. 

I  have  used  all  three 
plans  ;  Dr.  Gordon's,  in- 
deed, only  in  one  or  two 
instances,  but  in  one  of 
these  with  great  success. 
M}^  own  impression  is 
that  all  methods  give  a 
good  result  in  non-impacted  fractures  -which  can  be  and  are  accurately 
set  at  the  time  of  the  injury,  and  where  the  patient  is  healthy  and  tracta- 

*  On  the  Treatment  of  Fractures  of  the  Lower  Extremity  of  the  Radius,  Belfast, 
1862. 

*  See  Porter,  DubHn  Quar.  Jour.,  May,  18G5.  »  Ibid.,  Feb.  1862. 


Gordon's  splint  for  fracture  of  the  lower  end  of  the  radius. 


The  si)lints  apiilicd. 


COMPOUND    FRACTURES.  269 

ble ;  and  even  when  some  deformity  remains  the  movements  of  the  wrist 
and  fingers  ai"e  preserved  if  timely  passive  and  active  movements  are  in- 
sisted on.  Dr.  Gordon  seems  to  me  to  have  somewhat  exaggerated  the 
frequency  of  the  ill-success,  which,  however,  does  undoubtedly  sometimes 
attend  the  common  methods  of  treatment. 

Whatever  treatment  is  adopted,  the  part  should  not  be  kept  too  long 
stiff;  but  after  about  three  weeks  it  should  be  taken  out  of  the  splints, 
and  careful  passive  motion  given  to  each  tinger-joint  and  to  the  wrist,  the 
limb  being  first  well  steamed. 

The  lower  end  of  the  radius  is  also  in  rare  cases  comminuted  or  frac- 
tured in  such  a  direction  that  its  lower  fragment  is  displaced  forward,  and 
sometimes  the  lower  ends  of  both  bones  are  crushed.  Such  accidents 
should  be  treated  on  simple  straight  splints,  after  careful  reduction. 
When  comminuted  fracture  aflfects  both  bones  they  are  very  liable  to  be 
soldered  together  in  the  process  of  union,  causing  entire  loss  of  the  rota- 
tory movements  of  the  hand,  and  the  surgeon  must  combat  this  tendency 
as  well  as  he  can  by  timely  passive  motion. 

Fractures  of  the  carpal  bones  are  rare,  at  least  they  are  rarel}'^  diag- 
nosed— being  possibly  in  many  cases  masked  by  the  injury  to  the  soft 
parts,  which  is  usually  severe.  The  accident  in  itself  is  not  a  very  for- 
midable one,  for  two  or  more  of  the  carpal  bones  may  be  anchylosed 
together  without  any  loss  of  the  functions  of  the  hand.  I  had  a  case 
nnder  treatment  a  short  time  since  in  which,  after  a  severe  crush  of  the 
wrist  accompanied  by  fracture,  the  greater  part  of  the  semilunar  bone 
became  loose  and  was  removed,  but  the  patient  recovered  with  a  very 
useful  hand.  Rest  on  a  splint  and  cold  lotion  till  the  movements  of  the 
hand  are  no  longer  painful,  followed  by  careful  passive  motion  if  neces- 
sary, comprise  all  that  is  required  in  the  way  of  treatment. 

Fractures  of  the  inetacarpal  bones  and  phalanges  are  generally  the 
result  of  direct  violence,  though  any  of  these  bones  (at  least  any  above 
the  terminal  phalanges)  may  be  fractured  by  a  blow  or  a  pull  upon  the 
finger.  When  a  metacarpal  bone  is  broken,  the  nature  of  the  injury  is 
at  once  declared  by  the  dropping  of  the  knuckle,  and  the  break  in  the 
line  of  the  dorsal  surface  of  the  bone.  The  treatment  consists  in  band- 
aging the  fist  round  a  padded  stick  or  a  ball,  or  in  putting  the  hand  on  a 
palmar  splint  which  carries  a  pad  of  cork  or  other  material,  supporting 
the  dropped  knuckle  at  a  proper  level. 

Fracture  of  a  phalanx  requires  only  a  splint  reaching  into  the  palm  of 
the  hand,  and  keeping  the  finger  perfectly  quiet  and  straight. 

Treatment  may  be  given  up  in  about  three  weeks  in  both  cases. 

Gomj)ound  fractures  in  all  parts  of  the  upper  extremity  are  very  com- 
mon, and  are  of  far  less  gravity  than  the  corresponding  injuries  in  the 
lower  limb.  Gangrene  also,  if  it  occurs  after  the  injury,  is  of  less  con- 
sequence to  life,  and  secondary'  amputation  much  more  likely  to  succeed. 
Mucli,  therefore,  is  justifiable  in  the  vvay  of  removing  fragments,  endeav- 
oring to  promote  the  union  of  wounds,  and  so  saving  the  limb,  which 
would  not  be  allowable  in  compound  fractures  of  the  thigh,  leg,  and  foot. 
Indeed,  in  the  hand  it  is  often  better  to  allow  the  parts  to  slough  away 
and  afterwards  trim  up  the  stump  if  necessary,  rather  than  by  primary 
amputation  to  sacrifice  fingers,  or  parts  of  fingers,  which  may  ultimately 
recover  and  prove  very  useful.  Primary  resections  also,  which  are  so 
disastrous  in  the  hip  and  knee,  may  be  practiced  with  good  hope  of  suc- 
cess in  the  shoulder  and  elbow,  and  are  perhaps  preferable  to  the  mere 
removal  of  splinters — operations  which  will  most  likely  be  followed  by 


270  INJURIES    OF    THE    UPPER    EXTREMITY. 

anchylosis,  and  involve  probably  the  same  risk  to  life  as  the  more  formal 
excision.  This,  however,  does  not  apply,  I  think,  to  the  wrist  and  car- 
pns,  where  the  removal  of  fragments  is  less  likely  to  impair  the  move- 
ments of  the  fingers,  than  excision  of  the  whole  articnlating  surfaces. 

In  injuries  of  the  hand  the  thumb,  or  any  part  of  tlie  thumb,  should  be 
preserved  in  an}^  condition,  stiff  or  otlierwise.  Any  portion  also  of  the 
metacarpus  is  useful  if  in  connection  with  a  thumb  or  movable  fingers, 
since  a  very  efficient  apparatus  can  be  fitted  on  to  it.  But  if  the  flexor 
or  extensor  tendons  of  a  finger  are  torn  to  pieces,  or  its  joints  destroyed, 
so  tliat  it  must  be  stiff  afterwards,  it  would  onlj'  be  in  the  way  ultimately, 
and  should  be  at  once  amputated. 

Dislocation  of  the  Clavicle. — The  clavicle  may  be  dislocated  at  either 
its  sternal  or  acromial  end,  if  we  use  the  old  nomenclature.  It  has  now 
become  more  common  to  speak  of  the  latter  accident  as  a  dislocation  of 
the  acromial  extremity  of  the  scapula. 

The  sternal  end  of  the  clavicle  may  be  dislocated  forwards,  back- 
wards, or  upwards.  Dislocation  downwards  is  impossible,  on  account  of 
the  first  rib. 

Dislocation  forwards  is  the  most  common,  though  even  this  is  a  rare 
injur}^,  for  the  sterno-clavicular,  like  some  of  the  other  joints  which,  in 
the  skeleton,  appear  very  weak  (for  instance,  the  knee),  is  provided  witli 
so  many  and  such  powerful  ligaments,  and  is  so  protected  by  the  mech- 
anism of  the  parts,  that  it  is  little  subject  to  displacement.  The  force 
which  would  otherwise  act  on  this  joint  is  usually  neutralized  and  re- 
solved in  the  numerous  and  very  powerful  articulations  through  which  it 
is  transmitted,  and  wlien  this  is  not  the  case  it  is  generally  expended  in 
breaking  tlie  clavicle.  When  dislocation  forward  occurs  the  head  of  the 
bone  rests  on  the  front  surface  of  the  sternum.  The  only  ambiguity 
which  can  exist  is  between  this  injury  and  a  fracture  of  the  clavicle  close 
to  its  head  ;  but  the  shape  of  the  displaced  head  is  generally  quite  char- 
acteristic ;  or  in  case  of  doubt  measurement  before  reduction  and  exam- 
ination afterwards  will  show  in  the  case  of  fracture  that  the  injured  bone 
has  not  tlie  length  of  the  sound  clavicle  and  that  crepitus  is  present. 
Eeduction  is  usually  easy,  by  drawing  the  shoulders  backwards,  but  it  is 
difficult  to  keep  the  parts  in  position.  The  arm  must  be  put  up,  as  in 
fractured  clavicle,  with  the  elbow  carried  further  forward  than  in  the 
common  fracture;  or  the  hand  may  be  bandaged  on  to  the  opposite 
shoulder.  Nelaton  prescribes  that  a  truss  shall  be  applied  to  press  upon 
the  displaced  head.  In  the  only  case  I  have  seen  the  displacement  was 
not  corrected,  but  the  arm  remained  quite  useful,  and  this  is  the  ordi- 
nar}'  event. 

In  the  dislocation  backwards  the  head  of  the  bones  is  thrown  between 
the  sternum  and  the  traehea,  and  sometimes  produces  the  most  alarming 
dyspnoea,  or  even  death.  It  is  usually  caused  by  direct  force.  The  dysp- 
na-a,  the  consequent  bending  forward  of  the  head  (in  order  to  make 
room  for  the  displaced  bone),  and  the  changed  shape  of  the  parts,  leave 
no  doubt  as  to  the  nature  of  the  injurj'.  Reduction  is  generally  easy  by 
dravving  the  shoulders  backwards,  and  this  })osition  should  be  maintained 
by  "a  splint  passed  behind  the  shoulders,  with  a  pad  between  it  and  the 
spine,  the  shoulders  being  drawn  to  the  splint  by  a  bandage.'"     After 

1  See  the  account  of  a  characteristic  case  by  Mr.  Hulke,  in  the  System  of  Surgery, 
'M  edition,  vol.  ii,  p.  805. 


DISLOCATION    OF    THE    SHOULDER.  271 

about  a  fortniglit  the  s{)rnit  may  be  withdrawn  and  the  patient  kci)t  quiet 
in  bed  till  all  tenderness  and  pain  has  subsided. 

Dislocation  upwards  (sui)rasternal)  is  a  rare  injury,  of  which  only 
about  eight  cases  are  on  record.  Its  anatomy  is  now  fully  known,  from 
a  case  which  was  carefully  dissected  and  published  by  Professor  R.  W. 
Smith,'  the  man  having  died  of  other  iujnries.  Dr.  Smith's  account  con- 
tains two  excellent  drawings  of  the  appearance  of  the  part  during  life 
and  of  the  dissected  specimen.  The  head  of  the  bone,  carrying  the  in- 
terarticular  cartilage  with  it,  had  been  thrust  between  the  two  heads  of 
the  sternomastoid  muscle,  and  lay  in  contact  with  the  opposite  clavicle. 
The  sternohyoid  muscle  was  behind  it;  the  sternal  tendon  of  the  sterno- 
mastoid, tightly  stretched  over  it,  formed  a  considerable  prominence 
during  life.  The  rhomboid  ligament  was  ruptured  as  well  as  the  capsule 
of  the  joint.  Treatment  has  hitherto  been  found  unsuccessful  in  curing 
the  displacement,  but  a  good  use  of  the  arm  may  be  anticipated. 

Dislocation  of  the  acromial  end  of  the  clavicle  takes  place  usually  in 
the  upward  direction,?!,  e.,  the  clavicle  lies  npon  the  acromion  process.  If 
we  follow  the  nomenclature  of  Messrs.  Flower  and  Hulke  we  should  call 
this  a  dislocation  of  the  acromion  process  of  the  scapula  downwards.  It 
is  believed  to  be  caused  in  almost  all  cases  by  violence  applied  directly 
to  the  scapula,  which  is  relatively  by  far  the  more  movable  bone. 

The  accident  is  unmistakable.  The  shoulder  is  depressed,  the  arm 
apparently  lengthened  ;  there  is  pain  in  raising  the  arm,  voluntary  motion 
is  very  limited,  and  the  prominence  of  the  acromial  end  of  the  clavicle 
is  easily  felt.  The  deltoid  is  considerably  flattened,  in  consequence  of 
the  arm  falling  or  being  pressed  downwards,  by  which  the  fibres  of  the 
muscle  are  pulled  down.  Reduction  is  not  difficult.  It  is  accomplished 
by  drawing  the  siionlder  back,  while  the  dislocated  end  of  the  clavicle  is 
pushed  downwards  ;  but  the  bones  easily  slip  away  again.  The  shoulder 
must  lie  well  raised,  with  a  pad  in  the  axilla,  and  a  compress  or  truss 
placed  on  the  outer  end  of  the  clavicle.  Some  little  displacement  will 
not  seriously  incommode  the  patient  afterwards.  The  opposite  disloca- 
tion, viz.,  that  in  which  the  acromion  lies  above  the  clavicle,  is  very  rare. 
It  must  be  treated  on  the  same  general  principles. 

As  surgical  curiosities  cases  are  spoken  of  in  which  the  outer  end  of 
the  clavicle  has  been  thrown  beneath  the  coracoid  process  as  well  as  the 
acromion,-  and  cases  in  which  the  clavicle  has  been  dislocated  simultane- 
ousl}'  from  both  its  articulations.^ 

Didocation  of  the  Shoulder. — Dislocation  of  the  head  of  the  humerus 
takes  place  usually  in  one  of  three  directions — downwards,  inwards,  or 
backwards.  A  few  cases  of  dislocation  upwards  have  been  described, 
and  one  of  them  was  dissected  by  myself,  but  the  injury  is  a  very  rare  one. 

The  common  dislocation  is  downwards,  or  into  the  axilla  ;  but  the  posi- 
tion of  tiie  bone  is  not  usually  directly  below  the  glenoid  cavity,  as  would 
be  inferred  from  Sir  A.  Cooper's  language,  and  as  he  no  doubt  believed, 
but  rather  internal  to  it,  though  still  in  the  axilla,  and  somewhat  lielow 
its  natural  level.  Hence  the  dislocations  into  the  axilla  are  divided  into 
two  varieties, — the  subglenoid,  or  that  directly  downwards,  and  the  sub- 
coracoid,  or  that  downwards,  forwards,  and  inwards. 

The  latter  is  the  common  dislocation  of  the  shoulder,*  the  subglenoid 


'  Dublin  Journal  of  Med.  Science,  DubUn,  1872. 

2  System  of  Surgery,  vol.  ii,  p.  807.  '  Gaz.  des  Hop.,  1859,  No.  33. 

*  According  to  Messrs.  Flower  and  Hulke  thirty-one  out  of  forty-one  preparations 
of  dislocation  of  the  shoulder  preserved  in  museums,  and  forty-four  out  of  fifty  re- 
cent cases,  were  found  to  be  of  this  form. 


272 


INJURIES    OF    THE    UPPER    EXTREMITY. 


Fig.  86. 


Dislocation  of  the  shoulder.  An  imaginary  sketch,  shovrlng 
the  usual  appearance  in  the  axillary  dislocation.  In  the  dislo- 
cation inwards,  or  beneath  the  pectoral  muscle,  the  prominence 
of  the  shoulder  will  be  more  marked  ;  and  the  head  of  the  hu- 
merus will  form  a  considerable  prominence  in  the  situation  of 
the  furrow  between  the  deltoid  and  pectoralis  major. — See  A. 
Cooper,  2d  cd.,  pi.  xxviii,  Fig.  42. 

Fig.  87. 


Subcoracoid  dislocation  (after  Flower). 


being  decidedly  more  rare. 
Tlie  dislocation  inwards, 
"  below  the  pectoral  mus- 
cle," of  Sir  A.  Cooper,  or 
''  subclavicular,"  as  it  is 
now  usually  termed,  after 
Malgaigne,  and  that  back- 
wards "on  the  dorsum  scap- 
ulte,"  or  "  subsiDinous,"  are 
very  rarel}^  met  with, 

Thei'e  are  certain  symp- 
toms common  to  all  disloca- 
tions of  the  humerus,  viz.,  a 
loss  of  the  natural  rounded 
shape  of  the  shoulder,  a 
change  in  the  direction  of 
the  axis  of  the  humerus,  an 
increase  amounting  to  be- 
tween one  and  two  inches  in 
the  vertical  measurement  of 
the  shoulder  and  axilla,  loss 
of  the  power  of  voluntary 
motion,  and  resistance  to 
passive  movements  except 
in  certain  directions. 

1 .  Dinlocation  downvjards. 
— In  the  dislocations  into 
the  axilla  the  acromion  is 
prominent  and  the  deltoid 
flattened.  The  subcoracoid 
form  of  this  dislocation  is 
shown  in  Fig.  87.  The  head 
of  the  bone  usually  lies  im- 
mediately below  the  coracoid 
process,  in  front,  internal 
to,  and  rather  lower  than  its 
natural  situation.  In  other 
cases  the  head  of  the  bone 
is  thrown  further  inwards, 
so  as  to  rest  more  on  the 
venter  of  the  scapula  than 
on  the  upper  part  of  its 
neck,  as  it  does  in  the  usual 
subcoracoid  dislocation, Fig. 
88.  This  is  described  b}' 
Malgaigne  as  a  separate 
form,  under  the  name  of 
"intracoracoid"  dislocation  ; 
but  I  do  not  see  any  object 
in  separating  it  from  the 
other,  and  I  much  doubt 
whether  the  cases  could  be 
diagnosed  from  each  other 
during  life.  Mr.  Flower 
points  out  that  in  old  un- 


DISLOCATION    OF    SHOULDER. 


273 


Intra-coraeoid  dislocation  (after  Flower). 


reduced  dislocations  of  the  purely  snbcoracoid  form  the  newly  formed 
cavity  for  the  head  of  the  bone  will  trench  on  the  old  glenoid  fossa, 
and  will  also  be  formed  partly  by  the  coracoid  process,  and  that  such 
specimens  have  often  been  described  as  partial  dislocations.  In  the 
intra-coracoid  form  the  new 

cavity  is  independent  of  the  fig.  ss. 

glenoid  fossa,  and  the  cora- 
coid process  is  not  usually 
affected.  In  the  subglenoid 
dislocation  (Fig.  80)  there  is 
a  more  considerable  interval 
between  the  coracoid  process 
and  the  head  of  tiie  bone, 
which  latter  is  also  more 
prominently  felt  when  the 
fingers  are  thrust  into  the 
axilla.  In  both  forms  the 
arm  is  directed  away  from 
the  side,  but  more  so  in  the 
subglenoid ;  it  usually  ap- 
pears lengthened,  and  some- 
times is  really  so,  especially 
in  subglenoid  dislocations. 
In  the  subcoracoid  this  elon- 
gation is  usually  proved  by 
measurement  to  be  only  ap- 
parent, being  due  to  the  drop- 
ping of  the  affected  shoulder  ; 

sometimes  the  arm  is  even  shortened ;  there  is  often  considerable  pain 
from  pressure  by  the  dislocated  bone  on  the  nerves  of  the  brachial  plexus, 
especially  the  circumflex,  which  in  some  cases  is  so  much  injured  that  the 
deltoid  muscle  does  not  recover  its  functions  after  the  reduction  of  the 
dislocation  ;  and  in  rare  cases 
there  is  congestion  or  even 
oedema  from  pressure  on  the 
vein.  The  arm  can  be  moved 
backwards  and  forwards,  but 
cannot  be  lifted  or  brought 
to  the  side.  The  great  tuber- 
osity of  the  humerus  is  said 
to  be  often  torn  off,  and  some- 
times drawn  into  the  glenoid 
cavity. 

The  two  forms  of  disloca- 
tion ma}'  be  regarded  as  va- 
rieties of  the  same  injury, 
in  which  the  head  of  the 
humerus  has  been  driven 
through  the  lower  part  of  the 
capsule,  and  in  the  subglenoid 
form  has  been  arrested  by  the 
inferior  costa  of  the  scapula ; 
while  in  the  subcoracoid  it  has 
been  drawn  up  by  the  muscles 
under  the  coracoid  process. 

18 


Fig. 


Subglenoid  dislocation  (after  Flower). 


274 


INJURIES    OF    THE    UPPER    EXTREMITY. 


The  usual  causes  of  dislocation  into  tlie  axilla  are  either  direct  blows 
or  falls  on  the  shoulder,  or  a  fall  on  the  elbow  or  hand  when  extended, 
b^'  whic'li  the  lower  end  of  the  bone  is  violently  raised  and  its  liead  thrust 
against  the  lower  part  of  the  capsule.  Muscular  actions  of  the  same  kind 
(as  in  raising  the  arm  to  strilce  a  blow)  have  been  known  to  produce  it, 
especially'  when  the  shoulder  has  been  dislocated  before.  I  have  seen  it 
produced  (and  for  tlie  first  time)  wliile  the  patient  was  lying  in  bed  in  the 
hospital. 

2.  Dislocation  imvards. — In  the  dislocation  inwards  (subclavicular), 
(Fig.  90)  the  head  of  the  bone  usually  makes  a  considerable  projection 
on  the  front  of  the  chest,  below  the  middle  of  the  clavicle,  aud  usually 
can  easily  be  felt,  though  it  is  said  that  sometimes  it  lies  deeply  in  the 
subscapular  fossa.  The  head  of  tlie  humerus  cannot  be  felt  from  the 
axilla,  though  some  part  of  the  shaft  may  ;  the  arm  is  less  separated  from 
the  side  than  in  the  axillary  dislocations.  The  causes  of  this  dislocation 
are  the  same;  in  fact,  it  is  regarded  as  a  variety  of  the  common  disloca- 
tion, in  which  from  some  unknown  reason  the  liead  of  the  bone  has  been 
drawn  further  inwards  than  in  the  ordinary  subcoracoid  dislocation. 
There  can  be  no  doubt,  however,  of  the  accuracy  of  Mr.  Flower's  opin- 
ion, that  most  of  the  cases  described  as  "  dislocations  beneath  the  pec- 
toral muscle"  would  now  be  classed  as  "  subcoracoid."  The  true  subclav- 
icular dislocation,  in  which  the  whole  head  of  the  bone  lies  internal  to  the 
coracoid  process,  is  very  rare. 

3.  Didocalion  &ac^'ioart?.s' (subspinous)  is  a  well-marked  injury,  in  which 
the  head  of  the  bone  forms  a  considerable  prominence  on  the  dorsum  of 


Fm.  90. 


Fig.  91. 


.Subclavicular  ilisloeatioii  faftiT  Fluwer). 


Subspinous  dislocation  (after  Flower). 


the  scapula,  and  a  considerable  depression  is  left  beneath  the  coracoid 
process.  The  arm  is  usually  rotated  inwards,  pressed  closely  to  the  side, 
and  the  elbow  thrown  forwards.     It  is  caused  by  direct  violence,  or  by 


DISLOCATIOxV    OF    SHOULDER.  275 

falls  on  the  elbow  when  advanced,  or  by  violent  twisting  of  the  arm 
inwards. 

4.  Dislocation  upivards  (supra-coracoid)  can  only  occur  after  fracture 
of  the  coracoid  or  acromion  process  (usually  the  former)  ;  it  is  caused,  I 
believe,  always  by  direct  violence,  applied  in  the  upward  direction — the 
head  of  the  bone  lies  in  front  of  the  clavicle,  immediately  under  the  skin.^ 

Diagnosis. — The  rarer  forms  of  dislocation  of  the  shoulder  present 
usually  no  difficulties  of  diagnosis  ;  what  follows,  therefore,  relates  mainly 
to  dislocations  into  the  axilla,  though  here,  again,  the  errors  which  are 
unfortunately  common  are  more  often  the  result  of  haste  than  of  any  real 
difficulty  in  the  diagnosis. 

The  flattened  shape  of  the  shoulder  and  prominence  of  the  acromion 
process  are  usually  ver}'  characteristic  of  the  injury,  and  so  is  the  in- 
crease in  the  vertical  measurement  around  the  armpit.  Dr.  F.  Hamilton  '^ 
has  lately  pointed  out  two  diagnostic  signs  between  dislocation  and  all  the 
other  injuries  of  the  shoulder  which  will  be  found  useful  in  all  cases 
where  the  swelling  is  not  very  great.  1.  If  in  the  healthy  state,  or  when- 
ever the  head  of  the  bone  is  in  the  glenoid  cavity,  a  rule  be  laid  on  the 
outer  side  of  the  arm,  touching  the  elbow  and  shoulder,  it  will  be  distant 
from  the  acromion  process  at  least  half  an  inch,  generally  an  inch  or 
more.  In  any  form  of  dislocation,  on  the  contrary,  the  rule  will  touch  the 
acromion.  2.  If  the  surgeon  stands  behind  the  patient  and  places  the 
forefinger  and  thumb  on  each  side  of  the  acromion  process  just  external 
to  the  joint  with  the  clavicle,  the  forefinger  in  front  and  the  thumb  be- 
hind, and  then  carries  them  vertically  downwards,  the  tip  of  the  finger 
will  rest  on  the  centre  of  the  front  of  the  rounded  head  of  the  humerus, 
while  the  thumb  will  also  feel  its  posterior  part,  indistinctly  at  first; 
but  if  the  elbow  is  thrown  forwards  and  the  arm  rotated,  the  head  of  the 
bone  will  strike  the  thumb  more  plainly.  This  is  the  case  when  the  head 
of  the  bone  is  in  the  socket ;  but  if  dislocation  exists  the  head  of  the 
humerus  cannot  be  felt  by  the  thumb  thus  placed. 

Cases  occur  in  which,  from  paralysis  of  the  deltoid  muscle,  the  shoulder 
has  the  same  shape  as  in  dislocation  ;  but  when  this  is  the  result  of  in- 
fantile paralysis  the  history  is  different,  and  even  when  the  paralysis  fol- 
lows on  a  dislocation  (from  lesion  of  the  circumflex  nerve)  the  surgeon 
may  easily  satisfy  himself  that  the  dislocation  has  been  reduced,  by  the 
absence  of  any  prominence  in  the  axilla,  by  the  freedom  of  passive  mo- 
tion, and  bj'  the  vertical  measurement  round  tlie  shoulder — which  in  un- 
reduced dislocation  is  greater  than  on  the  sound  side — while  in  paralysis 
it  is  equal  or  less  ;  and  the  same  remarks  apply  to  wasting  of  the  deltoid 
after  lesion  of  the  circumflex  nerve  from  other  causes. 

From  fracture  of  the  surgical  neck  of  the  humerus  dislocation  may  be 
distinguished  by  the  more  pronounced  flattening,  by  the  difference  in 
shape  of  the  bone  which  is  felt  projecting  in  the  axilla,  and  by  the  crepitus 
which  is  felt  when  the  arm  is  reduced  to  its  natural  position,  such  reduc- 
tion being  usually  very  much  easier  in  the  fracture  than  in  the  disloca- 
tion, while  the  displacement  is  also  easily  reproduced.  The  higher  up 
the  fracture  is,  the  more  it  is  impacted,  and  the  longer  the  time  which 
has  elapsed  since  the  accident,  the  more  difficult  does  the  diagnosis  be- 
come ;  nor  is  it  always  by  any  means  easy  to  satisfy  one's  self  whether  there 
is  some  fracture  of  the  glenoid  cavity  or  neighboring  part  of  the  scapula 
in  cases  which  at  first  sight  seem  pure  dislocations.     The  difficult}^  is  iu- 

'  See  my  paper  in  the  Med.-Chir.  Trans.,  vol.  xli,  p.  447. 
^  See  London  Med.  Record,  April  21,  1875. 


276  INJURIES    OF    THE    UPPER    EXTREMITY. 

creased  by  the  effusion  of  fibrin  into  the  sheaths  of  the  tendons  and  cavity 
of  the  joint  which  usually  follows  on  unreduced  dislocation,  and  which 
gives  rise  to  a  sensation  of  crepitus  very  hard  to  distinguish  from  that  of 
fracture.  Tliere  are  few  practical  surgeons  who  have  not  had  to  confess 
the  gieat  ditliculty  of  pronouncing  a  definite  opinion  in  such  cases. 

The  diagnosis  may,  again,  be  complicated  by  fracture  either  of  the 
scapula  or  of  the  humerus.  In  a  former  section  (page  25fi)  I  have  dis- 
cussed the  question,  raised  by  Sir  A.  Cooper,  as  to  the  probable  frequency 
of  fracture  running  through  the  neck  of  the  scapula  and  leading  to  such 
displacement  of  the  glenoid  process  along  with  the  humerus  as  ma}'  simu- 
late dislocation.  But  exclusive  of  such  injuries,  in  which  there  is  no  dis- 
location, there  can  be  no  question  that  in  some  cases  where  dislocation 
does  exist  there  exists  also  fracture  of  a  portion  of  the  glenoid  cavity, 
or  of  the  coracoid  process,  or  of  the  great  tuberosity,  or  possibly  some 
other  part  of  the  upper  end  of  the  humerus.  Dislocation,  complicated 
with  fractui'e  of  the  glenoid  cavity,  will  produce,  as  Malgaigne  has  shown, 
many  of  the  s,ymptoms  which  Sir  A.  Cooper  attributed  to  fracture  of 
the  neck  of  the  scapula  ;  and  it  is,  as  far  as  I  can  see,  indistinguishable 
from  the  fracture  of  the  anatomical  neck  of  the  bone,  described  b}^  Lotz- 
beck ;  but  it  does  not  separate  the  coracoid  process  from  the  rest  of  the 
scapula,  and  therefore  may  be  distinguished  (though  not  without  diffi- 
culty) from  the  fracture  of  the  surgical  neck  of  the  scapula  which  Sir 
Ast  ley  so  clearly  describes.  Fractures  of  the  coracoid  process  or  of  the 
great  tuberosity  produce  crepitus,  but  do  not  cause  that  insecurity  of  re- 
duction which  is  so  marked  a  feature  in  fracture  of  the  neck  of  the  scapula, 
and  in  dislocation  complicated  with  fracture  of  the  glenoid  process.  The 
fracture  in  tliese  latter  cases  is  an  unimportant  complication,  only  neces- 
sitating longer  confinement  of  the  arm.  When  dislocation  is  complicated 
with  fracture  of  the  shaft  of  the  bone  the  injury  is  a  much  more  serious 
one,  since  reduction  is  often  impossible  ;  and  the  nearer  to  the  joint  the 
fracture  is,  the  greater  is  the  difficult}'.  Nor  is  it  always  easy  to  recog- 
nize the  real  nature  of  the  injury  at  the  time.  Much  care,  therefore,  ought 
to  be  bestowed  on  the  examination  of  every  case  of  fracture  high  up,  in 
order  to  ascertain  b}'  careful  exploration  of  the  axilla  that  the  head  of 
the  humerus  is  in  its  place.  Should  dislocation  be  detected  the  patient 
must  be  brought  into  a  condition  of  complete  anaesthesia,  and  all  avail- 
able means  used  to  manipulate  the  dislocation  into  position.  If  this  at- 
tempt fails  then  the  fracture  must  be  set  in  such  a  position  as  will  best 
restore  the  shape  of  the  humerus  ;  and  in  a  month  or  six  weeks,  when 
consolidation  seems  to  have  far  enough  advanced,  reduction  must  be  at- 
tempted, much  caution  being,  of  course,  observed  not  to  refracture  the 
bone. 

Reduction. — There  are  numerous  methods  of  reducing  these  disloca- 
tions, and  those  methods  seem  at  first  sight  so  different  from  eacli  other 
as  to  lead  the  student  to  suppose  that  the  force  is  applied  in  one  in  just 
the  opposite  direction  to  the  other.  For  instance,  in  the  common  method, 
witli  the  heel  in  the  axilla,  the  arm  is  pulled  directly  downwards,  towards 
the  patient's  feet,  while  in  another  method  it  is  pulled  directly  upwards, 
above  his  head.  But  Mr.  Skey'  has  shown  that  the  mobility  of  the  scapula 
to  a  great  extent,  at  any  rate,  neutralizes  these  differences,  and  that  in 
all  the  plans  of  reduction  the  arm  is  pulled  in  a  direction  more  or  less 
perpendicular  to  the  plane  of  the  glenoid  cavit}'. 

The  best  plan,  and  the  nriost  usual  one,  is  to  place  the  patient  in  tiie 


1  Operative  Surgery,  2d  ed.,  p.  105. 


DISLOCATION    OF    SHOULDER.  277 

horizontal  position.  The  surgeon,  sitting  down  on  the  edge  of  tlie  bed 
or  sofa  on  which  the  patient  lies,  puts  his  heel  (unhooted,  of  course, )  into 
the  axilla  and  presses  the  head  of  the  bone  upwards  and  outwards  with 
it,  while  he  pulls  on  tiie  hand  and  wrist,  slightly  rotating  the  arm  if  neces- 
sary'.^ The  dislocated  bone  generally  goes  in  with  a  snap,  and  the  natural 
appearance  and  mobility  of  the  joint  are  at  once  restored.  Recent  dis- 
locations are  generally  reduced  easily  enough,  especially  if  the  involun- 
tary resistance  of  the  muscles  is  obviated  by  calling  off  tiie  patient's  at- 
tention, or  b}'  making-  him  believe  that  the  proceeding  is  one  of  explora- 
tion only,  when  by  a  sudden  movement  the  bone  uiay  generally  be  slipped 
back;  but  if  the  patient  is  unusually  timid  (and  especially  if  it  be  a 
female),  or  a  very  muscular  person,  or  if  there  is  much  pain  in  the  part, 
or  unsuccessful  attempts  have  been  already  made,  it  is  better  to  induce 
anaesthesia,  which  very  much  facilitates  tiie  proceeding. 

Another  and  a  ver}'  good  method  is  to  lay  the  patient  flat  on  the  floor, 
or  with  his  head  to  the  foot  of  the  bed  or  sofa,  stand  behind  his  head, 
steady  the  scapula  with  the  left  hand,  and  pull  the  dislocated  arm  in  a 
line  with  the  patient's  body ;  i.  e.,  in  a  direction  which,  if  he  were  stand- 
ing, would  be  vertically  upwards  ;  or  to  place  the  patient,  sitting  on  the 
ground,  in  front  of  a  chair  or  sofa,  on  which  the  surgeon  stands  and 
steadies  tiie  scapula  vvith  his  foot,  while  pulling  the  arm  vertically  up- 
wards.'^ 

Sir  A.  Cooper  used  sometimes  to  employ  downward  traction  on  the 
arm,  the  patient  being  seated  in  a  chair,  and  the  surgeon  putting  his 
knee  in  the  axilla  ;  but  this  method  is  much  inferior  to  the  two  pre- 
ceding. 

Reduction  by  Manipulation. — Sometimes  a  sort  of  combination  of  these 
two  methods  succeeds  at  once,  and  with  little  or  no  pain  or  force.  The 
surgeon  steadies  the  shoulder  with  his  left  hand  and  supports  the  arm 
with  his  knee,  while  he  raises,  rolls  inwards,  and  slightly  pulls  on  the  dis- 
located arm,  pressing  the  head  of  the  bone  at  the  same  time  outwards  and 
upwards  with  his  left  hand.  The  head  of  the  humerus,  thus  disengaged 
from  the  scapula,  will  slip  into  its  socket  by  the  action  of  the  muscles. 
Some  authors  speak  of  the  efficacy  of  circumduction, '' the  arm  being 
made  to  describe  a  half  circle  over  the  face  and  head  ;"  and  other  sur- 
geons describe  the  manipulation  method  somewhat  differently.^  I  have 
no  experience  of  it,  having  never  met  with  a  case  in  which  the  disloca- 
tion, if  recent,  was  not  at  once  and  easily  reduced  by  the  heel  in  the 
axilla;  and  it  is  only  in  recent  cases,  if  I  understand  aright,  that  manipu- 
lation is  recommended. 

Another  and  a  very  powerful  method  is  thus  described  bj^Mr.  Flower: 
"  The  patient  is  seated  on  a  high  chair,  which  is  placed  about  two  feet 
from  an  open  doorwa}-.  The  surgeon  iiaving  his  back  against  the  door- 
post, places  one  foot  upon  the  side  of  the  chair,  and  with  his  knee  pressed 
into  the  axilla,  and  both  hands  upon  the  shoulder,  steadies  the  patient's 
body.  A  jack-towel  is  then  fixed  by  a  clove-hitch  knot  to  the  patient's 
arm,  just  above  the  elbow;  and  by  its  means  two  or  more  assistants, 
placed  on  the  other  side  of  the  doorway,  make  steady  extension  vertically 
outwards." 

^  If  necessary,  in  old  dislocatinns  a  jack-tovvol  can  be  fixed  on  the  arm,  by  a  clove- 
hitch,  above  the  condyles  of  the  luunerus,  on  which  the  surgeon  and  his  assistants 
can  pull.     This  is  not  required,  however,  except  in  old  dislocations. 

2  See  Lowe,  St.  Bartholomew's  Hospital  Reports,  vol.  vi,  p.  4. 

2  Bryant,  op.  cit.,  p.  792.  Pirrie,  Principles  and  Practice  of  Surgery,  2d  ed., 
p.  319. 


278  INJURIES    OF    THE    UPPER    EXTREMITY. 

Reduction  by  PuJIei/s. — As  a  general  rule  it  is  only  in  neglected  dislo- 
cations that  pullej'S  are  needed.'  The  patient  is  brought  fully  under 
ana?sthesia.  and  placed  either  in  the  sitting  or  reclining  posture,  the  bod}' 
fixed  to  a  firm  staple  on  the  side  opposite  to  the  dislocation  by  means  of 
a  leather  bandage,  which  encircles  the  shoulder  and  fixes  tlie  scapula,  its 
two  ends  being  secured  by  a  cord  to  the  staple.  The  arm  should  be 
bandaged  from  the  hand,  and  the  pulleys  attached  to  a  leather  collar 
fitted  to  the  arm  above  the  condyles  of  the  humerus.  Traction  is  made 
in  the  horizontal  direction,  with  gradually  increasing  force,  and  wlien  the 
surgeon  finds  that  the  liead  of  the  bone  is  moving  he  tries  to  manipulate 
it  into  the  glenoid  cavity.  In  cases  of  long  standing  it  is  well  to  begin 
by  breaking  down  all  adhesions,  as  far  as  possible;  and  if  any  tendons 
can  be  found  on  the  stretch  which  seem  to  oppose  reduction,  they  may  be 
subcutaneously  divided  a  few  days  before  the  attempt  is  to  l)e  made. 
Since  the  introduction  of  chloroform  the  limit  assigned  by  Sir  A.  Cooper 
to  the  time  at  wliich  attempts  at  reduction  may  be  made  has  been  much 
exceeded.  That  limit  was  fixed  b}'  him  at  three  months ;  but  cases  have 
now  been  recorded  in  which  reduction  has  been  eflTected  even  as  much  as 
two  years  after  the  accident.^  The  propriety  of  such  attempts  must,  how- 
ever, depend  in  a  great  measure  on  the  amount  of  inconvenience  which 
the  patient  complains  of.  There  can  be  no  question  that  the  necessary 
force  cannot  be  applied  without  danger.  The  artery  has  occasionally 
been  torn  in  reducing  a  dislocation,  though,  as  Mr.  Callender  has  sliown,^ 
the  cases  of  which  we  have  a  complete  record  are  verj'  few,  and  in  a  large 
proportion  excessive  violence  was  used  by  unskilful  persons.*  The  vein 
has  also  been  ruptured — though  this  is  even  more  rare — or  the  humerus 
fractured.  It  is  true  that  these  grave  injuries  are  not  common,  especiall}^ 
vvlien  the  patient  is  not  advanced  in  age  and  the  arteries  are  healthy,  yet 
no  one  can  have  used  or  seen  used  the  force  which  even  prudent  surgeons 
are  obliged  to  employ  in  such  cases  without  feeling  that  it  must  involve 
some  risk  of  immediate  damage  or  subsequent  inflammation;  and  the 
consideration  which  Sir  A.  Cooper  puts  forward  is  a  very  grave  one — 
whether  the  arm  is  reall}'  likely  to  be  useful  after  reduction.  It  must  be 
remembered  tliat  Sir  Astley  did  not  deny  the  possibility  of  reduction 
later  than  three  months;  he  even  says  he  had  seen  examples  as  late  as 
six  mouths;  but  he  says  "the  injury  done  in  extension  was  greater  than 
the  advantage  received  from  reduction."  And  1  would  remark,  tliat  in 
the  published  accounts  of  cases  of  late  reduction  we  are,  as  a  rule,  left 
quite  in  the  dark  on  this  head.  It  is,  therefore,  onh'  in  cases  where  the 
unreduced  dislocation  is  a  source  of  much  misery  to  the  patient  that  I 
should  be  disposed  to  make  the  attempt.  After  unreduced  dislocation, 
as  a  general  rule  the  limb  acquires  ver}'  considerable  usefulness — the 
patient  regaining  the  power  of  raising  the  arm  nearly  to  the  horizontal 
line  ;  the  parts  accommodate  themselves  to  their  new  position,  and  there 
is  neither  pain  nor  (edema. 

After  reduction  the  arm  should  be  bandaged  to  the  chest,  the  hand  and 

*  It  may  be  well  to  remind  the  reader  that  in  the  system  of  pulleys  in  common  use, 
where  parallel  strings  pass  round  a  number  of  pulleys,  the  force  applied  is  multiplied 
by  the  number  of  strings  on  the  block,  or  twice  th<.'  nuinl)er  of  the  pulleys. 

'  See  on  this  subject  an  interesting  paper  by  Mr.  Brodhurst  in  St.  George's  Hos- 
pital Reports,  vol.  iii,  p.  G7. 

■''  St.  Bar.  Hosp.  Reports,  vol.  ii,  p.  9(i. 

*  There  sfcms  no  doubt  of  the  truth  of  an  account  of  a  case  which  occurred  in 
France  a  few  years  ago,  in  which  an  old  woman's  forearm  was  pulled  offm  an  attempt 
to  reduce  a  dislocation. 


DISLOCATION    OF    SHOULDER.  279 

forearm  beino;  kept  inside  the  clothes,  so  tliat  no  moveinent  is  permitted; 
and  it  is  well  to  place  a  pad  in  the  axilla.  After  a  week  of  this  rigid 
confinement  the  patient  may  be  instructed  to  carry  the  arm  in  a  sling  for 
anotlier  ten  days  or  a  fortnight,  and  may  then  be  allowed  to  make  some 
use  of  it;  but  he  should  be  careful  to  avoid  violent  or  sudden  exertion 
for  a  considerable  time,  at  least  a  quarter  of  a  year.  Renewed  disloca- 
tion is  very  common,  and  each  time  the  joint  is  dislocated  it  becomes  less 
secure. 

Compound  dislocation  of  the  shoulder  is  a  rare  injury,  and  a  very  seri- 
ous one.  "It  still  remains  to  be  determined  by  experience,"  says  Mr. 
Hulke,  "whether  under  such  circumstances  reduction,  or  resection  of  the 
head  of  the  bone,  is  the  safer  method  of  treatment."  My  own  feeling 
would  be  decidedly  in  favor  of  reduction  in  healthy  persons,  and  in  the 
absence  of  complications  ;  but  where  the  patient  was  weak  or  old,  or  the 
exposed  bone  injured,  or  the  parts  much  lacerated,  it  would  probably  be 
better  to  saw  off  the  exposed  head  of  the  bone. 

Partial  Dislocations. — We  do  not  know  very  much  about  partial  dislo- 
cations of  the  shoulder.  The  case  so  frequently  (quoted,  described  by 
Mr.  Soden  of  Bath, ^  as  partial  dislocation  upwards,  with  rupture  of  the 
tendon  of  the  biceps,  was,  there  is  every  reason  to  believe,  an  instance  of 
chronic  osteoarthritis,  supervening  on  a  sprain.  Such  displacement  and 
disappearance  of  the  tendon  is  constant  in  that  disease.-  Mr.  Flower  "  is 
disposed  to  agree  with  Dr.  R.  Adams  in  denying  that  the  case  of  partial 
luxation  of  the  head  of  the  humerus,  as  the  result  of  accident,  has  ever 
been  satisfactorily  proved,  either  in  tlie  living  or  the  dead  subject."  Very 
lately,  however,  Mr.  Le  Gros  Clark  has  published  a  case  of  partial  dislo- 
cation of  the  head  of  the  bone  backwards,  which,  I  think,  must  be  allowed 
to  be  conclusive.  The  patient,  a  spare,  elderly  man,  had  slipped  in  get- 
ting over  a  hurdle,  about  two  hours  previously.  There  was  no  effusion 
into  the  joint;  the  movements  of  the  joints  were  almost  lost;  the  head  of 
the  humerus  was  "in  its  natural  position  as  regards  height,  but  its  pro- 
jection in  front  of  the  acromion  was  absent,  and  there  was  an  abnormal 
prominence  at  the  back  of  the  joint,  behind  and  below  the  acromion.  On 
gently  raising  the  elbow  from  the  side,  and  rotating  the  humerus,  its  head 
slipped  into  the  glenoid  cavity  with  an  audible  click,  and  the  joint  at  once 
resumed  its  normal  form  and  appearance — the  patient  exclaiming  that  he 
lost  his  pain  as  soon  as  he  felt  and  heard  the  bone  go  back."^  The  thin- 
ness of  the  patient  and  the  absence  of  any  effusion  left  no  doubt  of  the 
position  of  the  bone  ;  and  since  a  week's  rest  in  a  great  measure  restored 
the  use  of  the  joint,  Mr.  Clark  concludes  that  there  could  have  been  no 
laceration  of  the  capsule  or  tendons.  The  case,  also,  which  is  described  by 
Mr.  South*  shows  very  plainly  indeed  the  possibility  of  partial  disloca- 
tion of  the  head  of  the  humerus  forwards,  at  least  when,  as  in  that  case, 
the  coracoid  process  is  fractured — a  condition  which  Mr.  South  regarded 
as  essential  to  the  occurrence  of  partial  dislocation  in  this  direction.  In 
that  case  a  depression  existed  behind  and  below  the  acromion,  which  led 
to  the  supposition  that  some  displacement  of  the  head  of  the  humerus  or 
fracture  of  the  neck  of  the  scapula  existed,  but  still  the  roundness  of  the 
shoulder  was  not  lost.    On  making  certain  manipulations  the  head  of  the 

1  Med.-Chir   Trans  ,  vol.  xxiv,  p.  212. 

2  See  the  criticism  of  Mr.  Soden's  case,  by  Dr.  R.  Adams,  on  Rheumatic  Gout, 
2d  ed.,  1878,  pp.  140  et  seq. 

3  St.  Thomas's  Hospital  Reports,  New  Series,  vol.  v,  1874,  p.  145. 
*  Med.-Chir.  Trans.,  vol.  xxii,  p.  100. 


280  INJURIES    OF    THE    UPPER    EXTREMITY. 

humerus  was  felt  to  move  backwards,  and  then  the  appearance  of  a  pit 
ceased.  The  patient  having  died  two  da3S  afterwards  from  the  effects  of 
other  injuries,  the  liead  of  the  bone  was  found  in  its  proper  position  ; 
tliere  was  a  rent  or  slit  about  an  inch  long  in  the  capsular  ligament, 
through  which  the  cartilage  covering  the  humerus  was  exposed.  On  lift- 
ing up  the  shaft  and  pressing  the  liead  of  the  humerus  forwards  it  was 
seen  to  be  "  partially  thrown  forwards  and  over  the  front  edge  of  the 
glenoid  cavity,  so  that  it  became  fixed,  and  behind  it  the  dej^ression  below 
the  acromion  appeared,  in  consequence  of  the  sinking  of  tlie  tendons  of 
the  inlVa-spinatus  and  teres  minor  muscles  into  the  glenoid  cavity,  from 
the  altered  position  of  the  head  of  the  bone,  which,  however  did  not  pro- 
trude through  the  slit  in  the  capsule,  although  it  was  there  more  distinctly 
visible." 

From  these  cases  the  conclusion  would  be  that  partial  dislocation  of 
the  shoulder  is,  in  itself,  a  trifling  accident,  easily  remedied,  and  not 
liable  to  produce  any  permanent  mischief;  and  that  it  is  a  very  rare 
injury,  though  its  occasional  occurrence  is  undeniable  ;  and  very  possibly 
it  may  be  overlooked,  from  the  head  of  the  bone  having  slipped  back 
before  the  patient  is  seen. 

Didocation  of  the  elbow  is  a  tolerably  common  accident,  taking  place 
usually  in  youth,  as  the  result  of  a  fall  or  wrench,  or  sometimes  of  a  blow. 

If  diagnosed  at  once  and  properly  treated,  the  injury  is  one  in  which  a 
good  result  may  be  confidently  expected.  But  it  is  singular  how  very  often 
cases  are  met  with  in  which  the  accident  has  been  overlooked,  and  then 
the  dislocation  becomes  rapidly  irreducible.  I  cannot  remember  to  have 
seen  such  a  dislocation  reduced  after  six  weeks,  and  I  have  known  cases 
in  which  mischief  has  been  done  from  the  attempt.  It  is  charitable  to 
suppose  that  in  some  such  instances  of  mistaken  diagnosis  the  nature  of 
the  injury  has  been  masked  by  an  unusual  amount  of  contusion  and  inflam- 
mation ;  but  I  cannot  help  saying  that  no  such  explanation  could  be 
given  of  otliers,  and  that  the  patient  appeared  to  have  lost  the  use  of  his 
joint  from  the  negligence  of  the  surgeon.  The  practical  inference  is  that 
in  all  injuries  affecting  the  elbow,  the  surgeon  should  study  minutely  the 
relations  Ijetween  the  various  prominences  of  the  bones — viz.,  the  internal 
condyle,  olecranon,  external  condyle,  and  head  of  the  radius — and  should 
not  affect  to  give  a  diagnosis  until  he  has  observed  at  any  rate  the  fol- 
lowing points:  1.  Is  there  any  transverse  fracture  of  the  humerus?  t.  e., 
on  grasping  the  condyles  in  one  hand  and  the  lower  part  of  the  shaft  in 
the  other,  can  they  be  made  to  move  or  crepitate  on  each  other  ?  2.  Is 
there  any  longitudinal  or  partial  fracture  of  thelower  end  of  the  humerus? 
i.e.,  are  the  condyles  unnaturally  separated  from  each  other,  can  they 
be  made  to  crepitate  when  grasped  by  the  finger  and  thumb  of  opposite 
hands  and  moved  on  each  other,  or  is  there  a  movable  fragment  of 
either  (prol)ably  the  internal)  condyle  without  an}'  fracture  into  the 
joint?  3.  What  is  the  distance  between  the  olecranon  and  the  internal 
condyle  on  the  injured  as  compared  with  the  sound  side?  4.  Is  the  olec- 
ranon itself  fractured?  5.  Does  the  liead  of  the  radius  move  with  its 
shaft  on  passive  rotation,  and  is  it  in  the  normal  relation  to  the  external 
condyle?  6.  Do  the  axes  of  the  two  bones  of  the  forearm  correspond  in 
direction  ? 

I  allow  that  in  some  cases  some  of  these  questions  may  not  admit  of 
an  immediate  answer,  from  the  amount  of  swelling  present,  but  usually 
they  do,  or  at  any  rate  the  most  important  of  them.  If  they  do  not,  the 
diagnosis  of  the  case  siiould  be  deferred,  and  the  surgeon  should  not  be 


DISLOCATION    OF    THE    ELBOW.  281 

ashamed  to  say  that  he  cannot  at  present  say  what  the  natnre  of  the 
injuiy  is.  Unfortunately,  we  constantly  meet  with  cases  in  which  con- 
fident opinions  are  given  on  insufficient  data,  to  the  great  injury  of  the 
surgeon's  reputation;  and  what  is  worse,  to  the  permanent  detriment  of 
his  patient,  who  remains  satisfied  perhaps  that  his  arm  is  only  "sprained" 
till  it  is  too  late  for  the  overlooked  dislocation  to  be  reduced,  or  the  frac- 
ture to  be  set  and  the  motions  of  the  joint  restored. 

Dislocation  of  both  Bones  backivards. — The  commonest  dislocation  of 
the  elbow  is  that  of  both  bones  of  tlie  forearm  backwards.  The  radius 
and  ulna  maintain  their  normal  relation,  the  orbicular  ligament  remaining 
attached  to  the  sides  of  the  small  sigmoid  notch.  The  olecranon  projects 
considerably  ;  the  arm  is  semiflexed  (see  Fig.  81,  p.  2G2) ;  the  head  of  the 
radius  may  perhaps  be  felt  at  the  usual  distance  from  the  olecranon  :  but 
the  distance  between  the  tip  of  the  olecranon  and  the  internal  condyle 
very  greatly'  exceeds  that  on  the  other  side.  There  is  a  great  rounded 
prominence  in  the  bend  of  the  elbow,  or  rather,  perhaps,  pushing  the 
fold  of  the  elbow  downwards,  so  that  the  forearm  seems  shortened. 
There  is  commonly  no  crepitus  ;  though,  perhaps,  in  some  cases  the  pro- 
jection of  the  internal  condyle  may  have  been  chipped  off'. 

Most  of  these  distinctive  characters  of  the  backward  dislocation  of  the 
elbow  can  be  clearly  traced  on  Fig.  92,  taken  from  an  injury  of  this 
kind  which  I  accidentally  found  in  the  body  of  a  seaman  who  died  from 
a  different  cause. 

By  these  signs  the  dislocation  can  be  readilj*  distinguished  from  the 
injury  which  most  resembles  it;  i.e.,  a  fracture  of  the  lower  end  of  the 
humerus  just  above  the  condyles,  in  which  there  is  often  displacement  of 
the  forearm  backwards,  with  semiflexion,  projection  of  the  olecranon  and 
tendon  of  the  triceps,  and  a  prominence  near  the  bend  of  the  elbow.  But 
in  the  fracture,  though  the  olecranon  projects,  measurement  will  show 
that  it  is  at  the  same  distance  from  the  internal  condyle  as  on  the  sound 
side — the  prominence  which  is  formed  by  the  other  fragment  of  the 
humerus  is  not  in  or  below  the  bend  of  the  elbow,  but  above  it ;  and  has 
not  the  rounded  outline  of  the  head  of  the  bone.  And  the  diagnostic 
sign  on  which  Sir  A.  Cooper  laid  so  much  stress  is  of  great  value,  that 
reduction,  though  easy,  is  very  insecure,  the  displacement  being  imme- 
diately reproduced.  Also  when  the  parts  are  reduced  crepitus  may  be 
felt.  There  is  not,  therefore,  ordinarily  any  real  difficulty  in  diagnosing 
the  two  injuries.  (See  page  262  for  a  fuller  account  of  the  fractures  near 
the  elbow.) 

Such  are  the  sj'mptoms  and  the  pathological  anatomy  of  the  complete 
dislocation  backwards.  But  from  the  less  amount  of  flexion,  and  from 
the  great  ease  with  which  reduction  is  effected,  it  is  believed  that  in  manj'^ 
dislocations  the  displacement  is  not  complete — i.  e.,  the  coronoid  process 
is  not  carried  fairly  into  the  olecranon  fossa,  but  rests  on  the  trochlear 
surface,  from  which,  of  course,  any  slight  traction  will  replace  it  into  its 
natural  position. 

Dislocation,  ivith  Fracture  of  the  Coronoid  Process. — Again,  it  is 
believed  by  many  surgeons  that  this  displacement  of  both  bones  back- 
wards is  often,  accompanied  by  fracture  of  the  coronoid  process  of  the 
ulna,  as  was  the  case  in  the  remarkable  pair  of  specimens  one  of  which 
is  represented  in  Fig.  93.  I  am  not  prepared  to  speak  confidently  on  this 
point.  I  have  met  with  one  case  in  which  during  life  all  the  symptoms 
of  the  injury  were  very  plain, — dislocation  of  the  bones  backwards,  very 
easil}'  reducible,  some  crepitus  after  reduction,  and  constant  reproduc- 
tion of  the  displacement.    But  in  ordinarx'  cases  the  reduction  when  once 


282 


INJURIES    OF    THE    UPPER    EXTREMITY. 


effected  is  so  secure,  and  passive  movement  of  the  ulna  round  the  trochlear 
surface  of  the  humerus  after  reduction  is  so  smooth  and  uninterrupted, 
that  it  is  ditlicult  to  believe  in  the  existence  of  any  such  fracture.  Nor 
is  there  any  anatouiical  confirmation  of  the  doctrine  which  affirms  the 
frequency  of  fracture  of  the  coronoid  process,  as  far  as  I  know. 


Fin.  92. 


Fig.  92. — Old  dislocation  of  both  bones  of  the  forearm  backwards.  From  the  body  of  a  man  who  died 
from  other  injuries.  Nothing  is  known  about  the  accident,  a  shows  the  olecranon  process  projecting, 
with,  e,  the  triceps  muscle  attached  to  it.  6,  the  radius,  the  head  of  which  has  formed  a  new  articular 
cavity  for  itself  on  the  back  of  the  external  condyle  and  enjoyed  some  little  mobility.  The  coronoid 
process  of  the  ulna  was  lodged  in  the  olecranon  fossa,  and  was  almost  immovable,  so  thai  there  seems 
to  have  been  no  power  of  flexion  and  extension,  d  points  to  the  biceps  muscle,  which  remained  attached 
to  the  radius,  c,  to  the  brachialis  anticus,  which  had  been  torn  away  from  the  coronoid  process.  The 
principal  part,  here  shown,  was  fixed  to  the  humerus,  so  that  its  action  had  been  abolished.  Some 
fibres,  however,  were  also  attached  to  the  ulna  below  its  natural  insertion. — From  a  specimen  in  the 
Museum  of  St.  George's  Hosiiital,  Ser.  i,  No.  108. 

Fig.  93. — Dislocation  of  both  bones  of  the  elbow  backwards,  with  fracture  of  the  coronoid  process  of 
the  ulna,  o  shows  the  fragment  of  the  coronoid  process,  which  remains  connected  to  the  humerus.  6, 
the  surface  of  the  ulna,  from  which  it  lias  been  separated,  c,  the  upper  end  of  the  radius  displaced 
backwards,  as  was  also  the  ulna.  A  vertical  fracture  traversed  the  head  of  the  radius.  The  specimen 
in  the  Museum  of  St.  George's  Hospital  (Ser.  i.  No.  Ill)  was  taken  from  the  body  of  a  man  who,  while 
at  work  on  some  repairs  in  the  Hospital,  fell  from  a  great  height  into  the  courtyard,  and  was  taken  up 
dead.  Tliere  was  exactly  the  same  injury  of  the  elbow  on  both  sides,  even  to  the  longitudinal  splitting 
of  the  head  of  the  radius,  sliowiiig  that  he  must  have  come  down  with  both  hands  on  the  ground  in 
precisely  the  sunic  position. 

Reduction. — If  dislocation  backwards  remains  unreduced  it  leads  to 
very  lamentable  U>ss  of  the  motion  of  the  arm.  In  the  preparation,  Fig. 
92,  there  remains  no  movement  of  flexion  and  extension  whatever,  the 
coronoid  process  being  wedged  into  tlie  olecranon  fossa  and  tightly 
bound  down  there  by  inflammatory  adhesions,  the  brachialis  anticus  torn 
away,  and  the  ])icei)s  having  lu)  means  of  acting  on  the  radius,  which  is 
itself  firmly  attached  to  the  idna.  All  that  the  patient  seems  to  have  pre- 
served is  a  little  rotation  of  the  rtidius  in  the  new  cavity  which  it  had 
formed  on  the  outer  condyle.  But  when  treated  early  reduction  is  gen- 
erally very  easy.  Many  tli.slocations  of  the  eli)0\v  slip  in  on  the  least 
traction  being  made  on  the  hand,  probabl}-,  as  hinted  above,  because  the 
coronoid  process  is  not  fairly  lodged  in  the  olecranon  fossa.  If  the  coro- 
noid process  be  fractured  no  obstacle  to  reduction  can  possibly  exist. 


DISLOCATION    OF     RADIUS. 


283 


And  even  in  the  complete  dislocation  steady  traction  on  the  hand,  com- 
bined, if  necessary,  with  slight  rotatory  movements,  will  almost  certainly 
disengage  the  coronoid  process,  which  can  then  easily  be  slipped  roniid 
the  trochlea  by  bending  the  arm.  Chloroform  is  generally  nnnecessary, 
bnt  may  be  administered  if  the  patient  is  unusually  timid,  or  if  attempts 
without  it  have  failed.  If  the  surgeon  have  no  assistance  he  generally 
places  his  knee  on  the  projecting 
humerus,  to  make  counter-extension, 
steadies  the  arm  with  his  left  liand, 
grasps  the  forearm  with  his  right, 
and  pulls  it  downwards,  and  then, 
when  he  feels  the  displaced  bones 
move,  he  bends  the  forearm  sharpl}', 
and  they  slip  into  place. 

In  old  dislocations  either  the  pul- 
leys must  be  put  on  in  order  to  bring 
the  bones  of  the  forearm  downwards, 
and  when  they  are  thought  to  be  dis- 
engaged reduction  is  attempted  by 
acute  flexion  ;  or,  after  all  adhesions 
have  been  broken  down  by  A'arious 
movements,  the  case  is  treated  as  a 
recent  dislocation.  Care  must  be 
used  in  such  cases  not  to  fracture 
the  bones. 

Dislocation  of  ihe  Head  of  the 
Radius. — The    form    of   dislocation 


Dislocation  of  the  head  of  the  radius  backwards. 
The  head  of  tlie  radius  is  niucli  altered  in  form. 
The  orbicular  ligament  had  been  carried  away 
along  with  the  head  of  the  radius,  and  had  taken 
an  attachment  to  the  humerus  on  either  side  of 
the  dislocated  head,  so  that  the  motions  of  prona- 
tion and  supination  were  abolished.  The  outer 
which  is  most  frequent  next  to  that  condyleof  the  humerus  is  much  changed  in  shape 
of  both  bones    backwards  is   that    of    from  deposit  of  new  bone.    The  ulna  is  perfectly 

natural.  Flexion  and  extension  could  be  per- 
formed, through  about  a  quarter  of  their  natural 
extent.  The  preparation  in  St.  George's  Hospital 
Museum  (Ser.  i,  No.  109)  was  taken  from  the  body 
of  a  young  man  who  had  received  a  blow  on  the 
elbow  about  two  years  previously,  and  noticed  the 
change  in  the  shape  and  motion  of  the  joint  next 
day. 


the  iiead  of  the  radius  only,  the  ulna 
remaining  in  its  place.  This  occurs 
either  on  the  back  (Fig.  94)  or  the 
front  (Fig.  95)  of  the  external 
condyle.  Careful  examination  can 
hardly  fail  to  detect  in  the  disloca- 
tion backwards  the  projection  of  the 

displaced  head,  and  the  change  in  the  axis  of  the  bone,  which  are  so  well 
shown  in  the  figure;  in  the  dislocation  forward  the  loss  of  the  head  of 
the  radius  from  the  part  where  it  should  be  felt;  and  in  both  the  total 
loss  of  the  power  of  voluntary  pronation  and  supination,  and  the  almost 
total  loss  of  passive  motion.  If  the  injury  be  overlooked  the  patient  will 
lose  more  or  less  completely  the  power  of  turning  the  hand  except  b}'  the 
comparatively  awkward  device  of  rotating  the  humerus.  The  dislocation 
of  the  head  of  the  radius  is  remarkable  as  being  one  of  the  few  which  are 
not  uncommon  in  earl}'  life,  as  Fig.  95  shows.  It  has  been  known  to  be 
produced  by  traction  made  by  the  accoucheur  on  the  child's  hand  in 
delivery.     The  backward  dislocation  is  the  most  common. 

In  its  reduction  the  forearm  should  be  flexed  so  that  tlie  biceps  may 
be  relaxed,  and  tlien,  while  an  assistant  manipulates  the  hand  as  directed, 
so  as  to  approximate  the  head  of  the  radius  towards  the  ulna,  the  sur- 
geon tries  to  press  it  directly  into  the  lesser  sigmoid  cavity  by  the  ^Dres- 
sure  of  his  thumbs,  supported  by  the  counter-pressure  of  the  fingers  on 
the  other  side  of  the  limb. 

The  other  dislocations  are  much  rarer.  Both  bones  have  been  found 
dislocated  laterally,  the  outward  dislocation  being  the  more  common.     A 


284  INJURIES    OF    THE    UPPER    EXTREMITY. 

few  instances  liave  even  been  recorcled  of  dislocation  forwards,  the  olec- 
ranon process  being  thrown  more  or  less  completely  down  to  the  end  of 
the  trochlear  snrface  of  the  humerus,  and  the  arm  elongated  ;  or  the  ulna 
alone  may  be  dislocated  from  both  the  humerus  and  radius.     It  would 

Fig. 95 


Dislocation  of  the  head  of  the  .radius  forwards,  at  the  age  of  two  years,  witli  fracture  running 
through  the  cartilaginous  olecranon.  The  dislocation  was  compound,  and  the  child  died  of  pyaemia. 
— From  the  Museum  of  St.  George's  Hospital,  Ser.  i.  No.  110. 

serve  no  useful  purpose  to  describe  minutely  the  characters  of  these  rare 
injuries,  or  to  dwell  further  on  the  symptoms  of  the  fractures  of  the  va- 
rious processes  which  are  constant  accompaniments  of  dislocations  of  the 
elbow.  Great  care  is  necessary  in  the  examination  of  every  case.  After 
reduction  the  arm  sliould  be  kept  quiet  on  a  splint  for  a  fortnight  at  least, 
and  should  then  be  used  very  cautiously. 

Comjjound  Dislocations. — When  the  dislocation  is  compound  the  sur- 
geon is  guided  in  his  treatment  chiefly  by  the  amount  of  the  concomitant 
lesions.  If  these  are  trifling  it  is  better,  especially  in  elderly  persons, 
to  reduce  the  bones,  close  the  wound,  and  trust  to  earl^^  passive  motion 
to  restore  some  movement  to  the  joint.  If  the  bones  are  considerablj^ 
injured  it  may  be  better  to  perform  excision  of  the  whole  joint;  and  if 
the  great  A^essels  or  nerves  be  also  injured,  amputation  may  even  be  uec- 
essaiy,  though  this  is  quite  exceptional. 

Dislocation  of  Lower  End  of  Radius. — The  lower  radio-ulnar  joint 
may  be  dislocated  ;  and  as  in  tliis  joint  the  radius  is  the  movable  bone, 
it  is  usual  at  the  present  da}',  following  the  analogy  of  the  nomenclature 
of  other  dislocations,  to  call  this  a  dislocation  of  the  radius  from  the 
ulna,  instead  of  the  ulna  from  the  radius,  as  Sir  A.  Cooper  called  it. 
The  radius  seems  displaced  forwards  rather  more  commonly  than  back- 
wards;  the  hand  is  of  course  displaced  forwards,  and  the  styloid  process 
of  the  ulna  projects  backwards,  sometimes  comes  through  the  skin.  The 
opposite  dislocation  causes  similar  symptoms  reversed.  Tiiese  injuries 
are  caused  b}'  violent  twisting  of  the  liand.  They  are  to  be  reduced  by 
extending  the  hand  and  manipulating  the  radius  into  position.  If  there 
be  a  wound  it  must  be  carefully  closed,  and  in  any  case  the  hand  should 
be  kept  in  splints  for  aljout  a  fortnight. 

Dislocation  of  the  icrisl  occurs  almost  always  backwards;  the  bones  of 
the  carpus  project  on  the  dorsal  surface  of  tlie  forearm,  the  articular  sur- 
faces and  styloid  processes  of  the  radius  and  ulna  being  felt  below  them. 
The  dorsal  projection  gives  this  ijijury  some  resemblance  to  Colles's  frac- 
ture, especially  when  the  hand  is  somewiiat  twisted,  so  that  the  styloid 
process  of  the  ulna  projects  ;  and  the  two  injuries  were  generally  con- 
founded together  before  Colles's  time;  but  there  is  no  real  difficulty  in 
the  diagnosis,  for  the  position  of  the  styloid  processes  in  relation  to  each 
I 


DISLOCATION    OF    THUMB.  285 

other  and  to  the  hand,  is  an  unfailing  test.  In  the  dislocation  the  st_y- 
loid  processes  are  on  the  same  level,  and  lie  much  nearer  to  the  fingers 
as  well  as  much  lower  than  natural.  In  the  fracture  the  styloid  process 
of  the  radius  is  displaced  along  with  the  hand,  while  that  of  the  ulna, 
though  prominent,  is  at  nearly  the  same  distance  from  the  little  finger  as 
on  the  sound  sid*^. 

Reduction  is  usually  easy.  It  is  better,  I  think,  to  keep  the  part  quiet 
on  a  splint  for  a  few  days  at  first,  and  then  to  wear  the  hand  in  a  sling 
for  about  a  fortnight. 

The  dislocation  in  the  other  direction  (?.  6.,  with  tlie  hand  in  front  of 
the  forearm)  hardly  ever  occurs  as  a  traumatic  lesion.  Its  symptoms 
would  be  the  same  as  the  above  reversed. 

Dislocations  of  the  Carpus. — Though  the  bones  of  the  carpus  are  so 
small,  and  so  securely  locked  together,  yet  dislocations  do  occur.  Such 
as  I  liave  seen  have  been  compound.  The  Museum  of  St.  George's  Hos- 
pital contains  a  pair  of  semilunar  bones  which  were  exposed  in  a  com- 
pound dislocation  of  both  wrists,  and  were  removed  before  the  wounds 
were  dressed.  The  patient  died  from  other  injuries,  but  the  parts  were 
unfortunately  not  preserved.  Another  preparation  shows  dislocation  of 
the  rest  of  the  carpal  bones  from  the  semilunar,  which  alone  remains  at- 
tached to  the  bones  of  the  forearm.  The  scaphoid  was  fractured,  and 
the  fractured  portion  extracted  through  the  torn  dorsal  ligaments.  I 
saw,  a  short  time  since,  a  case  in  which  the  greater  part  of  the  semilunar 
bone  came  away,  but  the  patient  recovered  a  very  useful  hand.  In  other 
cases  the  head  of  the  os  magnum  has  been  the  protruding  part.  I  do 
not  think  any  special  directions  need  be  given  for  the  diagnosis  and 
treatment  of  such  injuries.  The  protruding  parts  are  generally  easily 
replaced,  and  the  patient  usually  recovers  the  utility  of  the  hand  ;  the 
great  point  is  to  see  that  the  motions  of  the  fingers  are  early  restored. 

Dislocation  of  the  Thumb. — The  first  phalanx  of  the  thumb  is  com- 
paratively often  found  dislocated  on  to  the  metacarpal  bone.  The  articu- 
lating surface  of  the  phalanx  usually  lies  on  the  dorsal  surface  of  the 
metacarpal  l)one,  though  a  few  cases  of  the  opposite  dislocation  hav^e 
been  met  with.  Either  may  be  recognized  at  once  b^-  the  shortening  of 
the  thumb,  and  by  the  projection  on  the  dorsal  aspect  of  the  hand, 
formed,  in  the  one  case,  by  the  displaced  end  of  the  first  phalanx,  in  the 
other  by  the  prominent  head  of  the  metacarpal  bone.  The  dislocation 
backwards  is  often  very  hard  to  reduce. 

When  the  first  phalanx  is  carried  backwards  it  takes  wath  it  the  two 
lieads  of  the  flexor  brevis  pollicis  and  tlie  sesamoid  bones  developed  in 
them  ;  the  anterior  and  lateral  ligaments  of  the  joint  are  torn  off  the 
head  of  the  metacarpal  bone,  which  tears  a  way  for  itself  through  the 
fibrous  tissue  uniting  the  two  heads  of  the  flexor  brevis,  between  which 
it  projects  as  a  button  does  out  of  a  buttonhole.  (See  Fig.  96.)  In  these 
two  conditions  consists  the  diflficulty  of  reducing  the  dislocation,  viz.,  in 
the  tension  of  the  short  flexor,  and  the  diflficulty  of  slipping  the  tissues 
forming  the  buttonhole  over  the  mushroom-shaped  head  of  the  metacarpal 
bone.  The  first  principle,  therefore,  in  reducing  any  dislocation  of  the 
thumb  which  presents  diflHculty  is  to  relax  the  short  flexor,  and  this  is 
done  by  forcibly  adducting  the  thumb;  i.  e.,  pressing  it  as  far  as  possible 
over  to  the  middle  line  of  the  hand.  This  being  done  by  an  assistant, 
the  surgeon  takes  the  displaced  first  phalanx  and  places  it  in  extreme 
extension,  in  order  to  relax  the  tissues  of  the  buttonhole,  and  to  push 


286 


INJURIES    OF    THE     UPPER    EXTREMITY. 


up  those  which  form  its  distal  part  over  the  projecting  head  of  the  meta- 
carpal bone.     This  is  done  by  drag-ging  the  hyperextended  thumb  down- 


FlG.  96. 


Fig.  97. 


Fig.  96. — Dislocation  of  the  thumb  backwards,  showing  how  the  displaced  jihalanx  carries  backwards 
with  it  the  heads  of  the  flexor  brevis  pollicis,  and  how  the  head  of  the  metacarpal  bone  is  consequently 
forced  forward  through  a  buttonhole  opening  in  the  tissue  which  unites  those  heads  in  front.  The 
margin  of  this  buttonhole  is  seen  constricting  the  neck  of  the  bone  just  above  the  letter  a  in  the 
figure. — From  the  dissection  of  a  dislocation  artificially  produced  in  the  dead  subject.    After  Fabbri. 

Fig.  97.— Reduction  of  dislocation  of  the  thumb  (after  Fabbri).  The  metacarpal  bone  is  flexed  as 
far  as  possible  by  squeezing  it  towards  the  centre  of  the  hand.  This  carries  the  displaced  phalanx 
with  it,  and  so  approximates  the  insertion  and  origin  of  the  flexor  brevis  pollicis,  relaxing  the  tissue 
forming  the  edge  of  the  buttonhole,  a.  The  dislocated  thumb  is  then  hyperextended  in  order  to  slip 
the  upper  edge  of  this  buttonhole  round  the  prominent  head  of  the  metacarpal  bone.  When  this  is 
even  partially  effected  the  muscles  will  draw  the  phalanx  into  position. 

The  tension  of  the  fibres  of  the  flexor  brevis  pollicis  in  the  former  figure  may  be  contrasted  with 
their  relaxation  in  this. 

wards,  i.  e.,  away  from  the  wrists,  and  then  acute  flexion  will  restore  it 
to  its  place.* 

Such,  I  have  no  doubt,  are  the  main  obstacles  to  the  reduction  of  this 
dislocation,  and  the  appropriate  method  of  obviating  them.  But  there 
are  probably  in  some  cases  other  causes  concurring,  such  as  the  interpo- 
sition of  some  of  the  torn  fibi'es  of  the  ligaments,  or  of  the  fascia  form- 
ing the  distal  portion  of  the  buttonhole  between  the  ends  of  the  bones, 
and  possibl3^  the  interlocking  of  the  bon^^  projections  themselves.  These 
minor  obstacles  can  usually  be  overcome  by  slight  rotatory  movements  of 
the  phalanx  during  extension. 

As  there  is  often  need  for  the  application  of  considerable  force,  it  is 
important  to  apply  some  apparatus  which  will  keep  (irmly  in  place  and 
at  the  same  time  not  cut  tlie  skin.  The  Indian  puzzle-toy,  which  holds 
the  more  firmly  the  more  it  is  pulled  upon,  may  be  found  useful;  and 
there  is  a  pair  of  forceps  (called  the  "American  forceps"),  manufactured 
for  the  purpose,  with  handles  like  those  of  the  lithotomy  forceps,  and  two 


'  The  difficulticb  attonrling  the  rodiiotion  of  thi.s  di.''location,  and  the  method  of 
uniting  them,  an;  admirably  described  in  u  memoir  by  Prof.  Fabbri,  in  vol.  x  of  the 
Meraorie  dell'  Accad.  delle  IScienze  dell'  Istituto  di  Bologna. 


DISLOCATION    OF    THE    FINGERS.  287 

sheets  of  leather  attached  to  the  blades,  which  cross  each  other.  These 
hold  very  firmly,  and  can  hardly  damage  the  soft  parts.  But  when  such 
contrivances  are  not  at  hand  a  clove  hitch  must  be  made  of  any  appro- 
priate material  (the  broader,  softer,  and  stronger  the  better)  and  applied 
around  the  first  phalanx,  hitching  against  the  projection  of  the  joint. 
Manual  extension  is  generally  suflticient;  but  I  had  once  occasion  to  use 
the  pulleys  successfully.  When  reduction  has  been  eflb'^ted  some  sur- 
geons recommend  that  the  joint  be  flexed  and  extended  once  or  twice  to 
disengage  any  of  the  tissues  which  may  have  slipped  between  the  bones. 

If  all  attempts  at  reduction  by  mere  manipulation  have  failed,  the  case 
should  be  left  for  a  time,  cold  being  applied  to  combat  inflammation;  and 
if  renewed  careful  attempts  have  no  better  result,  the  course  generally 
followed  is  to  make  a  subcutaneous  section  of  the  parts  between  the  skin 
and  the  displaced  phalanx  on  one  or  even  both  sides.  This  is  usually 
spoken  of  as  "  division  of  the  lateral  ligaments  ;"  but  it  really,  I  presume, 
involves  a  more  or  less  complete  division  of  the  head  of  the  flexor  brevis, 
and  is  successful  when  "the  buttonhole"  is  laid  open,  and  the  metacarpal 
bone  thus  liberated.  Another  plan,  recommended  by  Dr.  Humphry,'  is 
to  introduce  a  blunt  hook,  through  a  small  incision,  beneath  one  of  the 
sesamoid  bones,  and  draw  it  forwards  with  the  phalanx.  I  have  seen 
both  plans  successfully  adopted;  but  I  believe  neither  will  often  be 
required  if  Prof.  Fabbri's  directions  are  carefully  followed  in  the  manipu- 
lation. Finally,  if  all  fails  the  case  must  be  abandoned,  passive  motion 
being  early  and  sedulously  practiced.  Cases  are  on  record  in  which  the 
thumb,  though  dislocated,  has  been  very  freely  movable. 

When  the  dislocation  is  compound,  the  projecting  bone,  which  may  be 
either  the  phalanx  or  the  metacarpal  bone,  should  be  removed,  and  passive 
motion  early  practiced. 

Dislocation  forivards. — Of  the  dislocation  of  the  phalanx  forwards, 
four  examples  are  related  by  Nelaton.^  One  of  these,  though  seen  early 
and  treated  by  some  of  the  best  surgeons  in  Paris,  remained  irreducible. 

Dislocations  of  the  Fingers. — The  phalanges  of  the  fingers  are  rarely 
dislocated,  but  occasionally,  in  a  fall,  this  injury  may  take  place  at  any 
of  the  joints,  the  distal  bone  being  generally  thrown  behind  the  proxi- 
mal.^ Reduction  is  usually  quite  easy.  I  saw  one  case  of  old  dislocation  in 
which  I  found  it  impossible  ;  but  the  patient  was  not  in  a  condition  to 
explain  the  circumstances  to  me,  and  I  believed  that  it  had  been  neglected. 
After  the  reduction  the  finger  should  be  bound  up  for  a  few  days,  to  pre- 
vent any  use  of  it  until  the  torn  ligaments  have  consolidated,  and  then 
careful  passive  motion  should  be  given. 

1  Humphry  on  the  Skeleton,  p.  434. 

2  Path.  Chip.,  vol.  ii,  p.  423. 

^  While  this  sheet  was  passing  through  the  press  I  saw  a  case  in  which  the  distal 
phalanx  of  the  thumb  was  dislocated  and  forced  through  a  wound  in  the  palmar  sur- 
face.    The  injury  occurred  in  a  scuffle. 


288  INJUKIES    OF    THE    LOWER    EXTREMITY. 


CHAPTER    XV. 

INJURIES  OF  THE  LOWER  EXTREMITY. 

Sprains  of  the  joints  of  the  lower  extremity  are  amongst  the  com- 
monest injuries  in  surgery,  especially  of  the  ankle  and  knee,  and  in  the 
ankle  it  is  often  difficult  to  decide  whether  there  is  fracture  or  not.  The 
injury  is  often  a  severe  one,  causing  great  pain  at  the  time,  being  accom- 
panied probabh-  with  much  laceration  of  the  ligaments  and  other  struc- 
tures near  the  joint,  and  leading  frequently  to  prolonged  lameness. 
Severe  sprains  are  followed  generally  by  a  good  deal  of  effusion  into  the 
synovial  cavity,  which  is  sometimes  slow  to  disappear ;  and  they  often 
lay  tlie  foundation  of  permanent  disease  of  the  articulation.  Hence  we 
can  hardi}'  be  too  careful  in  our  treatment  of  them.  At  first,  while  the 
active  state  of  effusion  is  present,  antiphlogistic  measures  are  necessary. 
When  it  is  grateful  to  the  patient  the  sedulous  application  of  cold  by 
means  of  icebags  is,  I  think,  the  best;  but  if  this  is  not  tolerated  leeches, 
followed  by  warm  fomentations,  or  evaporating  lotions,  or  irrigation  with 
spirit  and  water,  will  t)est  check  the  tendency  to  effusion.  As  soon  as  the 
patient  can  bear  it  equable  pressure  by  strapping  and  bandage  or  b}' splints, 
with  pei'fect  rest,  should  be  adopted,  and  is  one  of  the  most  potent  means 
of  cure  in  such  injuries.  But  it  is  important,  as  soon  as  the  patient  has  lost 
all  pain,  or  if  he  has  not  quite  lost  pain,  yet  as  soon  as  he  can  bear  passive 
motion  without  renewed  swelling  and  inflammation,  to  commence  bringing 
the  joint  into  use,  b}'  cautious  motion  and  shampooing  at  first,  and  then 
by  more  free  motion  of  it  day  by  day,  combined  with  steaming  and  free 
rubbing  in  of  oil,  and  to  encourage  the  patient  to  exercise  it  as  much  as 
he  can  witliout  harm.  Sir  J.  Paget  has  called  attention  to  the  coldness 
which  aflects  joints  which  have  been  kept  too  long  at  rest,  and  he  cau- 
tions his  readers  in  the  following  emphatic  terms  against  tlie  bad  effects 
of  too  protracted  inaction  :  "Too  long  rest  is,  I  believe,  by  far  the  most 
frequent  cause  of  delayed  recovery  after  injuries  of  joints  in  nearly  all 
pei'sons  who  are  not  of  scrofulous  constitution.  In  the  healthy,  the 
chronic  rheumatic,  and  the  gouty,  it  is  alike  mischievous;  and  not  only 
to  injured  joints,  but  to  those  that  are  kept  at  rest  because  parts  near 
them  have  been  injured.  Mere  long  rest  stiffens  them  and  makes  them 
over-sensitive  ;  cold  douches  and  elastic  restraints  and  pressures  make 
them  worse,  and  nothing  remedies  them  but  movement,  whether  forced 
or  voluntary.'"  And  he  points  out  that  such  cases  are  the  most  frequent 
examples  of  the  class  which  are  cured  by  the  rough  manipulation  of  the 
bone-setter,  who  gets  a  joint  which  has  been  sprained  and  kept  too  long 
at  rest,  then  pretending  or  l)elieving  that  it  has  been  dislocated,  wrenches 
it,  and  tells  the  patient  that  it  has  been  put  in,  and  that  now  he  may  use 
it.  The  patient,  finding  himself  al)le  to  do  so,  naturally  believes  what 
the  quack  tells  iiim,  and  thinks  that  his  surgeon  has  overlooked  a  dislo- 
cation. The  real  fact  is,  that  rest  of  the  sprained  joint  has  been  carried 
on  too  long.     But  this  fact — though  there  can   be  no  doubt  of  it,  and 


'  Clinical  Lectures,  p.  96. 


FKACTURE  OF  CERVIX  FEMORIS.  289 

everyone  must  have  had  frequent  opportunities  of  verifying  it — must  not 
lead  us  into  the  opposite  error  of  decrying  the  use  of  complete  rest  in 
sprains,  especially  in  the  lower  limb ;  nor  into  that  of  insisting  on  too 
early  passive  or  active  motion,  which  would  reproduce  the  inflammation 
and  much  prolong  the  mischief.  Passive  motion,  shampooing,  etc., 
should  be  begun  as  early  as  seems  prudent,  but  always  gradually  and 
with  caution,  and  at  first  with  prolonged  intervals  of  rest. 

Wounds  of  the  lower  extremity  need  not  detain  us  in  this  place.  The 
injuries  of  large  arteries  (as  the  femoral)  have  been  spoken  of  above. 
The  wounds  of  joints,  and  especially  of  the  knee-joint,  are  the  most 
striking  feature  in  the  regional  surgery  of  such  injuries.  When  the  knee- 
joint  is  opened  by  a  clean  cut,  the  nature  of  the  injury  is  known  by  the 
escape  of  synovial  fluid  and  by  the  effusion  into  the  cavity.  Unless  a 
foreign  body  is  known  to  be  lodged,  no  probing  or  other  examination  is 
admissible.  Otherwise  the  cut  is  to  be  carefully  united,  and  the  joint 
equably  and  firmly  strapped,  the  limb  being  bandaged  from  the  toes  up- 
wards on  a  well-fitting  splint,  just  as  after  the  operation  for  removing  a 
loose  cartilage.  If  swelling,  pain,  and  fever  should  testify  to  the  access 
of  acute  inflammation,  then  the  joint  must  be  exposed,  leeches  very  freely 
applied,  and  afterwards  ice  kept  on  the  part  constantly.  If  the  case  does 
badly,  its  furtlier  progress  resolves  itself  into  the  diagnosis  and  treat- 
ment of  acute  abscess  in  the  joint  (for  which  see  the  chapter  on  Diseases 
of  the  Joints);  but  if  it  does  well,  the  symptoms  gradually  subside,  and 
the  patient  recovers,  usually  with  more  or  less  of  anchylosis,  though  pos- 
sibly in  some  cases  completely. 

Foreign  bodies  may  lodge  in  wounds,  especially  of  the  buttock,  and 
are  frequent  in  the  foot;  but  I  can  add  nothing  on  this  head  to  what  has 
been  said  above  (page  251). 

Fracture  of  the  neck  of  the  femui — a  common  accident  in  old  persons 
of  both  sexes — takes  place  either  entirely  within  the  capsular  ligament 
of  the  hip  joint,  or  else  partly  or  wholly  external  to  that  cavity.  The 
former  fractures  are  called  intra-capsular^  the  latter  exlra-co.psular. 

The  annexed  figures  (p.  290)  will  show  the  usual  forms  of  fracture  of  the 
neck  of  the  femur.  The  division  into  extra-  and  intra-capsular — which  was 
made  by  Sir  A.  Cooper,  and  which  is  ordinarily  followed  in  our  schools — 
appears  to  me  one  of  considerable  importance;  but  another  of  equal,  and 
according  to  the  judgment  of  some  writers  of  great  authority,  of  even 
greater  practical  value,  is  into  the  impacted  and  the  non-impacted  frac- 
tures. The  series  is  not,  of  course,  intended  to  exhibit  all  the  varieties 
which  are  met  with,  but  it  does  sliow  those  which  are  most  clearly  dis- 
tinguishable from  each  other,  and  the  characters  of  which  it  is  important 
to  bear  in  mind. 

Fig.  98  is  the  truly  intra-capsular  fracture  which  generally  occurs  in 
old  age,  and  often  from  slight  causes ;  it  is  usually  free  from  impaction, 
and  rarely  found  united  by  bone. 

This  fracture,  however,  may  be  impacted,  and  in  such  cases,  at  any 
rate,  bony  union  does  occur.     This  is  shown  by  Fig.  104. 

Fig.  99  shows  the  ordinary  impacted  extra-capsular  fracture  which 
occurs  both  in  old  age  and  at  earlier  periods,  in  which  the  upper  frag- 
ment (comprising  the  head  and  the  whole  of  the  neck)  is  driven  into  the 
cancellous  tissue  of  the  base  of  the  trochanter,  and  firmly  wedged  there; 
so  that  in  the  case  from  which  the  preparation  was  taken,  and  where  the 
same  fracture  had  occurred  on  both  sides,  at  four  years'  interval,  in  the 

19 


290 


INJURIES    OF    THE    LOWER    EXTREMITY. 


recent  fracture  the  upper  fragment  was  so  firmly  wedged  into  the  lower 
that  it  was  only  separated  by  maceration.  This  fracture  unites  always 
by  bone. 

Fig.  98.  Fig.  99. 


Fig.  98. — The  common,  uon-impacted,intra-capsular  fracture  of  the  neck  of  the  thigh-bone. — From  a 
preparation  in  St.  George's  Hospital  Museum,  Ser.  1,  No.  180. 

Fig.  99. — The  common,  impacted,  extra-capsular  fracture  of  the  cervix  femoris.  From  a  woman 
aged  seventy-four  at  the  time  of  her  death,  who  had  had  fracture  on  one  side  four  years,  on  the  other 
five  weeks,  before  her  death,  both  injuries  being  almost  exactly  similar.  The  old  injury  was  com- 
pletely united  by  bone ;  the  recent  one  was  firmly  impacted,  but  the  fragments  separated  in  macera- 
tion.— St.  George's  Hospital  Museum,  Ser.  i,  No.  207. 

Fig.  100,  on  the  other  hand,  represents  the  common  form  of  commi- 
nuted fracture  of  the  neck  and  trochanters,  also  produced  at  any  age  by 


Fig.  100. 


Fig.  101. 


Fig.  100.— The  comnu)ii,  comminuted,  non-impacted  fracture  of  the  neck  and  trochanters.— From 
a  specimen  (Ser.  i,  No.  142b)  in  the  Museum  of  St.  George's  Hospital. 

Fio.  101.— A  gunshot  wound,  causing  intra-capsular  fracture  of  the  neck  of  the  femur,  in  a  young 
man  (aged  2.'5).  A  charge  of  small  Hhot  passed  through  the  hip-joint,  from  a  very  short  distance,  at  the 
back  of  the  limb  ("  balled,"  according  to  the  common  expression),  cleanly  dividing  the  femur.  It  will 
be  noticed  that  the  back  part  of  the  bone  is  notched  by  the  shot  in  two  or  three  places.— From  a  speci- 
men in  St.  George's  Hospital  Museum,  Ser.  i,  No.  136. 


FRACTURE  OF  CERVIX  FEMORIS. 


291 


Fi<i.   102. 


considerable  violence,  and  in  which  impaction  is  usually  prevented  liy  the 
free  sj)littin>y  of  the  lower  fra<rinent,  tliough  in  other  cases  the  fragments 
may  be  variously  impacted  or  interlocked.  Union  will  occur  if  the  patient 
has  sufficient  vital  power,  and  if  not  interfered  with  by  inflammation,  al)- 
scess,  and  necrosis  of  detached  fragments. 

Fig.  101  is  introduced  to  illustrate  the  occasional  occurrence  of  lesions 
of  the  neck  of  the  femur  at  earlier  ages,  in  this  case  from  direct  wound  ; 
and  will  also  be  hereafter  referred  to  in  connection  with  the  treatment  of 
such  injuries  when  compound. 

Syviploms  and  DiaguoHis. — The  neck  of  the  femur  maybe  known  to  be 
fractured  Ity  the  following  signs.  After  an  injury,  of  more  or  less  severity, 
the  patient  is  unable  to  walk,  or  even  in  most  cases  to  move  the  limb, 
complains  of  gieat  pain  on  i)assive  mo- 
tion ;  the  atfected  limb  is  shorter  than  the 
other;  the  foot  as  well  as  the  whole  limb 
is  everted  in  most  cases.  If  no  impac- 
tion exists  the  length  of  the  limb  may  be 
restored  by  traction,  and  crepitus  will 
then  easily  be  obtained.  On  rotating 
the  limb  the  trochanter  is  observed  to 
move  through  a  smaller  arc.  If  the  frac- 
ture is  impacted  the  trochanter  moves 
along  with  the  head  of  the  bone,  and  in 
a  circle  of  which  the.  head  is  the  centre. 
The  position  of  the  trochanter  major  is  a 
matter  of  much  importance  in  fractures 
of  the  neck  of  the  thigh-bone.  In  the 
ordinary  non-impacted  fracture,  shown 
in  Sir  A,  Cooper's  figure,  the  trochanter 
is  sunk  as  well  as  displaced  upwards.  In 
the  rarer  cases  of  im|)acted  fracture  with 
inversion  it  is  of  course  prominent,  but 
in  all  cases  it  is  nearer  to  the  pelvis  than 
natural.  This  displacement  can  be  veri- 
fied either  by  "  Nelaton's  test "  of 
stretching  a  string  from  the  anterior 
superior  s[)ine  to  the  tuber  ischii — which 
in  the  natural  condition  only  just  touches 
the  top  of  the  trochanter,  or  lies  wholly 
above  it — or  by  Mr.  Bryant's  method  of 
measuring  the  vertical  distance  between 
the  top  of  either  trochanter  and  a  hori- 
zontal line  which  touches  both  the  an- 
terior superior  spines.^ 

The  diagnosis  between  a  case  of  frac- 
ture and  one  of  mere  contusion  of  the  hip 

is  usually  easy,  all  the  above  characteristic  symptoms,  except  the  loss  of 
motion,  being  absent  in  the  less  serious  injury.'^  There  are  cases,  indeed, 
in  which  the  shortening  is  very  slight,  and  where  the  eversion  consists 


Fracture  of  the  neck  of  the  thiijh-bone. 
After  Sir  A.  Cooper.  The  figure  shows  the 
advanced  age  of  the  patient,  the  shortening 
and  eversion  of  the  limb,  and  the  falling  in 
of  the  trochanter. 


1  Bryant,  On  the  diagnostic  value  of  the  iliofemoral  triangle.  Proc.  of  Med.-Chir. 
Soc,  vol.  vii. 

2  It  is  said,  however,  that  cases  of  fracture  occur  in  which  the  fragments  remain  at 
first  in  their  natural  contact  with  each  other  until  displaced  by  the  movementsof  the 
patient  or  some  accidental  cause.  If  this  is  true,  such  a  case  might  (though  only  lor 
a  short  time)  be  mistaken  for  a  mere  contusion. 


292  INJURIES    OF    THE    LOWER    EXTREMITY. 

less  in  obvious  turnint?  out  of  tlie  foot  than  in  a  fixed  condition  of  the 
limb;  wliere,  though  the  foot  does  not  visibly  point  outwards,  yet  it  can- 
not be  made  to  turn  inwards,  as  the  other  can.  Here  there  is  probably 
fracture  liigli  up,  witli  impaction,  and  the  patient  may  recover  very  per- 
fectl}'.  An  interesting  case  will  be  found  on  p.  133  of  Bigelow's  work. 
In  some  instances  it  appears  tliat  interstitial  absorption  of  the  cervix 
femoris  follows  after  mere  contusion,'  as  it  undoubtedly  does  after  frac- 
ture; and  in  such  cases  it  would  be  impossible,  some  months  after  the 
receipt  of  the  injury,  to  know  that  no  fracture  had  taken  place.  From 
dislocation  there  is  usually  no  difficulty  in  the  diagnosis.  Tlie  everted 
position  of  the  foot  and  the  free  mobility  of  the  limb  distinguish  the 
ordinary  cases  from  any  form  of  dislocation  (compare  Fig.  102  with  Figs. 
130,  132,  130,  and  140)  ;  while  in  an  impacted  fracture  with  inversion  of 
the  foot,"  simulating  at  the  first  glance  dislocation  on  to  the  dorsum  ilii 
or  into  the  sciatic  notch,  the  absence  of  the  head  of  the  bone  from  the 
buttock  will  distinguisli  it  from  the  former,  and  the  much  greater  freedom 
of  passive  motion  in  all  directions  (especiall}^  if  the  patient  be  under  the 
influence  of  chloroform)  from  the  latter  dislocation. 

There  is  a  very  rare  form  of  fracture  of  the  pelvis  in  which  the  head  of 
the  femur  is  driven  into  and  more  or  less  completely  through  the  ace- 
tabulum.* I  have  seen  this  injury  mistaken  for  fracture  of  the  cervix 
femoris,  and  the  mistake  is  really  of  very  little  consequence.  But  if  any 
doubt  existed  it  might  i)robably  be  set  at  rest  by  examination  under 
chloroform,  since  the  head  of  the  bone  is  believed  to  he  usually  jammed 
tightly  into  tlie  pelvis  in  these  cases.  But  the  injury  is  a  very  rare  one, 
and  little  is  therefore  known  as  to  its  symptoms. 

BiagnosiH  of  Intra-  from  Extra-capsular  Fracture. — The  above  account 
shows  tiiat  there  is  not  generally  any  great  difficulty  in  deciding  whether 
the  neck  of  tiie  femur  is  or  is  not  fractured  It  is  usually  less  easy  to  he 
sure  wliether  the  line  of  fracture  is  or  is  not  wholly  intra-  or  wholly  extra- 
capsular; and  indeed  the  great  majority  of  fractures  cannot  strictly  be 
limited  by  either  term,  for  the  line  of  fracture,  though  partly  or  chiefly 
below  tlie  attachment  of  the  capsule,  will  be  found  to  pass  up  into  the 
cavity  of  tlie  joint.  In  well-marked  instances  of  either  class  the  following 
rules  will  ap[)ly  :  1.  Intra-capsular  fracture  is  more  purely  an  injury  of 
old  age  than  the  extra-ca[)sular  form.  The  al>sori)tion  of  the  bone  from 
senile  atrophy,  producing  fatty  degeneration  of  its  tissues,  shortening, 
and  loss  of  the  natural  obliquity  of  the  neck  of  the  femur,  must  render  it 
prone  to  give  way  from  very  slight  causes ;  and  thus,  in  extreme  old  age, 
the  neck  of  the  thigh-bone  is  sometimes  broken  from  the  most  trifling 
injuries,  even  from  catching  the  toe  in  the  carpet  or  bedclothes.  Such 
fractures  are  in  all  probabilit}'  intra-capsular.     It  is,  however,  a  mistake 


^  I  have  myself  sc'Pn  this  shortonin;;  from  intorstitial  absorption  come  on  gradually 
in  a  case  which  was  carofiilly  fxaniiiicfl  soon  after  the  injury  by  myself  and  other 
surgeons,  who  wt-re  all  satisfied  that  no  fracture  existed. 

'•'  Inversion  in  impacted  fracture  depends  on  the  usual  kind  of  impaction  beini^  re- 
versed. Instead  of  the  neck  bein<;  driven  into  the  tissue.it  the  base  of  the  trochanter 
major,  driving  the  trochanter  baekwiirds,  tlie  two  trochanters  are  widely  separated 
from  each  otluT,  and  the  neck,  wedged  in  between  them,  has  so  pushed  forward  the 
trochanter  and  lower  fragment  as  to  turn  the  wh()]e  femur  inwards  on  its  own  axis. 
In  Bigelow's  work  and  in  sf)mo  papers  recenll}'  published  by  liim  in  th(i  Boston 
Medif'al  and  Surgical  .Journal,  January,  1875,  lh(i  reader  will  find  some  interesting 
speculations  on  the  strurture  of  the  neck  of  the  femur  and  the  effect  of  such  structure 
on  the  impaction  of  fracture 

^  See  Med.-Chir.  Trans.,  vol.  xxxiv,  p.  107.  There  is  a  specimen  in  the  Museum 
of  .St.  Georg(^'s  Hospital,  Ser.  i,  No.  12.3,  showing  this  injury,  which  was  mistaken 
for  fracture  of  the  neck  of  the  thigh-boni',  as  mentioned  in  the  text. 


FRACTURE  OF  THE  CERVIX  FEMORIS. 


293 


(though  one  often  committed)  to  believe  that  this  change  in  the  neck  of 
the  thigh-bone  is  one  whicli  is  universal  or  nearly  so  in  old  age,  and  that 
therefore  most  fractures  of  the  cervix  in  old  people  are  intracapsular. 
On  the  contrary,  the  change  in  question  only  occurs  in  some  proportion 
(hitherto,  I  believe,  undetermined)  of  the  aged  ;  and  the  extra-capsular  is 
certainly  more  common  in  old  age  than  the  intra-capsular  fracture.  This 
latter  form,  however,  is  almost  exclusively  found  in  the  aged.  When, 
tlierefore,  the  fracture  has  occurred  from  a  very  slight  cause  in  an  old 
person  we  conclude  that  it  is  probably  intra-capsular. 

2.  If  the  fracture  be  not  impacted  the  amount  of  shortening  which 
immediately  follows  the  injury  is  usually  less  after  the  intra-  than  the 


Fig.  103. 


Fig.  104. 


Fig.  103.— Section  of  the  femur  to  show  the  atrophy  of  its  head  and  neck,  and  the  alteration  in  the 
direction  of  the  latter  from  senile  changes.  The  head  is  on  a  lower  level  than  the  great  trochanter, 
and  the  neck  has  a  horizontal  instead  of  an  oblique  direction. — St.  George's  Hospital  Museum,  Ser.  ii. 
No.  7. 

Fig.  104. — Bony  union  of  intra-capsular  fracture. — From  St.  George's  Hospital  Museum,  Ser.  i.  No. 
142a. 

extra-capsular  fracture,  and  there  is  less  crepitus,  if  the  surgeon  thinks 
it  desirable  to  make  the  manipulation  necessary  in  order  to  elicit  the 
crejiitus.  But  this,  in  my  opinion,  should  rarely  if  ever  be  done.  It  puts 
the  patient  often  to  much  pain,  and  may  have  an  injurious  effect  on  the 
progress  of  the  case,  which  the  object  sought  to  be  obtained  does  not 
justify. 

3.  The  surest  test  between  an  intra-  and  extra-capsular  fracture  when 
it  is  available  (which,  however,  in  the  majority  of  cases  it  is  not)  is  to 
note  whether  the  trochanter  moves  with  the  lower  fragment.  If  the 
movement  of  the  lower  fragment  is  not  communicated  to  the  trochanter 
the  fracture  cannot,  of  course,  be  above  the  inter-trochanteric  line ;  but 
the  movement  of  the  trochanter  along  with  the  lower  fragment  does  not 
prove  the  contraiy  (^.  e,,  that  the  fracture  is  intra-capsular),  since  the 
fragments  may  be  more  or  less  closely  interlocked. 


294  INJURIES    OF    THE    LOAVER    EXTREMITY. 

Such  are  the  characters  which  seem  to  me  worthy  of  stud_v  when  we 
wish  to  distinguish  those  two  forms  of  fracture  from  each  other.  I  may 
add  that  they  become  less  trustworthy  the  more  completely  the  fragments 
are  impacted.  This  impaction  happens  much  more  frequently  in  the 
extra-capsular  form,  so  frequently,  indeed,  that  one  great  authority — Dr. 
R.  W.  Smith — believes  that  all  extra-capsular  fractures  are  impacted  at 
the  moment  of  injury,  though  doubtless  the  fragments  are  often  detached 
from  each  other  afterwards. 

When  the  impaction  is  complete  the  fragments  cannot  be  moved  on 
each  other  by  any  force  which  the  surgeon  would  employ.  Hence  the 
shortening  cannot  be  made  to  disappear,  nor  can  crepitus  be  elicited. 
But  in  less  firm  imjiaction  (or  perhaps  simple  interlocking  of  the  frag- 
ments) passive  motion  detaches  them,  crepitus  is  produced,  and  when 
extension  is  removed  the  shortening  is  found  to  have  become  much 
greater  than  before. 

The  treatment  of  fracture  of  the  neck  of  the  thigh-bone  will  depend 
mainl}'  on  the  age  and  constitutional  condition  of  tlie  patient.  Sir  Astley 
Cooper  proved  that  fracture  of  the  neck  of  the  thigh-bone  within  the  cap- 
sule does  not  usually  unite  l\y  bone.  In  some  rare  cases  it  will  do  so,  as 
shown  in  the  annexed  figure  ;  and  it  is  probable  that  when  it  does  do  so 
the  cause  is  gericrally  impaction  of  the  fractured  head  in  the  tissue  of  the 
cervix,  as  was  the  case  in  that  instance.^  More  commonly  the  union  is 
ligamentous  or  there  is  no  union  at  all.  and  in  the  latter  case  the  fractured 
surfaces  are  often  polished  oflT.  and  a  kind  of  false  joint  is  found  in  the 
interior  of  the  true  one.  The  causes  of  this  defect  of  union  are  variously 
stated.  There  can  be  no  doubt  that  the  main  reason  is  the  impossibility 
of  keeping  the  ends  in  contact,  and  perhaps  the  frequent  slight  displace- 
ments to  which,  under  the  action  of  the  muscles  inserted  into  the  tro- 
chanter, the  lower  fragment  is  constantly  liable.  But  many  other  causes 
have  been  assigned,  viz.,  the  age  of  the  patient,  the  atrophy  of  tiie  bone, 
the  percolation  of  synovial  fluid  between  the  fragments,  and  the  small 
supply  of  blood  to  the  upper  fragment — only  from  the  small  branch  wliich 
runs  in  the  ligamentum  teres.  The  first  is  a  cause  about  which  there  can 
be  no  doubt ;  and  in  the  only  other  very  common  injury  where  non-union 
is  the  rule,  viz.,  the  transverse  fracture  of  the  patella,  the  conditions  are 
similar  in  respect  to  the  impossibility  of  proper  coaptation  of  the  frag- 
ments, though  in  every  other  particular  they  are  usually  quite  different. 
This,  therefore,  may  safely  be  regarded  as  the  main  reason,  though  some 
others  may  conspire  in  preventing  l)ony  union.  This  want  of  liony  union 
exists,  however,  only  in  tiie  intra-capsular  fracture.  Extra-capsular  frac- 
tures unite  as  soundly  as  any  other  fracture. 

The  treatment  which  Sir  Astley  Cooper  recommended  consisted  merely 
in  supporting  the  knee  on  a  pillow,  keeping  the  patient  in  bed  until 
movement  was  no  longer  very  painful  to  him — say  from  a  fortnight 
to  three  weeks — and  then  allowing  him  to  get  up  and  move  al)Out  as 
mucli  as  he  could  with  ease.  The  result  of  this  would,  of  course,  be  the 
non-union  of  the  fracture;  but  this  was  a  matter  of  minor  importance  in 
Sir  A.  Cooper's  view,  since  he  laid  so  much  stress  on  the  fact  that  intra- 
capsular fractures  do  not  as  a  rule  unite  by  bone.  And  there  can  be  no 
doubt  that  if  attempts  are  too  much  persisted  in  to  procure  consolidation 
of  the  fracture  by  rigid  confinement   during  many  weeks,  the  patient 


1  Two  similar  instances  of  bony  union  of  intra-capsular  fracture  with  impaction 
are  rocordpd  and  ficurcd  by  Bigelow,  On  Dislocation  and  Fracture  of  the  Hip,  pp. 
131-135.     The  figures  are  strikingly  like  that  in  the  text. 


FRACTURE  OF  THE  TROCHANTER  MAJOR. 


296 


(being  an  old  person)  is  almost  sure  to  suffer  from  sloughing  produced  by 
the  splints,  or  from  bedsores,  and  will  very  likely  die.  And  in  such 
patients  the  treatment  above  described,  or  something  like  it,  is  the  best. 
But  this  does  not  apply  to  fractures  of  the  neck  of  the  thigh-bone  in 
3'ounger  and  more  vigorous  people.  In  them  the  fracture  is  either  im- 
pacted or  non-impacted.  If  the  former,  no  attempt  should  be  made  to 
disengage  the  fragments,  since  it  cannot  be  done  without  an  amount  of 
violence  which  would  be  highl\-  dangerous,  and  which  is  quite  unjustifi- 
able. Such  impacted  fractures  require  only  rest  for  their  consolidation. 
The  limb  is  steadied  by  the  application  of  a  weight  to  the  foot,  along 
with  a  case  of  splints  lightly  applied  to  the  thigh,  or  by  the  long  splint, 
for  about  six  weeks,  when  it  can  be  put  up  in  a  starched  pasteboard,  or 
a  Hides's  felt  splint.  Comminuted  and  other  non-impacted  fractures  in 
patients  tolerably  vigorous  and  not  too  old  are  to  be  treated  with  the  long 
splint,  just  like  any  other  fracture  of  the  thigh.     Some  surgeons  prefer 


Fig.  105. 


Earle's  bed,  or  the  double  inclined  plane  for  the  treatment  of  fracture  of  the  upper  part  of  the  femur. 
Extension  is  made  by  fixing  the  foot,  or  feet,  to  the  movable  foot-pieces  at  the  bottom  of  tbe  bed. 
Counter-extension  is  made  by  the  weight  of  the  body  gravitating  down  to  the  bottom  of  the  bed  in 
which  there  is  an  opening  for  the  passage  of  the  dejecta. 

Earle's  bed  in  these  cases,  and  it  is  certainly  less  exposed  to  the  risk  of 
producing  ulceration  or  sloughing  of  the  skin,  although  it  makes  far  less 
efficient  extension  than  the  long  splint. 

Some  alleged  cases  of  disjunction  of  the  upper  epiphysis  of  the  femur 
are  recorded  :  ^  but  they  do  not  seem  to  me  conclusive  as  to  the  real 
existence  of  this  lesion  as  a  substantive  injury. 

Fracture  of  the  trochanter  major,  without  any  solution  of  continuity  of 
the  shaft  or  neck,  has  been  known  to  occur  both  before  and  after  the 
junction  of  its  epiphysis.  One  in  an  old  man  is  recorded  and  figured  by 
Sir  A.  Cooper,^  and  in  a  girl  of  sixteen  b}-  the  same  author,  on  the 
authority  of  Mr.  Aston  Key.  It  is  caused  h}-  direct  violence.  The  S3'mp- 
toms  given  are  i^ain  at  the  part,  and  particularly  on  passive  motion,  ever- 
sion  of  the  foot,  deformity  of  the  trochanter,  and  crepitus,  without  short- 
ening of  the  limb.     The  injury-  is  to  be  treated  in  the  same  way  as  frac- 


1  Syst.  of  Surg.,  2d  ed.,  vol.  ii,  p.  859. 

'  On  Fractures  and  Dislocations,  2d  ed.,  pp.  158,  171. 


296 


INJURIES    OF    THE    LOWER    EXTREMITY. 


ture  of  the  cervix.    The  fracture  unites  well,  and  the  limb  will  very  proba- 
bly be  perfectly  useful. 

Fracture  of  the  body  of  the  femur  is  a  very  common  accident,  and  it 
generally  occurs  in  the  middle  of  the  bone,  at  a  variable  level.  The  cause 
is  usually  indirect  violence,  i.  e.,  a  fall  or  strain,  by  which  the  bone  is  bent 
and  snaps,  in  rarer  cases  it  breaks  in  consequence  of  a  direct  blow  upon 
the  tliigli.  There  is  rarel}^  any  difficulty  in  recognizing  the  nature  of  the 
injury,  as  the  lower  part  of  the  limb  is  freely  movable.  Exceptional 
cases,  in  which  impaction  causes  some  amount  of  difficulty,  will  be  recog- 
nized by  the  alteration  in  the  length  and  in  the  axis  of  the  limb. 

Three  forms  of  fracture  of  the  femur  are  described,  viz.,  fracture  of  the 
upper  third,  of  the  body,  and  of  the  lower  end. 

Fracture  of  the  upper  third  of  the  femur  is  a  formidable  injury.  In  the 
words  of  Sir  A.  Cooper,^  "it  is  a  difficult  accident  to  manage,  and  miser- 
able distortion  is  the  consequence  if  it  be  ill-treated."  The  distortion  to 
which  Sir  Astley  refers  is  that  shown  in  the  annexed  cop}'^  from  his  figure. 


Fig.  106. 


Fracture  of  the  upper  third  of  the  femur  with  great  displacement.  From  Sir  A.  Cooper's  work  on 
Fractures  and  Dislocations  (pi.  xii,  Fi;,'.  G),  thus  described  by  him:  "The  tliigh-bone  fractured  below 
the  trochanter  minor,  and  drawn  into  a  most  deformed  union  by  the  action  of  the  psoas  and  iliacus 
interuus  muscles." 


showing  the  upper  fragment  tilted  forwards  and  outwards,  and  the  lower 
fragment  lying  under  it,  irregularly  united  to  it  by  a  I)ridge  of  bone,  the 
axes  of  the  two  fragments  forming  a  great  angle.  But  tins  distortion  is 
not  the  one  which  is  always  found  in  these  cases.  Fig.  107,  from  tiie 
Museum  of  St.  George's  Hospital,  shows  an  equally  "  miserable  distor- 
tion," but  in  the  opposite  direction,  since  here  the  upper  fragment  re- 
mains in  its  natural  position,  wiiile  the  lower  fragment  is  driven  across 
the  front  instead  of  the  back  part  of  tiie  lower,  and  points  upwards  anct 
outwards.  In  both  cases  the  foot  must  have  been  far  from  tlie  ground, 
and  the  patient  could  onl}'  have  walked  witli  great  slowness  and  difficulty. 

*  See  the  section  On  Fractures  below  the  Trochanter,  in  Sir  A.  Cooper's  work 
On  Dislocations  and  on  Fractures  of  the  Joints. 


FRACTURE    OF    FEMUR. 


297 


Sir  A.  Cooper  refers  the  distortion  to  tlie  action  of  tlie  psoas  and  iliacus, 
and  to  tliat  only  ;  but  the  explanation  is  evidently  imperfect.  Allowing 
that  these  muscles  may  exercise  traction  on  the  upper  fragment,  it  is  evi- 
dent that  they  cannot  abduct  it  as  well  as  flex  it  (as  is  seen  in  Fig.  108), 
and  tliis  part  of  the  displacement  in  this  and  cases  similar  to  this  is  now 
generally  ascribed  to  the  pressure  of  the  lower  fragment,  which  often 
drives  the  bone  upwards,  though  other  surgeons  believe  that  the  action  of 


Fiu.  107. 


Fig.  108. 


Fig.  107.— Oblique  fracture  of  the  femur,  just  below  the  trochanter  minor,  most  irregularly  consoli- 
dated. The  upper  fragment  appears  to  have  retained  its  normal  position,  but  the  lower  one  crosses  the 
front  of  the  upper  fragment  obliquely  from  within  outwards,  and  is  firmly  united  to  it  by  a  bridge  of  new 
bone  passing  from  the  fractured  end  of  the  upper  fragment  to  the  surface  of  the  lower  fragment  below 
the  fracture.  The  medullary  canal  of  the  upper  fragment  was  filled  up  by  bone  at  the  seat  of  injury,  but 
in  the  lower  fragment  it  is  pervious.  The  head  of  the  femur  presents  several  irregular  projections  of 
bone,  one  of  which,  close  to  the  attachment  of  the  ligamentum  teres,  is  of  a  curious  hooklike  form,,  and 
fitted  into  a  similar  depression  in  the  acetabulum.  The  cartilages  of  the  hip-joint  were  almost  de- 
stroyed, but  there  was  no  pus  in  the  joint  nor  any  adhesions.  The  preparation  was  found  in  exam- 
ining the  body  of  a  man  aged  seventy-six,  who  died  of  disease  of  the  kidneys  and  bladder. 

Fig.  108. — Fracture  of  the  femur  immediately  below  the  trochanters,  seen  on  the  anterior  aspect. 
The  lower  fragment  has  passed  immediately  behind  the  upper,  and  the  latter  is  driven  into  a  position 
of  extreme  abduction,  so  that  the  head  is  inclined  considerably  inwards  and  forwards.  An  enormous 
callus  enveloped  the  two  fragments  behind,  and  in  this  anterior  view  a  broad  and  long  osseous  stalac- 
tite is  seen  leaning  against  the  lower  part  of  the  head  of  the  femur,  as  if  giving  it  support.  It  is  re- 
markable that  the  upper  fragment,  though  in  front  of  the  lower,  is  not  flexed  in  the  slightest  degree. 
On  the  contrary,  one  might  say  that  it  had  been  directed  a  little  backwards,  as  if  to  meet  the  lower 
fragment.  The  shortening,  due  to  the  riding  of  the  fracture,  seems  to  have  measured  about  an  inch. 
— From  Malgaigne's  Atlas,  pi.  xiii.  Fig.  1. 

the  abductor  muscles  is  also  called  into  play.  The  shortening  is  often 
caused  really  more  by  the  abduction  and  consequent  angular  deformity 
than  by  the  riding  or  anterior  displacement  (Fig.  109).  Evidently  the 
position  of  the  lower  fragment  is  the  point  to  which  the  greatest  atten- 
tion should  be  directed,  both  in  the  reduction  and  in  the  after-treatment. 
The  great  point,  as  it  seems  to  me,  is  to  disengage  this  fragment,  in  what- 
ever position  it  may  be  lying,  to  draw  it  down,  and  to  place  it  in  the  axis 
of  the  limb,  for  which  purpose  it  is  desirable  to  put  the  patient  under 
chloroform  ;  and  it  may  l)e  justifiable  in  extreme  cases  even  to  apply  the 
pulleys.  When  the  fracture  has  thus  been  completely  reduced  I  have 
never   seen  au}^  evil  consequence,  nor  any  difficulty  in  treating  it  by 


298 


INJURIES    OF    THE    LOWER    EXTREMITY, 


means  of  the  long  splint,  which  is  far  more  trustworthy  than  any  other 
apparatus  in  this  fracture.  1  have  never  seen  cases  successfully  treated 
by  the  double  inclined  i)lane  (Earle's  bed),  recommended  by  Sir  A.  Cooper; 
in  fact,  it  appears  to  me  to  exercise  no  influence  whatever  on  the  progress 
of  the  case,  and  to  be  very  insufficient  as  a  safeguard  against  the  repro- 
duction of  the  displacement,  which  is  the  real  danger.  If,  however,  the 
surgeon  is  so  under  the  influence  of  a  venerable  authority  as  to  fear  the 
action  of  the  psoas  in  displacing  the  upper  fragment,  he  can  adopt  Mr, 
Busk's  thigh-splint,  in  which  there  is  a  joint  at  the  hip,  so  that  the  body 
can  be  flexed  while  the  long  splint  steadies  the  lower  fragment. 

Fracture  in  the  Middle  of  the  Bone. — In  fractures  of  the  body  of  the 
bone  the  lower  fragment  generally  lies  behind  and  above  the  upper, 
either  to  its  inner  or  outer  side.     Fig.  110,  and  Fig.  30,  p.  145,  illustrate 


Fig.  109. 


Fig.  110. 


Fig.  100. — Fracturo  about  two  inches  below  the  .small  trochanter.  The  upper  fragment  is  directed 
considerably  outwards;  it.s  anterior  projection  docs  not  mea.sure  more  than  one-third  of  an  inch,  and 
thi8  is  all  the  shortening  that  is  due  to  the  riding  of  one  fragment  on  the  other,  wliile  the  .shortening 
due  to  the  angular  di'forinify  is  more  tlian  an  inch. — From  Malj-'aigne,  pi.  xiii,  Fig.  2. 

Fio.  110. — An  old.  badly  set  fracture  of  the  femur,  united  by  a  largo  bridge  of  bone,  which  covers  over 
the  medullary  canal  of  both  fragments.  The  upper  fragment  projects  on  the  outer  .side  of  the  lower, 
and  is  directed  from  aljove  outwards  and  forwards,  while  the  lower  is  dis])laci'd  considerably  upwards, 
and  points  from  below  alsf),  backwards  and  outwards.    Compare  this  with  Fig.  .'SO,  p.  14."). 

varieties  in  the  displacement  of  this  fracture,  but  it  is  certainly  almost 
constant  for  the  upper  fragment  to  be  in  front  of  the  lower;  tiie  foot 
also  is  always  everttid  or  rotated  outwards,  unless  in  some  rare  cases  the 
fragments  should  be  so  interlocked  that  it  is  driven  inwards.  The  main 
cause  of  botli  displacements  seems  to  be  the  weight  of  tlie  lower  part  of 
the  limb.     It  is  not  impossible  tliat  the  psoas  and  iliacus  may  raise  the 


FRACTURE    OF    FEMUR. 


299 


lower  end  of  the  upper  fragment,  and  that  the  hamstring  muscles  may 
draw  the  lower  backwards,  and  this  explanation  is  accepted  by  man}' 
authors;  but  it  seems  to  me  that  when  the  support  of  the  skeleton  is 
withdrawn  by  snapping  the  femur  the  leg  naturally  falls  backwards  and 
the  foot  outwards.  At  any  rate,  if  muscular  action  has  anything  to  do 
with  the  displacement  it  does  not  usually  affect  the  treatment  to  any 
recognizable  extent.  This  treatment  consists  first  in  the  careful  setting  of 
the  fracture,  and  in  doing  this  the  surgeon  should  not  grudge  the  time 
necessary  to  verify  its  accuracy.  He  should  ascertain  by  the  most  exact 
measurement  that  the  length  of  the  fractured  thigh  is  tiie  same  as  the 
other,  and  by  careful  comparison  of  the  various  points  of  the  two  limbs 
that  there  is  no  angular  or  rotatory  displacement.  The  treatment  which 
is  usually  adopted  at  St.  George's,  and  I  believe  at  all  the  other  London 

Fig.  111. 


Fig.  112. 


A  fracture  of  the  thigh  put  up  with  Desault's  long  splint  and  short  thigh-splints.  Fig.  Ill  ghoWS 
the  general  features  of  the  apparatus.  The  long  splint  extends  from  the  foot  to  the  axilla.  Desault's 
splint  is  provided  with  a  footpiece,  as  shown  in  Fig.  112.  Liston's  splint,  which  is  in  more  common  use, 
though  I  think  inferior  to  Desault's,  ends  in  a  notched  extremity,  extending  several  inches  below  the 
foot.  The  object  is  to  correct  the  tendency  to  eversion  of  the  foot  by  the  traction  exercised  on  it  by 
the  bandage  passing  through  the  notch.  The  objection  to  it  is  that,  in  the  words  of  a  late  house  sur- 
geon at  one  of  the  hospitals  where  it  is  in  use,  "it  is  apt  to  strain  the  ankle-joint,  and  .sores  are  liable 
to  form  about  the  malleoli,  and  overth?  tendo  Achillis"  (Lancet,  Oct.  10,  1874,  p.  .'512).  The  short  splints 
are  strung  on  the  perineal  band,  as  shown  in  Fii;.  112.  They  are  secured  by  a  couple  of  webbing  straps, 
and  the  long  splint  is  kept  in  position  by  a  bellyband.  The  perineal  band  is  passed  through  the  notch, 
then  around  the  splint  from  below  upwards,  and  finally  out  of  the  notch  again,  being  buckled  outside 
the  splint.    This  buckle  has  been  accidentally  omitted  in  Fig.  111. 

hospitals,  is  that  by  the  long  splint,  whether  Desault's  or  Liston's  makes 
little  matter,  assisted  by  short  splints,  encasing  the  thigh,  and  prevent- 
ing any  minor  displacements  of  the  fragments  on  each  other  (Figs.  Ill, 
112).     Tliese  latter,  perhaps,  are  not  absolutely  necessary,  and  some  sur- 


/ 


300 


INJURIES    OF    THE    LOWER    EXTREMITY, 


geons  only  use  the  short  splints  to  correct  any  deformity  which  is  obvi- 
ous. If  short  splints  are  not  used,  it  is  an  old  and,  I  believe,  good 
practice  to  bandage  the  limb  evenly  and  carefully  up  to  the  seat  of  frac- 
ture, and  some  surgeons  carry  the  bandage  up  the  whole  limb. 

There  are  many  other  methods  of  treatment,  of  which  I  cannot  profess 
much  personal  experience ;  for  though  I  have  occasionally  tried  some  of 
them  I  have  not  found  any  reason  for  thinking  that  they  are  superior  to 
the  above  in  the  ordinary  fractures  of  adults,  while  they  unquestionably 
involve  some  risk,  and  are  not  so  eas}'  of  application.  Thus,  the  Ameri- 
can surgeons  are  fond  of  applying  the  constant  extending  force  of  a  weight 
passing  over  a  pulley  at  the  bottom  of  the  bed,  counter-extension  being 
applied  by  fixing  a  perineal  band  to  the  head  of  the  bed,  so  that  the  pa- 
tient cannot  get  down  below  a  certain  level  in  it.  The  weight  is  in  some 
cases  supplemented  by  short  splints  applied  between  the  knee  and  the 
groin.  The  amount  of  weight  must  be  regulated  by  the  size  of  the  limb. 
For  an  adult  probably  ten  or  twelve  pounds  would  be  about  the  average 
(Fig.  113.) 

Other  plans  contemplate  a  combination  of  the  steadiness  of  the  long 
splint  with  the  i)ermanent  extension  produced  by  the  weight,  substituting 
for  the  latter  a  spring  or  india-rubber  band  or  accumulator  inserted  into 
a  jointed  splint.    Such  is  the  splint  invented  by  Mr.  Cripps,  in  which  the 


Fk:.  II?. 


Extension  apparatus  for  fracture  of  the  thigh.    Modified  from  Gurdon  Buck.    New  Yorlt 

Medical  Record. 


foot  is  drawn  down  and  kei)t  down  by  a  constant  elastic  force,  and  of 
which  Mr.  IJryant  speaks  in  high  terms;  and  other  similar  apparatus 
have  been  invented  by  Mr.  De  Morgan  and  other  surgeons;  but  I  have 
not  sufficient  experience  of  them  to  have  formed  any  opinion  of  tiieir 
real  practical  value  as  compared  with  the  usual  plan  of  treatment.' 

Many  surgeons  adopt  the  jjlan  of  putting  up  the  fractured  thigh  at 
once,  or  very  soon  after  the  accident,  in  an  immovable  apparatus,  such 
as  a  starched  bandage,  a  plaster  of  Paris  splint,  or  a  leather  collar. 

In  America  the  limb  is  sometimes  slung  by  means  of  a  bent  rod  adapted 
by  the  front  of  the  foot,  leg,  and  thigh,  the  knee-joint  being  slightly  bent. 


1  The  latest  of  these  plans  of  making  constant  extension  will  be  found  described 
by  Mr.  G.  B.  Browne,  from  Mr.  Erich.son',?  hospital  practice,  in  the  Lancet,  October 
10,  1874, 


FRACTURE    OF    FEMUR,  301 

Hooks  are  inserted  into  the  back  of  the  rod,  so  as  to  sling  it  from  a  pulley 
over  the  bed.  The  fracture  is  carefully  set,  and  the  rod  then  securely 
bandaiied  on  to  the  limb.  The  constant  traction  of  the  weight  of  the 
leg  and  foot  is  supposed  to  counteract  any  tendenc}'  to  shoi'tening.  But 
the  plan  should  on!}'  be  employed  (if  at  all)  when  a  wound  on  the  front 
or  side  of  the  limb  prevents  the  use  of  the  ordinary  splints.  Even  in 
such  cases  it  woidd  be  better,  in  my  opinion,  to  put  up  the  limb  in  plaster 
of  Paris,  cutting  a  hole  for  the  wound. 

Now,  if  we  wish  to  form  an  estimate  of  the  relative  value  of  these  new 
plans,  we  have,  in  the  first  place,  to  inquire  what  has  been  the  result  of 
the  old  treatment — tliat  by  the  long  splint.  I  think  we  may  take  it  as 
estal)lished  by  consent  of  all  the  best  writers  that  in  ordinary''  cases  of 
fractured  femur  in  the  adult  with  displacement,  the- result  of  treatment 
by  the  long  splint  is,  as  a  rule,  to  leave  a  certain  amount  of  shortening. 
Malgaigne,  in  fact,  goes  so  far  as  to  say:  "  When  the  fragments  remain 
in  contact,  or  when  we  can  replace  them,  and  keep  them  so  by  means  of 
their  serrations,  it  is  easy  to  cure  a  fracture  of  the  femur  without  shorten- 
ing; in  the  absence  of  these  two  conditions  the  thing  is  simply  impossi- 
ble" (Packard's  Malgaigne^  p.  581).  Without  going  quite  so  far  as 
this,  I  think  we  may  say  tliat  everyone  who  has  examined  liml>s  treated 
witli  the  utmost  care  by  our  best  surgeons  witli  the  long  splint  agrees  that 
if  they  are  measured  with  perfect  accurac}-  a  shortening  of  at  least  half 
an  inch  is  ordinarily  found  in  the  adult,  but  that  in  children  recovery 
without  shortening  very  often  takes  place,  and  is  probably'  tiie  rule.  In 
children,  however,  the  first  of  Malgaigne's  conditions  is  generally  present, 
i.  e.,  the  fragments  have  never  quitted  each  other,  but  remain  in  contact, 
so  that  as  soon  as  the  limb  is  straightened  it  is  found  to  be  the  same 
length  as  the  other.  By  those  who  advocate  the  use  of  permanent  exten- 
sion, either  by  the  weight  or  elastic  springs,  this  defect  is  attributed  to 
the  indisputai)le  fact  that  the  long  splint  can  make  no  active  extension, 
and  that  the  liandages  by  which  it  is  fixed  must  relax  to  such  an  extent 
as  to  prevent  the  extension  made  at  the  moment  of"  setting"  from  being 
accurately  maintained.  But  it  must  be  admitted  that  up  to  the  present 
time  we  have  obtained  no  reliable  evidence  that  the  treatment  by  perma- 
nent extension  gives  any  better  results,  and  it  may  also  be  said  that  in 
fact  the  results  of  tlie  long  splint,  though  not  mathematically  i)erfect,  are 
usually  good  enough  for  all  practical  purposes  ;  for  though  a  slight 
amount  of  shortening  may  in  all  cases  be  detected  by  measurement,  its 
amount  in  careful  hands  is  not  generally  so  great  as  to  be  perce])tible  to 
the  patient,  since  it  is  corrected  by  a  slight  involuntary  inclination  of  the 
pelvis,  and  he  walks  without  limping.  It  is  in  the  more  formidable  cases, 
in  which  the  fractured  ends  have  been  greatly  displaced,  or  where  the- 
fracture  is  double  or  comminuted,  that  the  shortening  becomes  really  a 
deformity,  and  it  is  yet  to  be  proved  that  in  such  cases  permanent  exten- 
sion could  be  so  applied  as  to  remedy  this  displacement,  or  that  if  applied 
it  could  be  tolerated  by  the  patient;  for  it  must  be  remembered  that  per- 
manent extension  is  much  more  likely  to  produce  ulceration  of  the  skin 
than  the  ordinary  method,  and  affords,  as  it  seems  to  me,  much  less  se- 
curity against  angular  deformity. 

The  method  of  putting  up  fractures  of  the  thigh  at  once  is  very  appli- 
cable in  the  case  of  infants  and  young  children.  In  them  the  long  splint 
is  not  well  l)orne,  and  the  bandages  are  constantly  soiled  with  urine  and 
ffeces,  and  require  renewal.  A  starch  or  gum  bandage,  or  better  still,  the 
leather  collar,  shown  in  Fig.  114,  will  keep  the  limb  straight,  which  generally 


502 


INJURIES    OF    THE    LOWER     EXTREMITY. 


f!^., 


Leather  collar  for  the  treatment 
of  fracture  of  tlie  (right)  femur  in 
a  chilJ.  The  upper  part  of  the 
collar  is  covered  with  oiled  silk,  to 
prevent  its  becoming  soiled  with 
urine  or  fieces. 


is  all  that  is  wanted,  and  the  chihl  may  be  nursed  if  in  arms.    IMie  collar  is 
better  than  tlie  immovable  apparatus,  since  it  can  be  changed  if  necessary. 

Some  surgeons  are  in  favor  of  treating  frac- 
tured thigli  in  young  children  without  any 
apparatus  at  all,^  merely  laying  the  limb  in  the 
abducted  position  flat  on  the  bed.  I  have 
treated  some  cases  successfully  in  this  way, 
but  it  seems  to  be  exposed  to  the  risk  of  angu- 
lar deformity,  as  evidenced  by  the  preparation 
represented  in  Fig.  115;  and  as  all  such  risks  are 
obviated  by  the  simple  plan  above  described, 
I  cannot  see  what  motive  there  is  for  running 
any  such  risk,  or  for  the  vertical  extension  of 
the  limb,  which  Mr.  Biyant  recommends.^  If 
the  surgeon  wishes  it,  a  weight  can  be  hung 
to  the  child's  foot  at  the  same  time  as  the 
collar  is  applied,  but  I  see  no  necessity  for  it. 

In  the  adult  a  fracture  of  the  femur  appears 
to  be  sufficiently  consolidated  to  bear  the 
weight  of  the  bod}'^  without  danger  in  nine  or 
ten  weeks.  The  usual  period  for  which  treat- 
ment is  continued  is  twelve  weeks.  Six  weeks  or  more  are  to  be  passed 
in  bed,  after  which,  if  on  examination  the  union  seems  firm  enough,  the 
immovable  apparatus  is  to  be  applied,  and  the  patient  allowed  to  move 
about  on  crutches  for  the  remainder  of  the  period.  When  the  immovable 
apparatus  is  used  from  the  first  the  patient  is  spared  this  confinement  to 
bed  :  so  that  Mr.  Erichsen,  who  is  the  main  advocate  for  its  use,  says  that 
he  scarcely  ever  finds  it  necessary  to  keep  patients  with  simple  fracture 
of  the  thigh  in  bed  for  more  than  six  or  seven  days.  Most  surgeons, 
however,  think  that  the  tedium  of  the  confinement  to  bed  is  overbalanced 
by  greater  safety,  and  therefore  employ  some  apparatus  by  which  the  seat 
of  fracture  is  exposed,  which  involves  the  necessity  of  keeping  the  patient 
in  bed. 

In  the  child,  under  twelve,  the  period  of  union  and  of  treatment  may 
be  reckoned  as  about  half  that  of  the  adult. 

Double  fractures  and  comminuted  fractures  are  more  diflicnlt  to  deal 
with,  and  require  more  care  in  their  reduction  and  treatment,  than  simple 
single  fractures.  In  such  cases  it  seems  to  me  undeniable  that  the  treat- 
ment by  the  long  splint  is  much  superior  to  that  by  permanent  extension. 
Compound  fi-acture  of  the  femur  is  a  very  grave  accident — tiie  danger 
inci'easing  with  age.  It  is  the  result  usually  of  gunshot,  or  of  very 
severe  falls,  in  which  the  end  of  the  bone  is  thrust  through  the  muscles 
and  the  skin.  The  first  question  is,  wluither  to  save  the  limb  or  ampu- 
tate. This  being  settled,  on  the  indications  described  at  p.  142,  the  limb 
must  be  i)ut  up  in  the  same  way  as  in  simple  fracture,  onl}'  that,  if  a  long 
splint  be  used,  it  must  be  liracketed,  if  necessary,  at  the  situation  of  the 
wound,  wiiich  is  hardly  ever  at  the  posterior  aspect  of  the  limb.  The 
surgeon  should  be  vigilant  to  detect  and  give  exit  to  matter  as  soon  as 
it  has  formed. 

Fractures  of  the  loioer  end  of  the  femur  are  very  common.     Long 


'  See  a  paper  by  Mr.  Bloxnrn,  "  Rcispectini^  tlio  Troatmcnt  of  Fractures  of  the 
Lower  Extremities  in  the  Wards  under  the  care  of  Mr.  Paget,"  St.  Bartholomew's 
Hopp.  Reports,  vol    ii. 

2  Lib.  cit.,  p.  954. 


FRACTURE    OF    FEMUR. 


303 


fissures  run  down  into  the  knee-joint  from  a  considerable  distance ;  but 
the  communication  witli  the  joint  is  often  a  matter  only  of  conjecture, 
and  they  heal  frequently,  as  l'  believe,  without  any  loss  of  motion  in  the 
joint.  More  frequently  the  lower  end  of  the  femur  is  separated  from  the 
shaft,  by  a  fracture  running  transversely  above  the  condyles,  and  often 
passing  vertically  down  between  them  into  the  joint ;  and  in  youth  (i.  e., 
below  the  age  of  nineteen  or  twenty)  the  fracture  often  passes  more  or 
less  entirely  through  the  line  of  junction  of  the  epiphysis,  constituting 


Fracture  of  the  femur  in  au  infant  fourteen  months  old,  which  had  been  treated  without  splints. 
The  child  died  of  measles  thirty-two  days  after  the  accident.  The  bone  is  seen  to  be  much  bent  at  the 
seat  of  fracture.  This  malposition  was  observed  and  could  easily  have  been  remedied  before  death, 
had  the  child's  condition  admitted  of  any  interference.  In  another  case  similarly  treated  the  bone 
also  bent,  but  was  easily  straightened,  and  the  cure  completed  by  means  of  a  leather  collar.  In  two 
other  cases  the  fracture  healed  well,  and  without  observed  shortening.— From  Holmes's  Surg.  Dis.  of 
Childhood. 

what  is  called  a  separation  of  the  epiphysis.  1  have  shown  elsewhere 
that  these  separations  of  the  epiphyses  are  usually  complicated  with  more 
or  less  of  fracture  of  the  shaft  or  of  the  bony  epiphysis  itself  (see  page 
139),  and  this  is  illustrated  by  the  two  figures  annexed,  in  one  of  which 
the  line  of  fracture  runs  up  into  the  shaft,  and  in  the  other  also  separates 
the  two  condyles  from  each  other.     Still  there  are  a  few  preparations  in 


304 


INJURIES    OF    THE    LOWER    EXTREMITY. 


our  museums  in  which  the  separation  is  confined  to  tiie  epiphysial  line. 
The  differential  diagnosis  of  separation  of  the  epiphysis  from  fracture 
must  be  generally  conjectural  only,  resting  on  the  patient's  age.  It  is 
conceivable  that  in  a  pure  disjunction  of  tiie  epipiiysis  the  surgeon  might 
succeed  in  absolutely  diagnosing  the  injury,  by  the  absence  of  bony 
crepitus,  together  with  the  mobility  of  the  fragment ;  but  I  am  not  aware 


Fiu.  117. 


Fig.  116. — Partial  separation  of  the  lower  epiphysis  of  the  femur.  The  part  of  the  epiphysis  which 
forms  the  inner  condyle  is  detached  from  the  shaft  by  a  fracture  traversing  the  epiphysial  line.  The 
fracture  then  bifurcates — one  line  running  down  into  the  lower  surface  (inter-condyloid  notch  of  the 
femur),  the  other  somewhat  upward,  detaching  the  outer  condyle  and  adjacent  portion  of  the  shaft 
from  the  rest  of  the  bone. — From  the  Museum  of  St.  George's  Hospital. 

Fig.  117. — Another  case  of  separation  of  the  lower  epiphysis  of  the  femur  complicated  with  fracture. 
The  line  of  fracture,  after  running  for  about  half  the  thickness  of  the  bone  in  the  line  of  junction  of 
the  epiphysis,  then  turns  upwards  into  the  shaft,  leaving  a  large  portion  of  the  latter  adhering  to  the 
outer  condyle.— From  the  Museum  of  St.  George's  Hospital. — See  Holmes's  Surg.  Dis.  of  Childhood. 

that  any  such  case  has  occurred.  The  only  importance  of  tlie  diagnosis 
would  be  that,  if  the  surgeon  could  satisfy  himself  that  tiie  epiphysial 
cartilage  had  been  injured,  he  might  warn  the  patient  or  his  friends  of 
the  possibility  of  subsequent  susjKMision  of  growth. 

Fracture  of  the  lower  end  of  the  femur  is  in  general  perfectly  easy  to 
diagnose.  When  the  fracture  runs  transversely  across  the  bone  the  lower 
Iragment  usually  falls  backwards  by  the  weight  of  the  limb,  assisted  per- 
haps by  the  hamstrings,  and  the  mobility  and  displacement  make  the 
nature  of  the  case  obvious.  If  the  separation  be  as  low  as  the  epiphysial 
line  it  involves  the  knee-joint,  vvhicli  will  be  more  or  less  swollen  ;  and 
this  swelling  may  mask  the  other  symptoms.  Here  also,  the  fracture 
being  within  the  knee-joint,  tlie  attachments  of  its  capsule  hold  the  bones 
together,  and  prevent  displacement  from  occurring,  at  any  late,  to  an}'' 
great  extent.  But  in  sucli  cases  tlie  loss  of  power  will  indicate  the  proba- 
ble nature  of  tlie  injury,  and  attentive  examination  under  cliloroform  can 
hardly  fail  to  elicit  definite  proofs  of  it. 


FRACTURES    OF    FEMUR. 


305 


Wlien  the  fracture  runs  down  between  tl»e  condyles  it  will  often  be 
found  that  the  breadth  of  the  lower  end  of  the  femur  is  perceptibly 
increased.     The  condyles  may  be  movable  on  each  other;  and  an  impor- 


FiG.  118. 


Fk;.  119 


Fl(i.  118.— Fracture  of  the  femur  above  the  condyles.  The  seat  of  fracture  is  more  than  3  inches  above 
the  lower  end  of  the  bone.  The  lower  fragment  is  drawn  behind  the  upper  and  displaced  upwards  as 
much  as  13^^  inch,  the  antero-po.sterior  diameter  of  the  femur  at  this  part  being  more  than  doubled. 
The  callus  is  formed  by  two  large  bridges  of  bone,  between  which  there  is  a  large  tunnel,  closed  below. 
The  medullary  canal  of  the  lower  fragment  is  seen  to  be  patent,  and  in  the  specimen  the  same  is  found 
to  be  the  case  in  the  upper  fragment  also. — From  Malgaigne's  Atlas,  pi.  xv.  No.  1. 

Fio.  119. — Fracture  ol  the  femur  just  above  the  condyles.  The  fracture  runs  obliquely  downwards, 
outwards,  and  a  little  forwards.  The  upper  Iragment  displaced  in  this  direction,  has  pushed  the  patella 
downwards  on  to  the  tibia,  so  that  the  patella  is  really  diflocated  downwards  from  the  femur.  The 
lower  fragment  remains  parallel  to  the  uppi'r. — From  Malgaigne's  Atlas,  pi.  xlv.  Fig.  1. 


tant  symptom  of  fracture  running  down  into  the  joint  is  the  sensation 
elicited  by  rubbing  the  patella  over  the  condyloid  notch.  If  there  be 
any  fracture  its  unevenness  is  very  plainly  felt,  in  contrast  to  the  smooth 
motion  of  the  kneecap  in  the  uninjured  limb. 

It  may  be  added  that  in  some  cases  the  capsule  of  the  knee-joint,  or 
even  the  patella  itself,  has  been  wounded  by  the  upper  fragment. 

The  treatment  of  such  fractures  is  usually  very  successful.  The  bent 
position  of  the  limb  is  best,  both  for  the  purpose  of  relaxing  tlie  ham- 
string muscles  and  of  pushing  the  lower  fragment  into  position  by  the 
projecting  angle  of  the  s{)lint.  The  surfaces  are  so  broad  in  fractures 
near  the  knee-joint  that  there  is  probably  no  shortening,  and  even  when 
the  fracture  runs  into  the  joint  it  often  heals  without  producing  any 
anchylosis.  If  anchylosis  is  apprehended  it  is  desirable,  after  six  weeks  of 
rigid  rest,  to  adapt  some  apparatus  which  can  be  removed  daily  or  every 
other  day,  for  the  purpose  of  giving  passive  motion  to  a  gradually  in- 
creased degree,  in  order  to  obviate  such  a  result.  Should  anchylosis  have 

20 


306 


INJURIES    OF    THE     LOWER    EXTREMITY. 


t:iken  place  it  must  be  treated  on  ordinary  principles,  and  will  often  yield 
to  the  treatment. 

Compound  fracture  into  the  knee-joint  is  an  accident  which,  as  a 
general  rule,  demands  amputation  ;  but  to  this  general  rule  exceptions 
may  be  made  in  cliildren  and  in  unusually  healthy  young  adults,  if  the 
surgeon  thinks  it  justifiable.  Mr.  Canton  has  reitorded  two  cases  in  which 
he  excised  the  knee-joint  for  the  secondary  results  of  abscess  in  the  joint, 
after  an  attempt  to  preserve  the  limh,  in  cases  of  simple  fracture,  or  par- 
tial separation  of  the  lower  epiphysis  of  the  femur  ;  but  amputation  became 
necessary  in  both.'  How  far  the  same  operation  would  be  applicable  in 
compound  fractures  into  the  joint  is  doubtful.  In  cases  of  gunshot  frac- 
ture excision  has  hitherto  proved  very  unsuccessful. 

Fracture  of  the  patella  is  a  ver}' common  injury,  and  occurs  in  two 
main  forms.  The  ordinary  form  of  fracture  is  transverse,  and  is  very 
commonly  caused  entirely  b}'  the  action  of  tlie  great  extensor  muscle, 

Fig.  120.  Fig.  121. 


Fig.  120. — Union  of  a  fracture  running  down  into  the  knee-joint.  The  patient,  a  middle-aged  man, 
recovered  with  a  very  useful  limb,  and  died  a  year  aftnrwards  from  adifTcrent  cause.  The  greater  part 
of  the  fracture  is  united  by  masses  of  new  bone,  but  tliere  is  no  new  bone  in  the  interval  between  the 
fragments  of  the  condyles,  and  the  fragments  of  the  cartilage  are  united  l)y  fibrous  tissue. — St.  George's 
Hospital  Museum,  Ser.  i,  No.  195. 

Fio.  121.— A  transverse  fracture  of  the  patella,  without  laceration  of  the  fibroustissue  in  front  of  the 
bone,  produced  by  violence  acting  from  within,  in  a  compound  fracture  of  the  femur,  one  of  tlie  frag- 
ments having,  as  it  seems,  been  driven  against  the  deep  surface  of  the  patella.  The  cartilage  covering 
the  patella  is  diseased. — From  St.  George's  Hospital  Museum,  Ser.  1,  No.  205. 

the  bone  being  snapped  by  the  muscle  before  the  patient  falls  to  the 
ground.  But  there  are  a  certaiu  proportion  of  cases  (ecpial,  according  to 
some  authors,  to  those  caused  by  muscular  action)  in  which  the  same 
transverse  fracture    is  produced    by   direct   violence.'^      In   some  cases 

'  Path    Trans.,  vol.  x,  p.  232;  vol.  xi,  p.  195. 

*  Mr.  Hutchinson  remarks  very  truly,  "In  thi>  numorous  cases  in  which  direct 
violence  i.s  applied  to  tlie  bone  at  the  moment  of  fracture,  there  i.s  almost  always  mus- 
cular contraction  i-imultaneoMsly  present,  and  it  is  impo.ssiblc  to  say  which  takes  the 
chief  share  in  the  re.«ult."     Med. -Chir.  Trans.,  vol   Hi,  p.  328. 


FRACTURES  OF  PATELLA. 


307 


disease  of  the  knee  has  preceded  and  raa}'  have  been  a  predisposing 
cause. ^ 

The  fracture,  though  called  transverse,  is  often  more  or  less  oblique. 
It  is  accompanied  by  a  laceration  of  the  fibrous  tissue  covering  the  bone; 
and  in  proportion  as  this  laceration  extends  completely  through  the  apo- 
neurosis of  the  extensor  muscle  the  upper  fragment  is  liable  to  be  torn 
away  from  the  lower  by  tlie  action  of  the  quadriceps  extensor  at  the  mo- 
ment of  the  accident,  or  to  be  pushed  up  by  the  accumulation  of  blood 
and  synovial  effusion  in  the  cavity  of  the  joint.  In  some  cases  the  fibrous 
investment  remains  entirely  untorn,  especially  when  the  fracture  is  the 
result  of  direct  violence.  This  is  illustrated  by  Fig.  121,  whicli  also 
shows  a  peculiar  cause  for  the  fracture,  viz.,  the  direct  impact  of  a  frag- 
ment of  the  femur.  Fig.  122  also  shows  the  ligamentum  i)atell8e  untorn 
on  one  side. 

The  symptoms  are  usually  ver3'  plain.  Tlie  patient  may  have  snapped 
the  bone  before  falling,  or  even  with  no  fall  at  all  (as  in  Boyer's  case, 
where  a  coachman  snapped  his  i)atella  in  making  an  eff'ort  to  hold  hitnself 
on  to  the  coachbox).  He  will  be  almost  or  entirely  unable  to  extend  the 
limb ;  there  will  be  swelling  and  effusion  into  the  knee,  and  a  depression 
will  be  felt  between   the  two  fragments,  the  upper  one  of  which  will  be 

Fig.  122. 


A  specimen  of  fracture  of  both  patelte,  occurring  in  a  severe  injury,  from  the  other  eft'octs  of  which 
the  patient  died  fifty  days  after  the  accident.  On  one  side  (a)  the  fragments  were  widely  separated, 
and  there  was  no  attempt  at  any  union ;  on  the  other  side  (b)  the  ligamentum  patelliSB  had  not  been 
completely  ruptured;  the  fractured  ends  were  in  close  apposition,  and  there  was  some  amount  of  fibrous 
union.  In  both  the  cartilage  bears  very  evident  traces  of  intlammation.  No  record  exists  of  the  treat- 
ment beyond  the  fact  that  both  knees  had  been  put  up  in  pasteboard  splints  before  the  final  accession 
of  the  fatal  symptoms,  which  were  due  to  traumatic  encephalitis  after  fracture  of  the  base  of  the  skull. 

movable  at  a  height  above  that  of  the  upper  border  of  tlie  bone  on  the 
other  side.  Sometimes  the  bulging  of  the  synovial  effusion  into  the 
depression  can  be  made  out. 

Treatment. — The  foot  and  leg  are  to  be  placed  on  a  straight  splint 
properly  padded.  It  used  to  be  considered  essential  to  raise  the  foot  in 
order  to  relax  the  extensor  muscle.  But  this  is  now  regarded  as  a  matter 
of  little  moment,  for  it  has  been  noticed  that  after  the  direct  results  of 
the  injury  have  subsided  the  quadriceps  muscle  is  not  contracted,  but, 

1  See  Fig.  121  in  text ;  also  Packard's  Malgaigne,  p.  602. 


308  INJURIES    OF    THE    LOWER    EXTREMITY. 

on  the  contrary,  quite  flaccid  and  inactive;^  and  it  has  been  found  on 
trial  tliat  the  results  of  treatment  in  the  horizontal  position  of  the  limb 
are  not  inferior  to  those  obtained  in  the  raised  position.-  Still,  I  am  not 
aware  tiiat  there  is  any  valid  objection  to  the  raised  position  of  the  foot 
on  a  comfortal)le  a()pai'atus.  I  have  often  questioned  patients  so  treated, 
who  have  complained  of  no  inconvenience;  but  if  they  do  find  the  posi- 
tion disafi^reeable  I  see  no  use  in  insisting  upon  it.  The  main  point  is  to 
keep  the  limb  extended  and  fixed  in  that  position.  The  next  point  is  to 
endeavor  to  bringdown  the  upper  fragment  and  keep  it  as  near  the  lower 

as   possil)le.      This    is    often    very 
f"'«- 1-'''-  difficult,   from    the   persistence    of 

effusion  in  the  joint,  and  from  the 
slight  hold  whicli  can  be  got  on  the 
fragment.  I  liave  often  emploj'ed 
Malgaigne's  hooks,  and  have  not 
experienced  any  bad  effects  from 
them.  At  the  same  time  cases 
have  been  recorded  in  which  sup- 
puration   has    followed,   and    even 

Malgaigne's  hooks   for   fractured    patella.      The  onC,  I   belicVC,  in  wllich  it  extended 

hooks  are  fixed  either  into  the  skin  and  fibrous  jnto  the  joint,  necessitating  ampu- 

tissue    above  and   below  the    fragments,   or    into  ^^^^^^^        gut  SUch    ill  COnsequeuCCS 

plaster  firmly  applied  in  these  situations,  and  the  •       i. 

upper  pair  are  then  gradually  approximated  to  the  are  SO  rare   aS    nOt  tO  Constitute,  tO 

lower  by  means  of  the  key  and  screw.  niy     mind,     aU}'    Valid     objection    tO 

the  careful  use  of  the  hooks.  I 
have  found,  however,  that  the,y  have  a  uniform  tendency  to  displace  the 
lower  edge  of  the  upper  fragment  upwards,  so  as  to  render  the  space 
between  the  two  fragments  V-shaped,  the  angle  backwards.  Very  close 
and  useful  union  may,  however,  often  be  obtained  l\y  their  means.  It  is 
desirable  not  to  apply  them  till  all  active  efiusion  has  subsided,  but  it  is 
not  necessary  to  wait  for  the  entire  removal  of  passive  effusion.  An- 
other plan — suggested,  I  believe,  by  Mr.  Callender — which  I  have  found 
useful,  is  to  hitch  under  the  upper  edge  of  the  upper  fragment  a  bandage 
or  strapping,  to  which  a  weight  is  attached,  over  a  pulley  at  the  end  of 
the  bed,  so  as  to  draw  the  upper  fragment  continuously  and  gentl}' down- 
wards. Numerous  other  plans  have  been  introduceil,  but  they  nia}'  all,  I 
think,  be  comprised  under  one  or  other  of  these  heads,  viz.:  (1)  to  trust 
to  nature,  assisted  or  not  by  the  raised  position  of  the  limb,  to  hring  the 
fragments  as  near  as  is  possible  on  the  subsidence  of  the  effusion  ;  (2)  to 
drag  the  upper  fragment  downwards  by  hooks  fixed  in  the  fil»rous  tissue 
above  it;  and  ('.i)  to  draw  it  downwards  by  tlie  traction  of  bandages  or 
strapping  applied  to  the  skin  over  its  upper  end. 

Union. — The  unif)n  of  the  ordinary  transverse  fracture  of  tiie  patella, 
in  wllich  the  fragments  have  been  separated  at  the  time  of  the  accident 
by  a  considerable  interval,  is  always  (as  far  as  has  been  proved  hitherto) 
by  ligament,  when  it  unites  at  all.  It  is  true,  that  many  preparations  of 
bony  union  exist  and  others  are  found,  as  shown  irj  Fig.  124,  where 
the  union  appears  bony  externally,  but  a  section  is  found  to  be  partly  or 
entirely  fibrous.  But  there  is  no  proof  that  in  such  cases  the  fragments 
have  ever  been  separated  ;  and,  in  fact,  from  the  traces  of  inflammation 
always  found  in  such  fractures  (as  evidenced  by  the  great  thickening  of  the 
bone),  it  seeras  more  probable  a  priori  that  they  have  been  injuries  due 

'   Hutchinson,  op.  cit.,  p    .380. 

'  Bloxam,  inSt.  Barth.  Hosp    Hop.,  vol.  iii,  p.  38(j. 


FRACTURES    OF     PATELLA. 


309 


Union  of  fracture  of  the  patella  with  hardly 


to  direct  violence,  as  in  Fig.  121,  above.  No  history  has  yet  been  put  on 
record  proving  that  the  displacement 
in  transverse  fracture  of  the  patella 
has  ever  been  so  effectually  corrected 
as  to  admit  of  bon}'  union.  The  cause 
of  this  want  of  bony  union  is  evi- 
dently the  separation  of  the  frag- 
ments, and  when  that  separation  has 
been  very  extensive,  it  is  common 
enough  for  the  fragments  to  be  en- 
tirely ununited. 

The  length  of  treatment  must  be 
regulated  by  the  consideration  of  the 
state  of  parts.  We  must  not  on  the 
one  hand  keep  the  knee  stiff  for  so 
long  a  time  as  to  risk  permanent  an- 
chylosis, nor  on  the  other  allow  move- 
ment so  early  as  to  endanger  the 
yielding  of  the  ligamentous  union. 
When  the  uniting  ligament  is  short 
and  strong,  the  knee  is  very  useful 
indeed  ;  and  it  is  doubtful,  whether 
bony  union,  accompanied  as  it  gene- 
rally is  by  much  inflammation,  is  any  separation  of  the  fragments  The  latter 
really  better  for  the  l)atient  than  a  are  enormously  enlarged  in  all  their  dimen- 
firm   fibrous  union  sions,  and  their  tissue  much  denser  than   nat- 

.  Ill  •       i  1         ural.     The   interspace   between    them   is  filled 

Asa  general  rule,  the  patient  ought  ^nh  dense  fibrous  tissue,  and  is  not  more  than 
to    be    kept    in   bed    for  six  weeks,  and     one-third  of  an    inch    in    extent.     During  life 

for  at  least  six  weeks  more  he  should   ^'>«  ""'^'^  ^""^"^  ''^''^  ^'^^'"'^'^  hony.-Krom  a 

,  ii         1-      1      •  !•     ^        I  •    I  -11     preparation    in    the    Museum   of    St.   George's 

keep  the   limb  in   a  splint  which  will   '^^^pj^^i   ^^^  i   ^^_  ,9e     j^^,,,;,,^  j^  ^^J^^^ 

not  allow  of  an}'  bending,  after  which    about  the  case   beyond  the  fact  that  the  man 
he  may   use    the   leg   cautiously  with   a    ^as  in  St.  George's  Hospital  with  fractured  pa- 

laced  bandage  having  an  aperture  in   teiia  many  years  before  his  death. 
front  to  receive  the  patella. 

The  fracture  is  often  reproduced  by  accidental  rupture  of  the  uniting 
ligament,  and  persons  wlio  have  fractured  one  patella  are  liable  to  frac- 
ture the  other.  I  have  even  seen  two  or  three  cases  where  the  patella  has 
been  broken  a  second  time  in  a  diflierent  place,  the  uniting  medium  of  the 
old  fracture  remaining  firm. 

Direct  Vertical  or  Y-ahaped  Fractures. — The  fracture  wiiich  is  purely 
the  result  of  direct  violence  is  sometimes  star-shaped  (or  Y-shaped)  or 
comminuted,  at  other  times  a  mere  longitudinal  crack  running  more  or 
less  vertically.  Tne  ligamentum  patellae  is  generally  untorn,  and  in  fact 
the  fracture  often  does  not  correspond  on  the  two  faces  of  the  bone,  so 
that  no  separation  of  the  fragments  is  i)ossible.  There  can,  therefore,  be 
no  doubt  that  such  fractures  are  susceptible  of  bony  union,  and  prepara- 
tions of  such  bon\'  union  exist  in  the  College  of  Surgeons'  and  other 
museums.  At  the  same  time  the  inflammation  caused  by  the  injury  is 
doubtless  more  deleterious  to  the  motion  of  the  joint  than  the  ligamentous 
nature  of  tiie  union  in  transverse  fracture,  allowing  that  in  the  latter  case 
the  bond  of  union  is  short. 

Compound  fracture  of  the  patella  is  a  rare  and  a  very  grave  accident^ 
usually  accompanied  by  other  injuries  to  the  articulation,  wiiich  necessi- 
tate amputation,  but  occasionally  occurring  alone,  and  then  allowing  the 
chance  of  saving  the  limb.     The  principles  on  which  the  surgeon  must 


310 


INJURIES    OF    THE    LOWER    EXTREMITY. 


be  ofiiided  in  his  choice,  whether  to  save  the  limb  entirely  oi*  to  excise  the 
joint,  or  to  amputate,  are  the  same  in  this  as  in  other  injuries  of  the  knee. 
If  the  limb  is  to  be  savetl  all  foreign  bodies  or  fragments  of  bone  should 
be  removed,  the  wound  carefully  closed  and  treated  in  the  manner  which 


Flo.  126. 


f^ 


Fig.  125.— a  patella,  showing  a  vertical  fracture  running  from  the  base  to  the  apex  of  the  bone,  so 
as  to  divide  it  into  nearly  equal  halves.  The  fracture  is  joined  above  by  a  small  oblique  fissure  ("  Y- 
shaped  fracture"),  which,  however,  is  not  visible  on  the  cartilage.  On  looking  at  the  cartilaginous 
surface  the  principal  fracture  is  seen  to  extend  through  the  cartilage  into  the  joint  at  the  lower  part 
only,  and  when  traced  upwards  on  this  aspect  is  found  to  break  up  into  two  principal  and  numerous 
smaller  fissure.-«,  which  have  uo  correspondence  with  the  fracture  of  the  bone.  The  patient,  a  young 
woman,  had  thrown  herself  out  of  a  third-floor  window,  in  a  fit  of  insanity,  and  died  on  the  following 
day.— St.  George's  Hospital  Museum,  Ser.  i,  No.  187. 

Fig.  126.— Internal  view  of  an  oblique  fracture  of  the  patella,  extending  downwards  from  near  the 
base  to  the  apex  of  the  bone.  The  articular  cartilage  is  also  cracked  transversely.- St.  George's  Hos- 
pital Museum,  Ser.  i.  No.  186. 

is  believed  most  likely  to  guard  against  subsequent  inflammation ;  in 
fact,  treated  like  a  simple  wound  of  the  joint  (see  page  289).^ 

Fracture  of  the  leg  is  perhaps  the  most  common  accident  which  is  met 
with  in  our  hospitals,  since  most  of  the  other  common  fractures  are 
treated  at  the  patient's  own  house.  It  occurs  mostly  in  adult  life,  chil- 
dren being  comparatively  rarely  the  subjects  of  this  injur}' ;  and  as  a 
general  rule,  when  the  fracture  is  simple,  the  patient  recovers  with  no 
permanent  disablement,  though  to  this  rule  there  are  unfortunately  nu- 
merous exceptions. 

The  fracture  usually  occurs  at  the  junction  of  the  middle  and  lower 
thirds  of  the  leg,  and  botii  bones  are  usually  broken,  the  fibula  often  at  a 
higher  level  than  the  til)ia;  the  lower  fragment  is  generally  displaced 
backwards,  as  tiiough  drawn  by  the  gastrocnemius,  so  that  its  upper  end 
projects  under  the  skin,  and  sometimes  punctures  or  perforates  it.  The 
displacement  varies  chiefiy  with  the  direction  of  the  fracture  through  the 
tibia  ;  when  this  is  nearly  or  truly  transverse  there  is  often  little  or  no 
displacement ;  when  the  fracture  runs  from  the  front  of  the  bone  oblicpiely 
downwards,  the  upper  end  of  the  lower  fragment  may  be  displaced  he- 
hind  the  l(;wer  end  of  the  upper  ;  but  generally  the  obliquity  is  in  the 
reverse  direction,  or  the  fracture  is  comminuted,  and  then  the  displace- 
ment is  as  described  above,  combined  very  probably  with  some  rotation 
of  the  lower  fragment  outwards.     "  Out  of  nineteen  specimens  of  united 


'  See  Poland,  in  Med.-Chir.  Trans.,  vol.  liii,  p.  49. 


FRACTURES    OF    THE    FIBULA.  311 

fracture  of  the  leg,"  examined  by  Mr.  81iaw,  "  sixteen  had  the  lower  frag- 
ment rotated  outwardly,  and  situated  somewhat  to  the  outer  side  and  he- 
hind  the  upper." ' 

There  is  hardly  ever  any  difficulty  in  the  diagnosis.  The  cause  should 
engage  some  attention.  Generally  the  fracture  is  the  result  of  indirect 
violence,  as  in  falls  on  the  feet.  But  it  may  be  caused  by  a  blow  or  kick 
on  the  part  itself,  which  is  of  course  accompanied  by  more  bruising  of 
the  soft  parts.  The  treatment  is  very  simple  in  ordinary  cases.  The 
bones  being  sedulously  brought  into  exact  apposition,  are  to  be  kept  so 
for  about  eight  weeks,  when  the  i)atient  may  be  allowed  to  use  the  leg, 
with  merely  the  support  of  a  bandage.  The  apparatus  for  maintaining 
the  bones  in  apposition  are  very  numerous.  It  is  usual  in  hospital  prac- 
tice to  apply  side-splints,  i.  f?.,  two  thin  pieces  of  board,  properly  padded, 
cut  somewhat  to  the  shape  of  tiie  side  of  the  leg,  and  provided  with  a 
footpiece.  These  are  kept  on  with  straps  and  bandages,  care  being  taken 
to  see  that  the  heel  is  well  padded,  so  that  the  skin  is  not  cut  by  the 
bandage,  and  to  see  that  the  foot  is  at  riglit  angles,  otherwise  the  upper 
end  of  the  lower  fragment  might  be  again  displaced  forward.  The  pa- 
tient is  then  kept  in  bed  for  four  weeks,  after  which  the  limb  is  encircled 
in  pasteboard  or  leather  splints  for  the  other  four  weeks,  and  he  is  allowed 
to  move  about  on  crutches  with  the  foot  slung  from  the  neck.  But  it  is 
very  common,  particular!}'  in  the  case  of  persons  whose  business  renders 
it  important  for  them  not  to  be  confined  to  bed,  to  put  up  the  fracture  in 
a  pasteboard,  plaster  of  Paris,  or  other  case  at  once,  if  there  is  no  bruising, 
or  else  as  soon  as  the  bruising  has  subsided  ;  and  the  practice  is  a  safe 
one,  if  care  is  taken  in  applying  the  bandage  at  first,  and  reasonable  pre- 
cautions observed  afterwards  to  guard  against  subsequent  swelling.  I 
have  never  myself  seen  any  ill  consequences.  Yet,  as  the  practice  cer- 
tainly involves  some  risk,  in  consequence  of  the  withdrawal  of  the  seat 
of  fracture  from  the  surgeon's  observation,  it  ma}'  be  well  to  explain  this 
to  the  patient,  and  obtain  his  consent.^  In  fractures  with  much  bruising, 
or  comminution,  or  displacement,  one  of  the  plans  recommended  below 
for  the  treatment  of  compound  fractures  may  be  employed. 

Fractures  of  the  tibia  alone  are  much  less  common,  since  the  force 
required  to  break  this  bone  generally  fractures  the  fibula  also,  and  they 
are  usually  the  result  of  direct  force.  There  is  little,  often  no  displace- 
ment, since  the  fibula  acts  as  a  kind  of  splint  and  prevents  the  separation 
of  the  ends.  They  must  be  treated  in  the  same  way  as  fractures  of  both 
bones,  and  are  peculiarly  appropriate  for  putting  up  in  a  case  directly 
after  the  accident,  provided  the  state  of  the  soft  parts  permits  it. 

Fractures  of  the  fibula  alone  are  very  common,  the  usual  cause  being 
indirect  violence,  as  a  false  step,  or  slipping  off  the  pavement,  or  falling 
with  the  foot  jammed.  The  bone  is  generally  fractured  near  the  junction 
of  the  lower  and  middle  third,  though,  especially  when  the  cause  is  a 
direct  blow,  any  part  may  be  broken.  The  diagnosis  is  not  alvvay  easy, 
for  there  is  often  no  displacement,  and  the  patient  can  in  rare  cases  even 


1  Path.  Soc.  Trans.,  vol.  ii,  p.  125. 

^  A  case  was  reported  some  years  ago  in  which  a  surgeon  put  up  a  fracture  of  the 
leg  (in  a  j'oung  child)  in  a  plaster  case  imiiu'diately  after  the  accident,  and  allowed 
the  parents  to  take  the  child  home.  The  parts  swelled,  and  the  little  patient  became 
uneasy.  The  parents  brought  the  child  back  to  the  surgeon.  Ho  was  in  too  great  a 
hurry  at  the  time  to  make  the  proper  examination  by  removing  the  apparatus.  The 
whole  skin  sloughed,  amputation  had  to  be  performed,  and  the  surgeon  was  justly 
cast  in  damasres. 


312  INJURIES    OF    THE    LOWER    EXTREMITY. 

walk.'  Whenever  a  patient  is  totally  or  almost  entirely  unable  to  walk, 
and  complains  of  fixed  pain  referred  to  a  certain  spot  in  the  libula  on 
active  or  i)assive  motion,  fracture  may  be  suspected.  The  best  plan  to 
detect  it  is  to  rotate  the  foot,  keeping  the  fingers  of  one  iiand  on  the 
suspected  i)art;  or  to  press  alternatel}^  on  both  sides  of  the  supposed 
fracture.  The  existence  of  the  fracture  will  be  proved  .either  by  crepitus 
or  by  the  fact  that  tlie  upper  part  of  the  bone  does  not  share  the  motion 
impressed  on  the  lower  fragment.  If  the  surgeon  remains  in  doubt 
whether  the  injury  is  a  fracture  or  a  severe  sprain,  he  should  treat  it  as 
fracture.  When  deformity  exists  there  is  no  diflficnlty  of  diagnosis.  The 
deformity  consists  in  eversion  or  abduction  of  the  foot,  winch  is  ascribed 
by  Malgaigne  and  others  to  efforts  made  l\v  llie  patient  to  walk,  in  which 
the  foot,  having  lost  the  guard  afforded  by  the  external  malleolus,  is 
necessarily  turned  outwards.  It  is  to  remedy  this  displacement  that  the 
various  formal  plans  of  treatment  are  designed.  Usually  nothing  is  re- 
quired beyond  side-splints,  or  a  case  of  pasteboard  or  plaster,  since  the 
displacement  is  easily  remedied  and  there  is  nothing  to  reproduce  it. 
The  fracture  should  be  kept  in  apposition  for  six  weeks.  The  plans 
wliich  are  intended  to  act  decidedly  on  the  displacement  are:  1.  Pott's 
method — the  patient  being  placed  on  the  injured  side,  with  the  knee  bent 
to  relax  the  gastrocnemius  muscle,  the  foot  inverted,  a  splint  applied  to 
the  inside  of  the  leg,  not  reaching  the  foot,  and  a  side-splint  with  a  foot- 
piece  to  the  other  side  of  the  leg  and  foot,  the  footpiece  being  more 
thickly  padded  than  the  leg,  so  as  to  turn  the  foot  inwards.  2.  Dupuy- 
tren's  method,  in  which  a  straight  splint  is  applied  to  the  inside  of  the 
leg,  reaching  several  inches  below  the  foot ;  a  wide  shaped  pad  is  applied, 
with  its  broad  end  downwards,  corresponding  to  the  internal  malleolus. 
The  foot  and  leg  arc  bandaged  to  the  splint,  and  by  making  the  pad  of 
sufficient  thickness  any  amount  of  inversion  of  the  foot  which  is  judged 
necessary  to  disengage  the  lower  fragment  (which  is  supposed  to  be  locked 
in  or  turned  towards  the  tibia)  can  be  secured. 

Pott's  fracture,  or  fracture  of  the  fibula  complicated  with  dislocation  of 
the  ankle,  will  be  found  treated  of  under  the  latter  heading. 

Compound  Fractures. — When  fractures  of  the  leg  are  compound  the 
injury  becomes  much  graver,  and  the  treatment  a  matter  of  more  anxiety. 
Many  such  fractures  prove  fatal  in  the  practice  of  civil  life  from  pyaemia 
or  diffuse  inflammation,  and  in  military  surgery  they  are  still  more  fatal. 
The  cause  of  the  accident  has  much  infiuence  on  the  progress  of  the  case. 
When,  as  often  happens,  the  fracture  was  originally  simple,  but  the 
patient  in  trying  to  move  has  pushed  one  fragment  (generally  tlie  upper) 
through  tiie  skin,  there  is  little  or  no  laceration  of  the  soft  parts  beyond 
the  mere  skin-wound,  and  there  is  generally  no  difficulty  in  getting  the 
bones  back  into  position  witli,  or  even  without,  a  slight  division  of  the 
skin,  which  sometimes  tightly  gras|)s  tlie  protruding  fragment.  But  when 
the  bones  have  been  crushed  by  a  heavy  body  passing  over  or  striking 
the  limb,  and  this  force  has  at  the  same  time  carried  the  lower  end  of  the 
leg  backwar<ls,  the  injury  is  often  extensive  and  ditlicult  to  deal  with  ; 
the  soft  parts  are  greatly  contused  and  lacerated,  the  bojies  comminuted, 
and  the  comminuted  fragments  very  likely  much  displaced,  so  that  they 
can  hardly  be  got  into  position  by  any  manipulation  ;  besides  which  the 


'  I  once  saw  a  ease  in  which  a  patient  had  been  walking,  though  with  pain  and 
diflScully,  fyr  some  days  after  a  fracture  of  the  libiila.  Still  more  rarely  a  patient 
can  walk  for  a  time  with  fracture  of  ijoth  bones. 


COMPOUND    FRACTURE    OF    THE    LEG. 


313 


periosteum  is  often  stripped  off  tlie  fragments  to  a  great  extent,  rendering 
their  subsequent  deatli  very  probable. 

Tlie  tirst  (piestion  is,  whether  the  limb  can  be  saved  or  not;  the  next, 
whether  to  remove  any  of  the  fractured  bone  or  not. 

In  resolving  to  save  the  liml)  or  to  amputate,  the  surgeon's  first  thought 
is  as  to  the  extent  of  laceration  of  the  soft  parts,  since  if  this  is  so  great 
as  in  his  judgment  to  make  traumatic  gangrene  inevitalile,  it  would  be 
folly  to  defer  an  operation  which  must  ultimately  follow,  and  which  can 
never  again  be  performed  with  so  go(Kl  a  prospect  of  recover}*.  Again, 
if  either  of  the  main  arteries  is  wounded  it  is  better  to  amputate,  at  least 
in  an  adult.  In  a  child  or  a  youth  pierhaps  it  might  be  justifiable  to  wait 
till  gangrene  had  commenced.  And  if  tlie  amount  of  exposed  bone  be 
very  great,  and  the  patient  advanced  in  3'ears  or  broken  in  iiealth,  it  may 
be  better  to  amputate.  But  the  experience  of  modern  surgery  has  shown 
conclusively  how  much  may  l)e  done  in  saving  limbs  which  would  some 
time  ago  have  been  unhesitatingly  condemned.  Many  of  these  cases  have 
been  brought  to  a  successful  termination  liy  the  '•  antiseptic"  method  and 
many  by  other  carefully  devised  plans  of  treatment.  Without  dogma- 
tizing on  the  subject,  I  believe  I  express  the  general  opinion  of  surgeons 
of  experience  in  saying  that  careful  attention  to  the  instant  closure  of 
the  wound,  graduated  support, 

and  exact  apposition  are  more  fig.  127. 

essential  to  success  than  any 
special  application.  Yet  it 
seems  rational  to  close  the 
wound  with  a  substance  which 
is  not  in  itself  liable  to  putrefy, 
and  which  tends  to  i)reserve  the 
parts  below  from  putrefaction. 
Sir  A.  Cooper  recommended 
lint  steeped  in  the  patient's 
own  blood,  believing  that  this 
would  form  a  medium  of  union  ; 
but  tliis  is  now  rarely  used. 
Many  other  sul)stances  are  in 
use.  Dry  cotton-wool  is  an  ex- 
c^lent  application ;  or  collo- 
dion, or  the  "styptic  colloid  " 

of  Dr.  Richardson  may  be  employed;  but  of  all  substances  which  I  have 
tried  it  seems  to   me  that  carbolized  oil  (about   1   of  the  acid  in   G  or  8 


Salter's  swing. 


Fig.  128. 


Macintyre's  splint,  modified. 

parts)  is  the  best.     Before  the  parts  can  be  reduced  it  is  often  necessary 
to  remove  a  projecting  splinter  with  the  saw  or  bone  nippers  ;  and  I  have 


314 


INJURIES    OF    THE    LOWER    EXTREMITY. 


removed  as  much  as  two  inches  of  the  tibia  with  perfect  success.  Great 
cave  shoukl  be  taken  to  watch  for  any  indication  of  the  formation  of 
matter,  and  to  give  it  exit  when  necessary  ;  and  if  general  swelling  of 
the  limb  or  ditfuse  inflammation  of  the  cellular  membrane  calls  for  it,  free 
incisions  should  be  practiced.  When  reduced  the  limb  must  be  put  upon 
a  back-splint,  with  a  footpiece,  such  as  Macintyre's  or  Assalini's,  which 

Fig.  129. 


Assalini's  fracture-box.  a,  foot-piece,  b  b  b,  buttons  for  attachment  of  straps,  bandages,  etc.,  to 
make  pressure  as  required,  c,  screw  for  drawing  the  footpiece  downwards  and  so  making  extension, 
or  increasing  it  from  time  to  (irae.  D,  screw  for  altering  the  inclination  of  the  footpiece.  E,  a  per- 
forated pad  attached  to  the  knee,  embracing  and  tixing  the  patella,  and  thus  making  counter-extension. 

will  hold  the  fractured  ends  securely  and  yet  give  access  to  the  wound. 
The  wound  is  always  on  the  front  or  side  of  the  leg  in  fractures  not  caused 
by  gunshot.  In  the  latter  some  special  contrivance  must  be  extemporized, 
if  the  wound  is  in  the  calf. 

Division  of  the  tendo  Achillis  has  been  highly  spoken  of  by  some  emi- 
nent surgeons,'  as  Mr.  De  Morgan,  as  a  preliminary  to  the  reduction  of 
some  simple  and  compound  fractures  of  the  leg,  where  the  upper  end  of 
the  lower  fragment  is  much  tilted  forwards  and  reduction  seems  to  be 
opposed  by  the  tension  of  that  tendon.  The  need  for  this  measure  may 
be  inferred  from  careful  examination  of  the  limb  under  chloroform.  If 
the  tendon  under  these  circumstances  be  still  rigid  I  have  no  doubt  that 
much  good  may  be  obtained  by  its  division,  though  in  the  few  instances 
in  which  I  have  myself  practiced  the  operation  I  cannot  say  that  it  was 
successful  in  obviating  deformity;  and  in  one  the  wound  suppurated 
extensively',  and  this  suppuration  much  retarded  the  cure. 

Finally,  I  may  say  that  a  certain  amount  of  displacement,  if  unattended 
b}'  much  shortening,  is  not  a  very  grave  evil,  and  that  in  cases  of  dis- 
placed simple  fracture  it  is  better  to  acquiesce  in  this  result  than  to  run 
any  risk  of  converting  the  simple  into  an  inflamed  and  so  into  a  compound 
fracture  by  injudicious  attempts  at  complete  reduction. 

Fractures  of  the  bones  of  the  foot  are  singularl}'  rare,  considering  the 
great  frequency  of  falls  and  sprains  in  that  part,  showing  tlie  efficiency 
of  the  protecti(Mi  which  the  ligaments  of  tlie  foot  afford.  Tliey  are  met 
with,  however,  l)otli  as  tlie  result  of  direct  and  indirect  force. 

The  OS  calcis  is  fractured  from  falls  on  the  heel  or  from  the  passage  of 
a  wheel  over  the  foot,^  and  the  nature  of  the  injury  may  escape  detection. 
This  failure  of  diagnosis  may  be  of  little  moment  to  the  patient,  since  no 
apparatus  is  needed  to  keep  the  parts  in   position,  and  by  the  time  he  is 


'  See  a  figure  in  the  chapter  on  Tenotom)'. 

*  It  is  said  that  the;  tuhcrosity  has  been  torn  from  the  rest  of  the  hone  by  muscular 
action,  but  this  seems  dubious. 


DISLOCATION    OF    THE    HIP.  315 

able  to  put  the  foot  to  the  ground  the  bone  will  be  consolidated.  But 
usually  the  increased  breadth  of  the  heel  will  point  to  tlie  nature  of  the 
injury,  and  crepitus  can  be  detected  by  proper  manipulation.  In  some 
cases  a  fragment  may  be  drawn  up  the  leg  by  the  action  of  the  gastroc- 
nemius. All  that  is  necessary  is  rest  and  soothing  applications.  When 
the  fracture  is  compound  and  the  fragments  are  completely  severed,  it 
may  be  well  to  remove  the  loose  portions. 

The  astragalus  can  only  be  broken  by  indirect  force,  and  when  fractured 
the  fragment  is  very  often  dislocated  also,  leading  to  the  symptoms  of 
dislocation.  When  this  is  complicated  with  a  wound  (compound  fracture 
and  dislocation)  the  displaced  portion  should  be  removed  ;  otherwise  the 
parts  should  be  reduced  and  kept  in  position  for  about  six  weeks,  when 
the  power  of  standing  and  walking  will  probably  be  regained. 

Fractures  of  the  other  bones  of  the  tarsus  call  for  no  remark;  indeed, 
as  separate  and  distinct  injuries  they  are  unknown,  though  any  of  the 
smaller  tarsal  hones  may  be  implicated  in  severe  crushes. 

Fractures  of  the  metatarsal  bones  and  phalanges  require  only  rest, 
when  simple.  When  compound  the  question  of  amputation  is  regulated 
mainly  by  the  amount  of  the  accompanying  laceration. 

Dislocation  of  the  Hip. — The  dislocations  of  the  hip-joint  ai'e  usually 
described  now,  as  they  were  by  Sir  Astley  Cooper,  as  occurring  in  four 
chief  directions:  1.  Upwards  and  backwards  on  the  dorsum  ilii.  2. 
Backwards  into  the  sciatic  notch.  3.  Downwards  into  the  obturator  fora- 
men. And  4.  Inwards  on  to  the  pubes.  Other  dislocations,  called 
"anomalous."  are  met  with,  which  perhaps  would  be  better  styled  "un- 
common ; "  the  fact  seeming  to  be  (as  stated  by  Mr.  Bryant^)  that  "there 
is  good  reason  to  believe  that  the  head  of  the  thigh-bone  may  rest  at  any 
point  round  its  socket." 

The  following  are  the  features  of  the  common  dislocations  : 

1.  In  dislocation  on  to  the  dorsum  ilii  the  limb  is  considerably  short- 
ened, and  is  inverted,  so  that  the  knee  points  inwards  over  the  lower 
part  of  the  uninjured  thigh,  and  the  toes  rest  on  the  instep  of  the  sound 
foot.  The  trochanter  major  is  elevated,  lying  nearer  the  spine  of  the  ilium 
than  natural,  and  is  turned  outwards,  so  that  the  buttock  is  broader  and 
flatter  than  the  other;  the  head  of  the  bone  is  to  be  felt  on  the  dorsum, 
more  or  less  distinctly,  according  to  the  fatness  of  the  parts.  Voluntary 
movement  is  abolished,  and  passive  motion  (which,  it  should  be  observed, 
elicits  no  crepitus)  is  nearly  abolished  in  all  other  directions,  but  may  be 
effected  to  a  slight  extent  in  the  direction  where  the  displacement  points: 
i.  e.,  flexion,  adduction,  and  internal  rotation. 

The  diagnosis  of  this  injury  is  generally  very  easy — from  fracture  of 
the  neck  of  the  lemur  by  the  fixed  |)osition  of  the  limb,  the  absence  of 
crepitus,  and  the  position  of  the  bone  on  the  dorsum  ilii ;  from  disloca- 
tion the  result  of  disease  by  the  history  of  the  case  ;  and  from  the  other 
dislocations  by  the  symptoms  which  will  be  immediately  described. 

Redaction. — The  period  at  which  reduction  can  be  effected  was  fixed 
by  Sir  A.  Cooper  at  about  two  months — and  this  seems  to  be  true  in 
general — for,  though  dislocations  have  been  successfully  reduced  at  very 
long  periods  after  the  injury,"  it  must  always  be  doubtful  whether  more 

'  Bryant's  Practice  of  Surgery,  p.  802. 

2  Mr.  Erichsen  gives  references  to  several  cases  in  which  old  dislocations  have  been 
reduced.     The  longest  period,  however,  for  the  hip  is  seventy-eight  days. 


316 


INJURIES    OF    THE    LOWER    EXTREMITY. 


Fig.  130. 


harm  will  not  be  done  by  the  necessary  force  than  the  prospect  of  benefit 

from  the  rednction  of  the  bone  jnstifies.  This 
must  be  left  to  the  judgment  of  the  surgeon, 
founded  on  the  symi^toms  of  the  case  before 
him,  and  the  result  of  careful  examination  un- 
der antiestliesia.  But  it  may  be  observed  that 
the  attempt  is  far  more  hopeful  and  far  more 
justifiable,  now  that  auftsthetics  are  used,  than 
it  was  in  Cooper's  time.  'I'lie  obstacle  to  reduc- 
tion is  not  onl}'  that  the  head  of  the  bone  will 
probably  have  contracted  adhesions  to  the 
iicigliboring  parts — for  these  adhesions  will 
most  likely  yield  to  properly  applied  force — but 
that  the  shape  of  the  parts  may  have  changed, 
the  acetabulum  l»eing  more  or  less  filled  with 
inflammatory  deposit,  and  the  head  of  the  femur 
enlarged  by  inflammation,  and  resting  in  anew 
socket  which  it  has  worn  for  itself  on  the  dor- 
sum ilii.^  But  this  is  by  no  means  always  the 
case.  Thus,  Mr.  Brodhurst  says  that  he  has 
found  the  cotyloid  cavity  retaining  its  depth  and 
covered  with  cartilage  after  the  head  of  the  fe- 
mur had  been  dislocated  for  three  years,  and 
refers  to  a  case  in  whicii  Fournier  found  the  ace- 
tabular cavity  perfectly  natural  thirteen  years 
after  dislocation  ;  and  from  these  cases  he  in- 
fers that  the  altered  shape  of  the  head  can  never 
prevent  the  return  of  the  bone  into  the  articular 
cavit}".'  However,  I  cannot  but  believe  that  in- 
flammatory changes  do  sometimes  go  on,  both 
in  the  dislocated  head  and  in  and  around  the 
articular  cavit}^,  which  render  the  secure  reduc- 
tion of  the  joint  impossible  ;  and  tiiat  the  presence  or  absence  of  these 
changes  depends  in  a  great  measure  on  the  amount  of  motion  of  the  parts. 
There  has  been  a  great  change  in  recent  times  in  the  proceedings  for 
reducing  a  dislocation  of  the  hip.  Sir  Astley  Cooper,  who  was  the  great 
authority  on  this  subject,  taught  that  the  diHicultyin  reduction  depended 
mainly  on  the  resistance  of  tlie  muscles,  and  prescribed  that  this  resist- 
ance should  be  overcome  by  traction  exercised  very  much  in  the  line  of 
the  dislocated  femur.  The  patient  was  accordingly  to  be  laid  on  his  back 
and  the  limb  extended  by  i)ulling  the  knee  in  a  direction  crossing  the 
lower  third  of  the  opposite  tiiigli  ;  the  pulleys  being  generally  used  and 
a])plied  to  the  femur  just  above  the  condyles,  while  the  pelvis  was  fixed 
i»y  a  perineal  band  to  a  staple  behind  the  patient's  head.  But,  since  the 
use  of  chloroform,  dislocations  are  generally  reduced  without  any  such 
expenditure  of  force,  and  the  succe.'^s  of  the  "flexion  method"  lends  ad- 
ditional probal)ility  to  Bigelow's  opinion,  that  the  obstacle  to  reduction 
is  to  be  found,  not  in  the  muscles,  liut  in  the  resistance  of  the  librous 
capsule  of  the  joint,  and  mainly  of  tliat  excessively  strong  part  of  it  which 
is  usually  described  as  "  ilio-foinoral,''  and  which  he  describes  and  figures 


r)i.sloc;itioii  on  the  dorsuin  ilii. 


'  For  iin  example  of  the  enlari^i.-ment  of  a  dialocatod  bono,  and  the  new  socket 
formed  on  the  .'■urt'ace  upon  whidi  it  rest.'*,  see  the  head  of  the  radius  in  the  drawing 
of  old  dislocation  of  the  elbow,  Fiji.  It-,  p.  2H2. 

''  St.  Gi;urgc's  IIosp.  Reports,  vol.  iii,  p.  70. 


DISLOCATION    OF    THE    HIP. 


317 


as  the  "Y-ligament,"  the  fibres  bifurcating,  more  or  less  clearly,  below  at 
its  attachment  to  tlie  anterior  trociianteric  line,  so  as  to  resemble  tlie  let- 
ter Y  reversed.  That  the  ligament  sometimes  has  this  arrangement  is 
indisputable,  and  it  is  equally  indisputable  that  in  many  cases  (1  think  in 
the  great  majority)  no  such  disposition  of  the  fibres  can  be  shown  to  exist 
unless  made  by  the  dissector.  Nor  does  Bigelow  describe  it  as  a  con- 
stant structure.  His  words  are  :  ''  The  divergent  brandies  of  the  Y-liga- 
ment are  sometimes  well  developed,  with  scarcely  any  intervening  mem- 
brane. In  other  cases  the  intermediate  tissue  is  thicker,  and  requires  to 
be  slit  or  removed  before  the  bands  are  distinctly  defined  ;  and  sometimes 
the  whole  triangle  [?'.  e.,  the  wliole  ilio-fomoral  ligament]  is  of  nearly  uni- 
form thickness."  Anatomically,  therefore,  I  consider  the  descriptions  in 
the  ordinary  text-books  more  correct  than  one  would  be  which  should 
adopt  Bigelow's  description  of  the  occasional  disposition  of  this  ligament 
as  being  u"niversally  met  with.  But  this  is  a  matter  of  very  sliglit  mo- 
ment. What  is  really  important,  and  what,  I  tiiink,  is  perfectly  indubit- 
able, is  that  the  chief  symptoms  of  dislocation^  and  the  chief  obstacles 

Fig.  131. 


Reduction  of  dislocation  on  the  dorsum  ilii.    By  Sir  A.  Cooper's  method. 

to  its  reduction  are  caused,  not  by  tlie  muscles,  but  by  that  part  of  the 
capsule  of  the  joint  which  remains  untoru  ;  and  that  flexion  of  the  thigh 
by  relaxing  this  part  of  the  capsule  is  the  essence  of  success  in  reduc- 
tion. Anyone  can  convince  himself  of  this  who  will  take  the  trouble  to 
produce  these  dislocations  on  the  dead  sulyect.  He  will  then  see  that  in 
all  forms  of  dislocation  the  capsule  is  freely  torn  away  (tiiough  to  a  vari- 
able degree)  from  the  rest  of  the  acetabulum,  but  that  the  upper  and 
outer  part  of  the  capsule  and  the  ilio-femoral  ligament — representing  the 
two  branches  of  Bigelow's  Y-ligament — remain  untorn  ;  and  he  can  easily 
satisfy  himself  that  by  extending  the  limb  this  powerful  ligament  is  at 
once  put  on  the  stretch,  and  that  if  a  dislocation  be  reduced  by  force  ap- 
plied in  that  direction  it  can  only  be  at  the  expense  of  some  laceration 
of  the  untorn  part  of  the  capsule.  It  will  also  at  once  strike  the  experi- 
menter that  the  reduction  of  the  dislocation  must  be  most  easily  effected 
by  a  reversal  of  the  manipulation  by  which  it  can  be  produced.  This 
manipulation  is  carefully  described   in  Professor  Fabbri's  work'^  for  all 


1  The  inversion  is  clearly  caused  b}'  the  tension  of  this  powerful  ligament. 

*  Sulle  liizzazioni  traumatiche  del  femore.  In  the  '2d  vol.  of  the  Memorie  della 
vSoc.  Med.  Chip,  di  Bologna,  1841  It  is  much  to  be  regretted  that  this  work  is  so 
little  known  in  this  country,  never  having  been  translated  into  English. 


318  INJURIES    OF    THE     LOWER    EXTREMITY. 

the  usual  kinds  of  dislocation  of  the  hip.  That  on  the  dorsum  is  most 
easily  produced  as  follows  :  The  thick  fascia  lata  having  been  divided 
subcutaneously  by  a  transverse  incision  above  the  trochanter,  in  order  to 
render  it  easier  to  manipulate  the  limb,  the  thigh  is  to  be  forcibly  ab- 
ducted till  the  ligaments  are  heard  to  crack — i.  e.^  till  the  capsule  is  torn 
olf  the  inside  and  back  of  the  acetabulum.  Now  the  limb  is  flexed,  ro- 
tated violently  inwards,  and  driven  up  by  pushing  the  bent  knee  up- 
wards, and  so  the  head  of  the  bone  is  lodged  on  the  dorsum.  It  can  be 
brought  down  again  into  the  acetabulum  with  the  greatest  ease  b}'  rotating 
it  outwards  again  and  pulling  it  towards  thejoint. 

Assuming,  then,  that  it  is  mainly  the  tension  of  the  untorn  portion  of 
the  capsule  which  resists  the  reduction  of  the  head  of  the  bone,  and  that 
this  tension  is  lessened  by  the  flexed  and  increased  by  the  extended 
position  of  the  thigh,  the  ease  with  which  dislocation  of  the  hip  is  often 
reduced  under  chloroform  by  manipulation  is  readil}'  explained.  The 
necessary  manipulation  is  as  follows  :  The  patient  is  placed  on  his  back 
on  the  floor,  completely  antesthetized ;  the  surgeon  flexes  the  leg  on  the 
thigh,  and  the  thigh  completely  on  the  pelvis,  and  then  abducts  the  limb. 
All  this  is  easily  done  with  the  left  hand  ;  or,  if  the  limb  is  very  large, 
should  be  done  b}'^  an  assistant,  who  will  be  carefid  to  follow,  and  not 
impede,  the  surgeon's  movements.  Then  the  thigh  is  grasped  by  the 
knee,  and  powerful  rotation  made  outwards  ;  and  if  this  does  not  suc- 
ceed, inwards.^  Or,  the  thigh  being  flexed,  the  surgeon  may  put  his  foot 
(having,  of  course,  taken  his  boot  off)  on  the  pelvis,  and  lift  the  head  of 
the  bone  up  into  its  place  by  traction  on  the  bent  knee.  Bigelow  also 
describes  the  same  method,  but  reversed,  by  suspending  the  patient's 
knee  across  a  board,  and  with  the  buttocks  supported  a  few  inches  from 
the  floor.  The  surgeon  then  with  his  foot  thrusts  the  pelvis  down,  so 
bringing  the  acetabulum  down  to  the  femur.  If  manipulation  does  not 
succeed,  the  pulleys  must  be  employed;  but  it  seems  better  to  place  the 
patient  on  his  side  and  make  traction  on  the  bent  knee  (as  Sir  Astley 
recommends  in  the  sciatic  dislocation),  rather  than  by  direct  extension 
to  endanger  further  rupture  of  the  ilio-femoral  ligament. 

2.  Dislocation  of  the  head  of  the  femur  into  the  sciatic  notch,  or  dis- 
location backwards,  is  a  variety  of  the  dorsal  dislocation,  and  one  which, 
if  we  adopt  Bigelow's  views,  need  not  be  described  separately  from  it. 
It  is  distinguished  from  the  dislocation  on  the  dorsum  merely  by  the 
symptoms  being  less  marked  ;  there  is  less  shortening,  flexion,  and  in- 
version;-' the  knee  being  only  sliglitly  advanced,  and  the  great  toe  of  the 
affected  side  resting  on  the  ball  of  tiie  opposite  great  toe.  The  head  of  the 
bone  is  also  much  less  perceptible,  from  its  being  sunk  more  or  less  into 
tlie  notch,  and  from  the  mass  of  muscle  which  covers  it,  and  passive 
motion  is  almost  abolished,  except  in  the  sense  of  flexion,  in  consequence 
of  the  locking  in  of  the  head  of  the  femur. 

I  have  described  this  dislocation  according  to  the  accounts  left  by  the 
best  autliors,  and  which,  as  far  as  my  memory  serves,  corresi)ond  to  the 
phenomena  of  those  dislocations  which  I  have  seen  in  which  the  head  of 

*  "Flexion  lies  iit  tho  foundation  of  success  in  the  reduction  of  femoral  dislocation, 
and  compared  witli  this,  the  rest  of  the  manipulation  is  of  secondary  importance." — 
Bigelow,  p.  29. 

'^  Ther(;  are  other  cases,  however,  in  which  tlic  inversion  is  even  greater  tlian  in 
the  dorsal  dislocation. 


DISLOCATION    OF    THE    II I  P. 


319 


the  bone  has  been  thought  to  be  in  the  sciatic  notch.     At  the  same  time 
we  must  recollect  that   Professor  Bigelow 
has  asserted   that  there  is   no   proof  that  fig.  132. 

the  head  of  the  femur  was  really  lodged  or 
impacted  in  the  sciatic  notch  in  any  case; 
nor  am  I  aware  of  any  post-mortem  exam- 
ination which  absolutely  proves  that  the 
head  of  the  bone  was  driven  into,  or  im- 
pacted in,  the  sciatic  foramen.  In  the 
cases  referred  to  by  Mr.  Quain  (Med.-Chir. 
Ti'ans.,  vol.  xxxi),  as  dissected  immediately 
after  the  injury  by  himself  and  Beclard, 
tiie  head  of  the  bone  lay  rather  between 
the  two  notches — i.  t;.,  on  the  spine  of  tiie 
ischium — than  in  the  foramen.  In  Mr. 
Symes's  case  (quoted  by  Holthouse,  Syst.  of 
(S'wrgr.,  ii,  898)  the  head  of  the  bone  was 
imbedded  in  the  torn  fibres  of  the  gluteus 
maximus,  "lying  in  the  great  ischiatic 
notch  upon  the  gemelli  and  the  great  sacro- 
sciatic  nerve."  It  could  not,  therefore, 
have  been  impacted  in  the  foramen.  Nor 
in  experiments  on  the  dead  body  have 
I  ever  succeeded  in  driving  the  head  of 
the  bone  into  the  foramen,  though  it  may 
easily  be  lodged  anywhere  near  it;  and, 
in  fact,  the  entire  passage  of  the  head  of 
the  femur  into  the  sciatic  foramen  is  im- 
possible, from  their  relative  size.  That  Sir 
A.  Cooper's  description  does  not  apply  to 
all  dislocations  called  sciatic  is  plain  enough 
from  reading  the  cases  described  by  Quain, 

Wormald,  and  others  ;^  but  I  think  it  is  going  too  far  to  say  with  Bigelow 
that  the  dislocation  should  not  be  separately  described,  or  with  Malgaigne 
that  it  is  an  invention  of  Sir  Astley  Cooper.  Professor  Fabbri  has  de- 
scribed two  kinds  of  the  posterior  luxation — ^one  which  he  calls  "ischio- 
sciatic,"  in  which  tlie  head  of  the  bone  rests  just  behind  the  acetabulum, 
and  which  corresponds  to  Bigelow's  "dorsal  dislocation  below  the  tendon 
of  the  obturator  internus,"  both  in  the  position  of  the  neck  with  regard 
to  that  tendon  and  in  the  great  inversion  of  the  limb  ;  while  in  the  other 
kind,  which  he  calls  "sacro-sciatic,"  the  head  of  the  bone  is  carried 
ful'ther  back,  so  as  to  lie  on  the  sciatic  notch.  It  is  far  less  perceptible 
from  the  surface  of  the  body,  and  all  the  characters  of  the  injury  cor- 
respond exactly  to  those  described  by  Cooper.  The  experiments  by 
which  these  two  forms  of  dislocation  may  be  produced  at  will  on  the 
dead  subject  are  minutely  described  in  Fabbri's  work. 

The  method  of  reduction  is  very  much  the  same  as  in  the  dorsal  dis- 
location.    Sir  A.  Cooper  directs  that  the  patient  be  placed  on  his  sound 


Dislocation  into  the  sciatic  foramen. 


1  Mr.  Samuel  Lee  has  lately  related  an  interesting  case  of  dissection  ^f  a  recent 
dislocation  of  the  hip  backwards,  in  which  the  head  of  the  bone  was  situated  below 
the  pyriformis  muscle  and  immediately  behind  the  acetabulum.  Here  the  capsule  of 
the  joint  was  freely  lacerated  all  round,  a  small  portion  only  remaining  attached  to 
the  femur  in  front  and  behind,  and  "  in  manipulation  it  was  found,"  says  Mr.  Lee, 
"  that  the  muscles  were  the  main  obstacles  to  reduction." — St.  George's  Hospital  Re- 
ports, vol.  vii,  p.  169. 


320 


INJURIES    OF    THE    LOWER    EXTREMITY. 


side  and  the  limb  drawn  across  the  opposite  thigh — i.e.,  somewhat  flexed 
— in  order  to  disengage  the  head  of  the  bone  from  the  notch  ;  and  if  the 
tlexion  be  a  little  more  than   Sir  Astley  figures,  the  method  will  in  all 


Fig.  133. 


KeduL-tiou  of  dislocation  into  the  sciatic  notch  by  Sir  A.  Coopers  metliod. 

probability  succeed.     Pulleys,    however,  are  usually   unnecessary,  since 
the  bone  can  be  reduced  by  manipulation  quite  easily,  in  the  same  way 


Fio.  134. 


Fig.  135. 


Fio.  134.— This  figure  shows  the  head  of  the  bone  in  its  socket,  with  the  obturator  tendon  in  its 
natural  position  behind  it.  The  part  of  the  capsule  which  lies  beneath  the  tendon  and  behind  the 
Y-ligamcnt  has  been  slit,  both  to  demonstrate  its  thickness  and  to  allow  the  head  of  the  bone  to  rise 
as  high  as  the  ischiatic  notch. — After  Bigelow. 

Fig.  135.— This  figure  shows  the  head  of  the  bone  dislocated  below  the  tendon  into  the  neighborhood 
of  the  sciatic  notch.  If  the  tendon  were  not  present,  the  capsule  would  produce  much  the  sameed'ect 
in  binding  the  head  of  the  bone  close  upon  the  ilium  without  the  interposition  of  the  muscle. — After 
Bigelow. 

as  the  ordinary  dorsal  dislocation.'     Indeed,  the  only  difference  which 
Professor  Bigelow  recognizes  between   the  two  dislocations   is,  that  he 

'  See  a  case  by  Mr.  Wormald  in  which  thp  diffloc.ttion  was  reduced  by  flexion  six 
weeks  after  the  accident,  when  pulleys  had  been  used  in  vain. — Med.  Times,  August 
16,  1866. 


DISLOCATION    OF    HIP. 


321 


believes  the  head  of  the  bone  to  have  escaped  from  the  cavity  of  the 
joint  below  the  tendon  of  the  obturator  internus  in  the  sciatic  disloca- 
tion, while  in  the  other  it  has  passed  out  either  above  or  througli  the 
rotator  muscles.  But  although  the  rent  in  the  capsule  may  be  below  the 
obturator  tendon,  the  head  of  the  bone,  according  to  this  author,  rests 
usually  upon  (i.e.,  behind)  the  tendon.  And  he  denies  that  any  disloca- 
tion of  the  hip  really  exists  which  deserves  the  name  of  a  dislocation 
into  the  sciatic  notch,  or  that  that  notch  ever  causes  the  difficulty  in 
reducing  the  dislocation.  The  obstacle  to  reduction  he  places  in  tiie 
resistance  of  the  Y-shaped  ligament  and  the  tension  of  the  obturator 
internus  muscle,  whicii  is  now  placed  in  front  of  instead  of  behind  the 
head  of  the  bone,  and  is  therefore  interposed  between  it  and  the  ace- 
tabulum. The  same  manipulation  as  is  used  in  the  common  dorsal  dis- 
location will  relax  and  overcome  these  obstacles.  The  Y-ligament  being 
relaxed  by  flexing  the  thigh  to  a  right  angle,  tlie  same  manoeuvre  draws 
the  head  of  the  bone  down  below  the  tendon  towards  the  rent  in  the 
capsule  by  whicli  it  escaped,  when  the  depression  of  the  pelvis  or  the 
lifting  of  tiie  thigh  will  probably  reduce  it ;  or  it  can  be  slipped  into  the 
socket  by  rotation  outwards. 

Fig.  136.  Fig.  137. 


Fig.  136  — Dislocatii)n  into  the  obturator  foramen. 

Fig.  137.— Reduction  of  tlie  obturator  dislocation,  after  Sir  A.  Cooper's  method. 

A  glance  at  Fig.  13.5,  and  at  Figs.  138  and  139,  will,  I  hope,  make 
the  theory  of  reduction  by  flexion  intelligible  to  the  student,  so  far 
at  least  as  it  is  admitted  by  surgeons.     In  the  dorsal  dislocations  the 

21 


322 


INJURIES    OF    THE    LOWER    EXTREMITY 


head  of  the  bone  lies  behind  the  Y-ligament  (adoi)ting  Bigelow's  terms) 
and  above  the  acetabulum.  Flexion  relaxes  the  ligament  and  also  the 
tendons  (obturator  internus  and  others)  which  are  on  the  stretch,  and 
then  rotation  outward  with  abduction  draws  the  head  of  the  bone  down 
towards  the  socket.  In  the  dislocations  below  the  Y-ligament,  on  the 
other  hand,  the  head  of  the  bone,  being  below  the  socket,  is  most  easily 
directed  into  it  by  rotation  inwards. 

3.  Dislocation  downwards  or  on  to  the  obturator  (thyroid)  foramen  is 
a  much  less  common  accident  than  those  above  described.  It  is  a  well- 
marked  injury,  differing  from  all  the  other  lesions  about  the  hip-joint  in 
the  fact  tiiat  the  limb  is  really  lengthened,'  so  that  the  patient  cannot 
stand  up  straight,  but  must  bend  the  i)ody  forward  ;  and  as  the  thigh  is 
also  flexed,  he  only  touches  the  ground  with  the  point  of  the  foot,  which 
is  usually  directed  pretty  straight  forwards,  though  sometimes  it  is 
everted.  The  limb  is  also  abducted.  The  trochanter  is  less  prominent 
than  natural,  and  the  fold  of  the  buttock  lower. 

The  only  method  of  reduction  which  I  have  ever  seen  used  in  this  dis- 
location has  been  that  which  is  shown  in  Sir  A.  Cooper's  plates.     A  band 


Rwlucfion  of  thyroid  dislocation  liy  rotating  and  tircumducting  the  flexed  thigh  luwards. 

After  HiL'eldw. 


is  passed  round  the  perineum,  and  is  hilclied  under  the  belt  which  steadies 
the  pelvis.  The  latter  encircles  the  two  iliac  spines,  and  is  fixed  into  a 
staple  in  the  wall  on  the  patient's  sound  side.  The  perineal  band  is  at- 
tached to  the  i)ulleys  on  the  patient's  sound  side  and  somew'nat  behind 
his  head,  so  that  extension  draws  the  head  of  the  femur  upwards  and  out- 
wards, i.e.,  towards  tiie  acetabidiim.  The  surgeon  grasps  the  foot  and 
draws  it  across  the  middle  line  of  the  body — thus  prizing  the  head  of  the 
bone  in  the  same  direction — and  reduction  is  then  in  most  cases  easy. 


'    III  tlie  <urly  ^tiigos  of  hip  digeuse  tlie  limb  apj^eara  to   be   lengthened,  but  this 
appearance  is  deceptive. 


DISLOCATION    OF     HIP. 


323 


The  mech.mlsm  (  I  tli  ni  in  Bin  re  shown  in  the 
previous  figure  is  here  seen.  The  inner  branch 
of  tlie  Y-liganient  being  wound  round  the  ni'ck, 
the  head  must  rise  towards  the  socket  as  the 
fenuir  is  depressed  inwards.    After  Bigelow. 


Fig.  140. 


The  flexion  method  consists  in  the  following  manipnlation  :  The  patient 
being  laid  on  the  floor,  the  hip  is  flexed  to  a  right  angle,  so  as  to  relax  the 
Y-ligament,   and    the  knee    is   bent 

acutely,  to  give  a  purchase  lor  the  fk;.  139. 

surgeon's  hands.  The  limb  is  a 
little  abducted,  to  disengage  the 
head  of  the  femur;  then  the  thigli 
is  rotated  strongly'  inwards  and  ad- 
ducted,  the  knee  being  carried  down 
to  the  floor.  The  effect  of  this  ma- 
noeuvre is  thus  described  by  ]?ige- 
low :  "  The  trochanter  is  fixed  b}^ 
the  Y-ligament  and  the  obturator 
muscle,  which  serve  as  a  fulcrum. 
While  these  are  wound  up  and 
shortened  b}'  rotation  the  descend- 
ing knee  pries  the  head  upward  and 
outward  to  the  socket."  But,  ac- 
cording to  the  samfe  author,  rotation 
outward  will  also  succeed  in  some 
cases,  and  he  gives  an  instance  in 
which  the  dislocation  was  so  reduced 
after  the  inward  rotation  had  failed. 

This  dislocation  may  also  be  re- 
duced by  flexing  the  limb  and  drawing  the  head  of  the  bone  outwards 
by  means  of  a  towel  passed  round  the  upper 
part  of  the  thigh,  or  by  placing  the  patient 
with  a  post  between  his  legs  (the  bedpost 
is  generally  used)  and  prizing  the  head  out- 
wards by  crossing  the  foot  inwards.  Or  the 
limb  may  be  flexed  upwards  and  outwards, 
and  the  head  of  the  bone  dragged  or  jerked 
directly  towards  the  socket. 

Bigelow  agrees  with  Sir  A.  Cooper  in 
stating  that  in  the  manipulation  of  reduction 
the  obturator  may  be  converted  into  a  sci- 
atic dislocation,  but  he  does  not  seem  to  sec 
any  disadvantage  in  this.  In  fact,  regarding 
the  dorsal  dislocation  (of  which  the  sciatic  is 
a  variety)  as  one  eas,y  to  reduce,  he  recom- 
mends that  in  case  of  difficulty  in  reducing 
the  obturator  dislocation  it  should  be  con- 
verted into  a  dorsal,  and  then  reduced  as 
above. 

Bigelow  also  describes  several  other  meth- 
ods of  reducing  this  dislocation,  which  1 
think  it  unnecessary  to  quote.  From  the 
ease  with  which  the  few  cases  of  obturator 
dislocation  that  I  have  seen  have  been  re- 
duced by  Cooper's  method,  I  slK)uld  be  my- 
self disposed  to  have  recourse  to  it  when 
moderate  attempts  by  manipulation  in  the 
various  wajs  above  described  had  failed. 

4.  Dislocation  on  the  Pubei^. — The  last  of 

the    four    regular    dislocations    of  the    hip    is  Dislocations  on  the  pubes. 


324  INJURIES    OF    THK    T.OWER     EXTREMITY. 

that  upon  the  pubes,  which,  however,  is  not  a  common  accident.  I  can 
only  remember  seeing  one  instance  of  it ;  and  Bigelow,  whose  experience 
of  these  accidents  appears  to  have  been  hirge,  says  he  had  never  met  with 
it  in  the  living  body. 

It  seems  that  the  head  of  the  bone  ma}'  lie  either  in  front  of  (and  more 
or  less  upon )  the  horizontal  ramus  of  the  pubes,  or  on  the  ilium  below  the 
anterior  inferior  spine  ;'  and  the  further  inwards  the  head  of  the  bone  has 
been  thrown  the  further  outwards  must  the  lower  part  of  the  limb  be 
turned.  The  main  features  of  this  dislocation  are  the  eversion  of  the  foot, 
with  slight  shortening,  and  more  or  less  abduction.  The  head  of  the  bone 
being  very  readily  felt  will  prevent  any  possibility  of  confounding  this  in- 
jur}'  with  fracture  of  the  neck  of  the  femur.  In  reference  to  the  Y-ligament, 
the  dislocation  would  be  described  as  above  the  ligament,  and  Bigelow 
believes  that  the  eversion,  which  is  so  prominent  a  symptom  in  this 
injury,  is  produced  partly  by  the  tension  of  the  obturator  internus 
muscle,  but  mainl}^  In-  that  of  the  ligament,  which  embraces  the  neck  of 
the  bone. 

The  method  of  Sir  A.  Cooper  consists  in  drawing  the  dislocated  limb 
down  in  hyper-extension,  so  as  to  disengage  it  from  the  pelvis,  and  then 
by  passing  a  towel  under  the  upper  part  of  the  femur  the  head  of  the 


Reduction  of  dislocation  on  the  pubes  l)y  Sir  A.  hooper's  method. 

bone  is  directed  towards  the  acetabulum  and  lifted  over  its  edge,  the 
liml)  being  rotated  inwards  at  the  same  time,  if  necessar}'^,  b}'  grasping 
the  knee  and  ankle. 

The  flexion  metho'l  is  also  very  successful.  Under  chloroform  the 
difficulty  in  flexing  the  thigii  will  be  overcome  by  drawing  the  bone 
downwards,  then  it  is  to  be  rotated  inwards  or  outwards,  and  directed 


•  The  render  may  bo  referred  to  an  interestinj;  pHper  by  Mr.  Cad2;e,  of  Norwich, 
in  the  38th  vol  of  the  Med.-Chir.  Trans.,  wliich  contains  a  very  cl<'ar  description 
and  a  representation  of  the  dissccition  of  a  case,  rend(!r(Kl  doubly  important  by  the 
fact  that  its  symptoms  are  rrlatcid  during:!;  life  by  the  younger  Travi-r.s  (in  the  20th 
vol.  of  the  same  series),  and  that  it  is  quoted  in  one  of  the  editions  of  Sir  A.  Cooper's 
great  work  (5th  ed  ,  p.  95)  as  an  instance  of  dislocation  on  the  pubes.  The  head  of 
the  bone  laj-,  howevfM-,  really  not  on  the  pubes,  but  on  the  ilium,  occupying  the  in- 
tiiTvn\  between  its  two  anterior  spinous  processes ;  and  Mr.  Cadge  r(ffers  to  four  other 
cases,  two  of  them  veiitled  by  dissection,  wher(!  the  liead  of  the  bone  was  in  this  po- 
sition ;  and  on  account  of  this  frequent  inaccuracy  (spi-aking  strictly)  of  the  ordi- 
nary nomenclature,  Mr.  Cadge;  would  substitute  the  term  "dislocation  under  the 
crural  arch,"  or  "  upwards  and  forwards,'  which  would  no  doubt  be  more  correct. 


DISLOCATIONS    OF    KNEE.  325 

towards  its  place  by  slight  rocking  movements;  or  manipulation  differ- 
ing only  slightly  from  tiiat  employed  in  the  obturator  dislocation  may  be 
used,  which  Professor  Pirrie'  (who  has  had  two  successful  cases)  thus 
describes  :  "  Flex  the  thigh  on  the  abdomen,  adduct,  rotate  inwards,  and 
bring  down  the  knee."  Or  the  dislocation  may  be  treated  by  extension 
of  the  thigh,  with  counter-extension  by  the  heel  in  the  perineum,  as  in 
dislocation  of  the  humerus;  and  during  this  manoeuvre  Bigelow  recom- 
mends to  bring  the  patient  into  a  sitting  posture,  press  the  foot  against 
the  pubes,  and  rotate  inwards. 

Unuaual  Dislocations. — The  anomalous  dislocations  of  the  hip  on  record 
have  by  this  time  become  tolerabl3'  numerous.  I  am  not  sure  tliat  a  de- 
scription of  them  would  be  worth  the  space  required.  The  one  which  is 
of  most  consequence  is  that  variety  of  the  dorsal  dislocation  in  which  the 
limb  is  everted,  called  in  Italy  "  Monteggia's  dislocation,"-  in  which  the 
affected  limb  is  crossed  more  or  less  over  the  other  and  rotated  consid- 
erably outwards — the  head  of  the  bone  lies  near  the  anterior  superior 
spine  of  the  ilium,  and  the  trochanter  is  very  prominent.  The  chief 
element  in  the  production  of  this  dislocation  is,  as  Fabbri  has  shown, 
violent  rotation  of  the  flexed  thigh  outwards  ;  and  it  can  be  reduced  by 
a  manoeuvre  not  very  dissimilar  to  the  reduction  of  the  dorsal  dislocation. 
The  limb  is  to  be  moderately  flexed,  slight  movements  of  internal  rotation 
and  "  wagging"  movements  are  to  be  given  to  it,  and,  if  necessary,  the 
head  of  the  bone  is  at  the  same  time  to  be  directed  by  pressure  towards 
the  acetabulum. 

Other  anomalous  dislocations  are  those  downwards,  in  which  the  head 
of  the  bone  has  passed  beyond  the  obturator  foramen  into  or  near  to  the 
lesser  sciatic  notch, ^  bac/civards  and  downwards,'*  where  it  is  lodged  be- 
tween the  spine  of  the  ischium  and  the  acetabulum  ;  and  finall}'  that  in 
which  the  head  of  the  bone  is  thrown  forwards  into  the  perineum. 

Some  amount  of  fracture  of  the  acetabulum  tolerably  often,  as  it  seems, 
complicates  dislocation.  I  have  already  remarked  on  the  point  (p.  243), 
and  need  only  add  that  the  realit}'  of  the  injury  was  proved  by  dissection 
in  Mr.  Quain's  case,  as  well  as  by  almost  unmistakable  symptoms  in 
many  others  which  have  not  been  dissected. 

Traumatic  dislocations  of  the  knee  are  as  rare  as  pathological  disloca- 
tions are  common — a  surprising  testimony  to  the  efHcacy  of  the  mechanism 
of  the  joint,  since  the  articular  surfaces  are  so  flat  and  so  little  adapted  in 
shape  to  each  other  that  we  should  have  expected  them  to  have  been 
easily  displaced ;  but  the  firm  capsule,  the  great  tendon  in  front  of  the 
joint,  the  powerful  crucial  ligaments,  and  the  strong  muscles  ai'ound  hold 
these  large  flat  surfaces  so  securely  together  that  we  very  seldom  see  even 
partial  dislocation,  and  complete  dislocations  are  amongst  the  rarest 
accidents  in  surgery'. 

The  usual  dislocation  is  a  partial  dislocation  laterally,  the  internal 
articular  surface  of  the  tibia  being  thrown  on  to  the  external  condyle  of 
the  femur,  or  vice  versa.  The  alteration  in  tlie  shape  of  the  limb  and  in 
the  axis  of  its  two  parts  is  so  characteristic  that  the  injury  can  hardly  be 
mistaken,  though,  as  Mr.  Holthouse  has  pointed  out,  a  separation  of  the 
lower  epiphysis  of  the  femur  may  at  first  sight  present  some  resemblance 


'  Principles  and  Practice  of  Sura^ery,  3d  ed  ,  p   425.     Abduction  in  this  form  of 
dislocation  would  rather  tend  to  increase  the  tension  of  the  ligament. 

2  Fabbri,  op.  cit.,  p.  609.     Bigelow,  p.  92.     Holthouse,  in  Syst.  of  Surg.,  p.  905. 

3  Luke.  Med.  Times  and  Gaz  ,  June  2,  1858. 
••  Adams,  Path.  Trans.,  vol.  xxi,  p.  305. 


326  INJURIES    OF    THE    LOWER    EXTREMITY, 

to  this  dislocation.  The  dislocations  of  the  tibia  forwards  or  backwards 
are  sometimes  complete  ;  and  in  such  cases,  particularly  when  the  tibia 
is  carried  forwards,  the  popliteal  vessels  may  be  so  stretclied  by  the  pro- 
jection in  the  ham  that  gangrene  may  ensue.  The  nature  of  the  injury 
is  obvious. 

Reduction  in  all  these  injuries  is  generally  easy,  for  they  are  necessarily 
accompanied  by  great  laceration  of  the  neigliboring  structures.  If  the 
skin  is  also  torn,  so  that  the  dislocation  is  compound,  amputation  will  be 
the  safest  course  under  ordinary  circumstances,  though  in  young  subjects 
and  in  the  simpler  cases  the  surgeon  may  justifiably  make  an  attempt  to 
preserve  the  limb. 

Dislocation  of  the  Pafella.—The  patella  may  be  dislocated  on  to  either 
condyle  of  the  femur,  an  accident  which  usually  occurs  from  a  blow  on 
the  part,  as  from  a  fall  on  the  edge  of  the  bone,  but  sometimes  from 
muscular  action  only.  The  patella  is  more  commonly  thrown  on  to  the 
outer  than  the  inner  condyle  ;  in  fact,  it  is  believed  that  the  dislocation 
inwards  is  only  possible  in  persons  whose  ligaments  have  been  previously 
relaxed.'  The  symptoms,  when  the  dislocation  is  complete,  are  charac- 
teristic ;  "the  articular  surface  of  the  patella  rests  on  the  outer  side  of 
the  condyle,  with  its  inner  margin  directed  forwards;  the  breadth  of  the 
knee  is  increased,  tlie  limb  is  slightly  flexed  and  fixed,  and  any  attempt 
to  move  it  from  this  position  causes  great  pain."  If  the  dislocation  be 
Incomplete — i.  e.,  if  any  portion  of  the  articular  surface  of  the  patella 
remains  in  contact  with  the  trochlear  surface  of  the  femur — the  symptoms 
are  less  marked,  though  similar. 

In  order  to  reduce  the  dislocation  the  quadriceps  muscle  must  be  relaxed 
by  flexing  the  thigh  on  tlie  pelvis,  the  body  being  at  the  same  time  bent 
forwards.  Then,  if  the  raised  edge  of  the  patella  be  depressed,  the  bone 
will  lie  disengaged,  and  the  musclesyvill  restore  it  to  the  natural  position. 
The  limb  should  be  placed  on  a  splint  for  two  or  three  weeks. 

Sometimes  the  patella  is  dislocated  edgewa3's.  either  its  outer  or  inner 
edge  being  buried  between  the  condyles  (usually  the  former,  according 
to  Malgaigne).  It  is  the  result  of  direct  violence,  and  in  some  cases  much 
difficulty  has  been  found  in  reducing  it,  or  it  has  actually  remained  irre- 
ducible, in  consequence  of  some  interlocking  of  the  edge  of  the  bone 
which  is  impacted  in  the  intercondyloid  notch. 

In  some  cases  the  usual  method  of  reduction  will  at  once  succeed.  If 
not,  chloroform  should  be  given  and  the  knee  flexed,  as  in  Mr.  Flower's 
case,  related  by  Mr.  Holthouse.'^  The  division  of  tlie  ligamentum  patellre 
has  even  been  resorted  to  unsuccessfull}' ;  and  in  cases  of  extreme  diffi- 
culty it  might  be  worth  while  to  divide  any  fibres  of  this  ligament,  or  of 
the  capsule,  which  can  l)e  felt  on  the  stretch  ;  but  if  the  bone  be  then  irre- 
ducible  it  would  be  better  to  leave  it  alone  for  a  time,  and  if  the  joint  is 
aftervvards  the  seat  of  inflammation  or  of  much  pain,  to  remove  it  either 
by  excision  or  amjjutation. 

The  term  "dislocation  of  the  patella  upwards"  is  applied  to  cases  in 
which  the  ligamentum  patellae  has  been  torn  and  the  lateral  attachments 


'  See  Hulthouse,  in  Syst.  of  Surjs;  ,  vol.  ii,  p.  913. 

■•^  In  this  ciise  tho  patolhi  was  twistfd  on  its  longitudinal  axis,  with  its  outer  edge 
projecting  forwards  under  tlie  skin,  and  its  inner  edge  buried  between  the  condyles 
of  the  femur  and  the  head  of  the  tibia.  Tin?  limb  was  extended,  and  all  attempts  at 
reduction  by  bending  the  knee,  manipulating  the  jiatella,  etc.,  produced  great  pain, 
and  were  unavailing  till  chloroform  was  given,  when,  on  bending  the  knee,  the  bono 
directly  slipped  back  into  its  }dace.     Sy^-t.  uf  Surg.,  vol.  li,  ji.  913. 


DISLOCATION     OF    FIBULA.  327 

of  the  patella  also  so  far  lacerated  as  to  permit  of  a  considerable  amount 
of  displacement  upwards.  The  hollow  presented  below  the  patella  by  the 
torn  ligament,  and  the  exposure  of  the  trochlear  surface  of  the  femur  be- 
neath the  skin,  mark  the  nature  of  the  injury.  The  treatment  is  the  same 
as  for  fracture  of  the  patella.  I  once  had  the  opportunity  of  watching  a 
case  for  some  time  in  which  tlie  patient  obtained  almost,  if  not  quite,  com- 
plete restoration  of  the  functions  of  the  limb. 

The  semilunar  cartilages  are  apt  to  be  partially  dislocated  from  the  head 
of  the  tibia  by  slight  injuries,  such  as  a  stumble,  or  even  by  catching  the 
toe  in  the  bedclothes,  when  their  attachments  have  been  previously 
stretched  by  inflammation  of  the  joint,  and  their  own  substance  enlarged 
so  as  to  increase  their  prominence.  The  symptoms  are  sudden  and  severe 
pain  in  the  joint,  which  remains  semiflexed  and  cannot  be  straightened, 
with  some  synovitis.  It  will  be  remarked  that  these  symptoms  close]}' 
resemble  those  of  loose  cartilage,  and  it  seems  certain  that  many  of  the 
cases  described  as  dislocation  of  the  semilunar  cartilages  were  cases  of 
loose  cartilage,  while  in  others  the  precise  nature  of  the  injury  is  doubt- 
ful ;  but  in  the  well-marked  cases  in  which  the  edge  of  the  interarticular 
cartilage  has  been  felt  projecting,  and  the  appropriate  manipulations  have 
at  once  restored  the  motion  of  the  joint  at  the  same  time  that  they 
reduced  the  projection,  there  is  no  reason  to  doubt  the  diagnosis,  though 
it  has  not  as  3et  been  established  by  dissection.  The  necessary  manipu- 
lation consists  in  completely  flexing  the  knee  on  the  thigh,  which  can  be 
done  gradually,  and  then  suddenly  extending  the  limb  fully.  As  this 
maj'  be  otherwise  impossible,  Mr.  S.  Smith,  of  Leeds,'  recommends  thai 
a  few  feints  be  first  made  by  extending  only  to  a  right  angle,  and  then, 
when  the  patient  is  off  his  guard,  to  perform  the  complete  extension.  If 
this  plan  does  not  succeed,  the  limb  may  be  bent  (under  chloroform,  if 
thought  desirable),  and  an  assistant  having  placed  his  arm  in  the  popliteal 
space,  to  serve  as  a  fulcrum,  the  tibia  may  be  drawn  downwards  as  far  a& 
possible  and  rotated  slightly.  At  the  same  time  pressure  may  be  made 
on  the  projecting  edge  of  the  cartilage  m  ith  the  thumbs.  If  tiie  reduction 
is  successful  the  patient,  who  could  not  move  his  limb  before,  can  at  once 
walk  naturally. 

Dislocation  of  the  head  of  the  fibula  is  illustrated  by  Boyer's  case,^  in 
which  the  whole  bone  was  driven  upwards  and  dislocated  at  the  upper 
tibio-fibular  joint  in  a  case  of  dislocation  of  the  ankle.  Generally,  how- 
ever, it  is  a  consequence  of  relaxation  of  the  ligaments.  If  met  with  as 
a  substantive  injury  the  biceps  is  to  be  relaxed  by  bending  the  knee,  and 
the  displaced  bone  forced  downwards.  A  compress  is  then  to  be  firmly 
adapted  to  the  head  of  the  bone  and  retained  there  by  strapping,  while 
the  knee  is  to  be  placed  on  a  splint  for  about  three  weeks. 

Dislocations  of  the  ankle  occur  in  four  different  directions — the  bones  of 
the  foot  being  displaced  outwards,  inwards,  backwards,  or  forwards,  in  the 
order  of  their  frequency.  The  only  one  which  is  at  all  common  is  the  dis- 
location of  the  foot  outwards,  which,  as  being  always  accompanied  by 
fracture  of  the  fibula  above  the  malleolus,  is  called  PotVs  fracture^  after 
the  surgeon  who  first  accurately  described  the  injury.  The  fibula  is  frac- 
tured nsually  about  two  inches  above  its  lower  end;  the  internal  malleo- 
lus is  prominent,  the  deltoid  ligament  being  ruptured  ;  the  astragalus  is 

1  In  an  interesting  paper  entitled   On  Internal   Derangement  of  the  Knee-joint. 
Lancet,  Sept.  20,  ISoL 
•i  Mai.  Chir.,  vol.  iii,  p  883. 


328 


INJURIES    OF    THE     LOWER    EXTREMITY. 


Fig.  14-J 


Pott's  fracture;  showing  the  projection  of  the  internal  malle- 
olus, the  displacement  of  the  foot  outwards,  and  the  depression 
at  the  point  of  fracture  of  the  fibula. 


separated  from  the  tibia,  and  the  sole  of  the  foot  everted.  Very  fre- 
quently, however  (in  fact,  I  think,  usually),  the  malleolus  of  the  tibia 
is  fractured  instead  of  the  ligament  being  ruptured,  so  that  the  injur}' 

does  not  correspond  ex- 
actly' to  Pott's  description. 
The  cause  of  the  accident 
is  almost  always  a  fall  on 
the  foot,  in  which  it  is 
twisted  outwards.  Reduc- 
tion is  usually  easy  by 
grasping  the  foot  and  draw- 
ing it  downwards  (the  gas- 
trocnemius having  been  re- 
laxed by  bending  the  knee 
and  extending  the  toes), 
and  then  manipulating  it 
into  position.  If  pain 
and  involuntary  action  of 
the  gastrocnemius  oppose 
this  manoeuvre  chloroform 
must  be  given. 

Much  has  been  written 
on  the  treatment  of  Pott's 
fracture.     I  confess  that  I 
have    never    seen    a    case 
which  required  any  other 
treatment    than    an    ordi- 
nary fracture  of  the  leg   does — i.  e.,  either    side-splints  or  pasteboard 
splints  for  about  six  weeks;  or,  if  the  swelling  and  inflammation  of  the 
joint  is  considerable,  treatment  with  the  part  exposed  in  a  fracture-box  at 

first;  but  cases  may  occur 
^'^-  '^^-  in  which  there  is  some  un- 

usual difficulty  in  keeping 
the  foot  at  right  angles  to 
the  leg,  and  with  the  sole 
level  (which  is  the  main 
point  in  the  treatment  of 
this  injury),  and  then  it 
may  be  necessary,  as  rec- 
ommended by  Pott,  to 
place  the  patient  on  his  in- 
jured side  with  the  limb 
flexed,  in  order  to  relax 
the  gastrocnemius  muscle, 
and  splints  applied,  reach- 
ing on  the  inner  side  no 
lower  than  the  ankle,  while 
on  the  outer  side  the  splint 
reaches  to  the  foot,  and 
may  be  padded,  so  as  to 
drive  the  foot  inwards. 
Diipiiytren  recommended  to  api)ly  to  the  inner  side  of  the  limb  a  thick  pad, 
to  press  on  the  tiljia,  so  as  to  force  it  outwards,  supported  by  a  long  splint 
projecting  below  the  inner  edge  of  the  foot,  to  which  the  foot  was  drawn 
l)y  a  bandage,  so  as  to  incline  the  sole  inwards  as  far  as  seemed  necessary. 


The  skeleton  of  the  foot  and  leg  in  a  case  of  Pott'.s  fracture,  in 
which  the  internal  malleolus  is  not  injured.     After  Pirric 


DISLOCATIONS    OF    ANKLE. 


329 


The  patient  was  to  be  allowed  to  leave  his  bed  in  three  or  four  weeks.* 

The  dislocation  inwards  is  also  often  accompanied  by  fracture  of  the 
tibia  and  possibly  of  the  fibula  also.  It  in  caused  by  a  twist  of  the  foot 
in  the  opposite  direction,  and  requires 

merely  the  same  treatment  as  fracture  i'"'"-  i44. 

of  the  \eg,  after  tlie  parts  have  been 
carefully  reduced,  for  wliich  purpose 
chloroform  is  to  be  o;iven  if  necessary. 

Dislocation  of  the  foot  backwards 
occurs  occasionally  as  the  consequence 
of  a  violent  shock  on  the  forepart  of 
the  foot,  or  a  fall  backwards  with  the 
foot  in  a  hole,  and,  like  other  disloca- 
tions of  the  foot,  is  often  complicated 
witii  fracture  of  the  malleoli.  The 
accident  is  easily  recognized  by  the 
shortening  of  the  dorsum  of  the  foot 
and  the  relative  positions  of  the  leg 
and  heel  on  the  two  sides.  The  toes 
are  generally  pointed  downwards.  Re- 
duction is  generally  easy,  but  the 
tendo  Achillis,  according  to  Mr.  Bry- 
ant, sometimes  requires  division  before 
the  parts  can  be  kept  in  position.^ 

The  opposite  dislocation — that  of 
the  foot  forward — is  still  more  rare. 
The  heel  is,  of  course,  shortened  more 
or  less  as  the  dislocation  is  more  or 
less  complete.  It  is  distinguished 
from  fracture  low  down,  with  displace- 
ment, by  tlie  position  of  the  malleoli,  which  would,  of  course,  be  carried 
away  with  the  foot  in  fracture,  and,  therefore,  retain  their  natural  rela- 
tion to  the  heel;  while  in  dislocation  they  would  be  nearer  to  the  heel 
than  natural.  Reduction  has  often  been  found  impossible,  but  the  section 
of  the  tendo  Achillis  has  been  known  to  facilitate  it.' 

Compound  Dislocations. — When  these  dislocations  are  compound,  am- 
putation used  to  be  considered  necessary,  till  Sir  A.  Cooper  showed  that 
this  was  not  always  the  case.  It  remains  true,  however,  that  it  is  very 
frequently  the  safest  course,  though  in  young  healthy  persons,  where  the 
vessels  have  escaped  damage  and  there  are  no  other  serious  complications, 
the  limb  and  the  joint  may  ofted  be  saved.  Anchylosis  will  ensue,  but 
the  increased  mobility  of  the  transverse  tarsal  joint  will  in  a  great  measure 
compensate  for  this.  In  other  cases,  where  there  is  much  comminution, 
the  surgeon  may  remove  the  loosened  portions  of  bone,  or  even  excise 
the  whole  joint.*  When  the  limb  is  to  be  saved  the  wound  must  be  ex- 
amined and  cleansed,  and  then  carefully  closed  with  equable  and  gentle 
pressure.  Suppuration  should  be  watched  for,  and  the  matter  evacuated 
as  earl}'  as  possible,  and  such  general  treatment  adopted  as  the  pain 

'  De  la  Fracture  de  I'Extremite  inf^rieure  du  Perone.     Le90iis  Orales. 

''  Bryant's  Surgery,  p.  813.     Cock,  in  Guy's  Hosp.  Reports,  1855. 

3  Poland,  Guy's  Hosp.  Reports,  1855. 

*  See  a  successful  case  of  primary  excision  of  the  ankle  by  Mr.  H.  Lee,  in  Med.- 
Chir.  Trans.,  vol.  Ivii,  p.  137.  Since  the  publication  of  that  case  Mr.  Lee  has  per- 
formed another  similar  operation  at  St.  George's  Hospital. 


Dislocation  of  the  foot  inwards.    After  Pirrie. 


330 


INJURIES    OF    THE    LOWER    EXTREMITY. 


or  fever   indicates, 
necessary. 


Secondary  amputation   not    unfrequently  becomes 


Fro.  145. 


Dislocation  of  the  astragalus,  by  which  is  meant  a  dislocation  of  that 
bone,  both  from  its  articulation  with  the  hones  of  the  leg  in  the  ankle- 
joint  and  from  those  with  the  os  calcis 
and  scaphoid,  in  the  tarsus,  is  a  very 
severe  and  dangerous  injury.  It  must 
not  be  confounded  with  tliat  which  forms 
the  subject  of  the  next  section,  viz.,  the 
dislocation  of  the  bones  of  the  foot  from 
the  astragalus,  the  subastragaloid  dislo- 
cation, in  which  the  ankle-joint  is  unaf- 
fected. The  diagnosis  rests  upon  the 
unnatural  relation  between  the  head  or 
other  projecting  part  of  the  displaced 
astragalus  and  either  of  the  malleoli 
which  may  be  perceptible.  In  the  sub- 
astragaloid dislocation,  though  tlie  head 
of  the  astragalus  is  unnaturally  promi- 
nent, it  retains  its  natural  distance  from 
the  malleoli ;  but  when  the  astragalus  is 
itself  dislocated,  in  whatever  direction  the 
dislocation  may  have  been,  this  measure- 
ment is,  of  course,  altered. 

The  directions  in  which  the  astragalus 
may  be  dislocated  are  forwards,  back- 
wards, and  to  either  side,  the  latter  being 
compound.  The  dislocation  forwards  is 
the  most  common  (Fig.  145).  The  head 
of  the  displaced  bone  forms  a  considera- 
ble promiuence  on  the  dorsum  of  the  foot 
far  in  front  of  its  normal  position  ;  one 
or  other  malleolus  is  usually  buried  in 
the  foot ;  the  movements  of  the  ankle- 
joint  are  abolished.  There  may  be  a 
wound  exposing  the  displaced  bone,  and  in  many  cases  a  fracture  co- 
exists with  the  dislocation,  so  that  strictly  only  a  portion  of  the  bone  is 
dislocated.  The  part  which  retains  its  natural  connections  is  generally 
the  articulating  surface  of  the  head. 

In  dislocation  of  the  astragalus  backwards  the  posterior  edge  of  the 
bone  presses  on  the  tendo  Achillis,  the  tibia  is  prominent  in  front,  and 
the  anterior  part  of  the  foot  appears  shortened.' 

The  lateral  dislocations  are  complicated  with  laceration  of  the  skin, 
and  often  with  fracture  of  the  malleolus,  though  instances  are  recorded 
in  which  the  malleoli  have  been  proved  to  be  entire. 

Simple  dislocations  of  the  astragalus  ought  to  be  reduced  when  that 
is  possible.  Chloroform  is  usually  required,  and  the  patient  should  be 
brought  fully  under  its  influence.  If  the  entire  bone  has  been  driven 
forwards  out  of  the  ankle-joint,  it  is  clear  that  the  contraction  of  the 
muscles  forming  the  tendo  Achillis  has  to  be  overcome  before  the  bones 
of  the  foot  can  be  drawn  away  from  the  tibia  and  fibula.  The  first  point, 
therefore,  is  to  endeavor  to  effect  this  by  bending  the  knee  and  exercising 


Partial  dislocation  of  the  astragalus  for- 
wards; the  posterior  part  of  the  bone  is 
still  in  contact  with  the  articular  surface 
of  the  tibia. 

a.  The  rounded  head  of  the  astragalus, 
projecting  on  the  dorsum  of  the  foot  about 
as  far  forward  as  the  root  of  the  great  toe. 

b.  The  external  malleolus,  which  re- 
mains in  position,  and  in  front  of  which 
is  seen  the  articular  facet  corresponding 
to  it  on  the  astragalus. — From  a  prepara- 
tion in  the  Museum  of  St.  George's  Hos- 
pital.   Ser.  i,  No.  212  a. 


B.  Pliilli|p8,  in  Med.  Gazetto  for  1834. 


DISLOCATION    OF    ASTRAGALUS.  331 

stead}'  traction  on  the  foot,  and  if  this  should  fail  and  the  tendon  is  felt 
firmly  contracted,  to  divide  it  siihcutaneously.  If  reduction  is  still  im- 
possible careful  search  should  he  made  for  the  anterior  tibial  tendon, 
which  sometimes  slips  round  the  displaced  head  of  the  bone  and  prevents 
its  reduction.  If  this  or  any  other  tendon  can  be  felt  on  the  stretch  it 
will  be  well  to  divide  them.  Finally,  on  the  failure  of  all  such  efforts, 
the  case  is  to  be  left  alone.  Instances  have  occurred  in  which  all  has 
gone  on  well,  union  has  taken  {)lace  between  the  displaced  astragalus  and 
the  parts  around  it,  and  the  patient  has  recovered  with  a  foot  lamed,  in- 
deed, but  quite  useful.  Usually,  however,  matters  do  not  go  on  so  kindly. 
Either  suppuration  sets  in  or  else  (with  or  without  suppuration  and  dif- 
fuse inflammation)  gangrene  comes  on.  In  the  latter  case  amputation 
should  be  at  once  performed  as  low  down  as  is  consistent  with  dividing 
healthy  parts.  In  cases  of  suppuration  unaccompanied  by  gangrene,  in 
healthy  youthful  subjects,  the  bone  should  be  excised,  and  even  in  those 
more  advanced  in  life  the  same  course  is  perfectly  defensible.  A  free 
incision  should  be  made  so  as  to  avoid  the  anterior  tibial  artery,  the  bone 
should  be  denuded  sufficiently  to  afford  a  firm  grasp  for  the  lion-forceps, 
b}'  means  of  which  it  should  he  twisted  out  of  its  bed,  any  remaining  at- 
tachments being  divided,  and  care  being  taken  to  avoid  the  tendons, 
vessels,  and  nerves.  Recovery  is  marvellously  complete  after  this  opera- 
tion. I  have  seen  patients  who  were  able  to  walk  almost  if  not  quite  as 
well  and  as  far  as  before  the  injury. 

In  cases  of  compound  dislocation  the  choice  generally  lies  between  ex- 
cision and  amputation,  the  surgeon  being  guided  by  the  anrount  of  con- 
comitant injury,  and  by  the  state  of  health  and  age  of  the  patient.  There 
are  even  cases  in  which  the  injury  to  the  surrounding  parts  is  slight  and 
the  patient's  condition  exceptionally  encouraging,  where  an  attempt  may 
be  made  to  reduce  the  bone  and  [)rocure  its  consolidation  with  the  parts 
around — in  which  case,  though  the  movements  of  the  ankle  will  be  abol- 
ished, the  foot  will  be  on  the  same  level  as  the  other.  Such  an  attempt 
to  save  the  bone  could,  however,  only  be  justifiable  in  the  most  favorable 
conditions  of  age  and  health.  As  a  general  rule  the  removal  of  the  dis- 
placed bone  is  indicated. 

Siibastragaloid  Dislocation. — The  rest  of  the  foot  is  sometimes  dislo- 
cated from  the  lower  surface  of  the  astragalus,  an  injury  which  was  at 
first  confounded  with  the  dislocation  of  the  astragalus  itself,  and  which 
certainly  bears  a  good  deal  of  resemblance  to  it,  both  in  its  symptoms 
and  treatment;  but  as  the  anatomy  of  the  injury  is  quite  different,  and 
thpre  are  some  important  points  of  difference  in  its  surgical  management, 
it  is  necessary  to  bear  the  difference  in  mind.  A  comparison  of  Figs. 
145  and  14fi  will  make  it  clear  to  the  reader  at  once.  In  the  former  the 
astragalus  has  been  driven  in  great  part  out  of  the  box  formed  for  it  by 
the  upper  articulations  of  the  ankle  above,  the  joint  surfaces  of  the  cal- 
caueum  below,  and  that  of  the  scaphoid  in  front.  In  the  latter,  on  the 
other  hand,  the  astragalus  retains  its  connection  with  the  bones  of  the 
leg,  the  ankle-joint  is  quite  intact,  and  the  injury  affects  only  the  astrag- 
alo-calcanean  and  astragalo-scaphoid  joints.  The  other  bones  of  the  foot 
are,  in  fact,  driven  off*  from  the  lower  surface  and  head  of  the  astragalus. 
Hence  the  term  "•  suhaxtragaloid  dislocation  " — i.  e.,  dislocation  of  the  os 
calcis  and  scaphoid  bones  from  the  astragalus — which  is  now  usually  ap- 
plied to  the  injury. 

The  main  diagnostic  sign,  as  explained  in  the  previous  section,  is  the 
natural  distance  between  the  head  of  the  astragalus  and  the  malleoli  or 


332 


INJURIES    OF    THE     LOWER     EXTREMITY. 


malleolus.     This  can  always  be  ascertained  ;  for,  though  one  malleolos' 

may  he  buried  in  the  soft  parts,  the  other  is  thereby  rendered  prominent.* 

The   foot   is   displaced  usually  inwards  or  outwards,  the   sole  being 

everted  in  the  former  and  the  external  malleolus  buried,  and  vice  versa 


Subastrasaloid  dislocation.  Mr.  Keate's  case,  described  by  Mr.  Pollock  in  Med.-Chir.  Trans.,  vol.  xlii, 
p.  40.  a.  Tendon  of  tibialis  anticus.  6.  The  head  of  the  astragalus  projecting  beyond  and  internal  to 
this  tendon,  which  is  lodged  in  the  neck  of  the  bone.  The  astragalus  is  still  in  its  natural  connection 
to  the  bones  of  the  leg.  Its  posterior  inferior  extremity  is  pressed  into  the  groove  on  the  upper  surface 
of  the  08  calcis.  There  is  nofracture  except  of  the  tip  of  the  external  malleolus,  which  still  retains 
its  ligamentous  connection  with  the  os  calcis.  The  tendons  are  seen  not  to  have  been  divided,  and  the 
dislocation  remained  unreduced.  Amputation  was  afterwards  required,  but  the  patient  died. — From 
a  preparation  in  St.  George's  Hospital  Museum.    Ser.  i.  No.  212. 

in  the  latter  form  of  dislocation.  In  the  dislocation  of  the  foot  outwards, 
the  tibial  tendons  being  displaced,  one  or  other  of  them  is  apt  to  slide 
behind  the  head  of  the  astragalus.  In  the  figure  it  is  the  tendon  of  the 
tibialis  anticus  which  thus  embraces  the  neck  of  the  bone  ;  in  other  cases 
it  has  been  that  of  the  tibialis  posticus,  while  a  case  is  on  record^  in 
which  reduction  could  not  be  etfected  until  both  these  tendons  had  been 
divided. 

Subastragaloid  dislocation  of  the  foot,  either  backwards  or  forwards, 
also  takes  place,  the  latter  much  more  rarel}^,  as  it  seems,  or  displacement 
anteriorly  or  posteriorly  is  combined  with  the  lateral  dislocation.  This 
was  so  in  the  case  which  furnished  our  illustration — the  bones  of  the  foot 
being  driven  so  far  backwards  that  the  projecting  head  of  the  astragalus 
rested  on  the  cuneiform  bones,  and  its  calcanean  facets  on  the  cup-shaped 
articulating  surface  of  the  scaphoid. 

The  treatment  of  this  injury  will  depend,  in  the  first  place,  on  the  pres- 
ence or  absence  of  laceration  of  the  skin,  or  of  extreme  contusion.  If  the 
injury  be  compound,  most  surgeons  hold  that  amputation  is  necessary. 
There  are,  however,  cases  in  which  an  attemjjt  to  preserve  the  part  may 
be  made,  such  cases  being  those  in  which  the  wound  is  a  tolerably  clean 
one,  the  soft  parts  little  injured,  and  the  patient  young  and  in  good  health. 
In  other  cases,  where  the  astragalus  is  much  exposed  or  somewhat  injured. 


'  In  a  case  quoted  by  Mr.  Pollock,  from  Sir  J.  Pnp;et'8  practice,  it  is  said :  "  There 

was  no  swpllincj  about  the  foot  or  ankle,  and  tho  nature  of  the  injury  was  as  evident 
as  it  would  have  been  in  a  skeleton.  Tho  astragalus  was  felt  in  its  normal  relation 
Ui  the  tibia  and  fibula." 

-  Quoted  by  Mr.  Pollock  in  Med.-Chir.  Trans.,  vol.  xlii,  p.  56. 


DISLOCATIONS    OF     FOOT.  333 

but  the  other  conditions  are  favorable,  it  is  right  to  excise  the  astragalus. 
■But  in  the  majority  of  compound  dislocations  the  better  course  appears 
to  be  to  remove  the  foot,  which  may  be  done  either  by  Syme's  or  Piro- 
goffs  method,  or  b}^  the  snbastragaloid  amputation,  if  the  projecting  bone 
be  uninjured. 

In  simple  and  other  dislocations,  when  the  surgeon  determines  to  reduce 
the  dislocation,  the  patient  should  be  thoroughly  narcotized,  the  knee  bent 
and  the  foot  extended,  so  as  to  relax  the  gastrocnemius  as  much  as  possi- 
ble, and  attempts  made  to  manipulate  the  parts  into  position.  This  will 
often  succeed,  especially  when  the  foot  is  dislocated  inwards  or  forwards. 
But  if  the  tendo  Achillis  is  much  stretclied,  and  all  attempts  at  reduction 
Increase  its  tension,  it  will  become  necessary  to  divide  it  subcutaneously, 
and  then  the  dislocation  inwards  will  probably  yield  to  the  manipulation. 
In  the  dislocation  outwards  the  tibial  tendons  should  next  be  divided,  if 
they  can  be  felt  on  the  stretch.  There  are,  perhaps,  cases  in  which  these 
tendons  may  require  division,  and  not  the  tendo  Achillis.  Finally,  on 
the  failure  of  these  measures  the  case  should  be  left  to  itself,  the  foot 
being  lightly  supported  on  a  splint,  and  cold  sedulously  applied  to  ward 
off  inflammation.  On  the  first  appearance  or  threatening  of  active  in- 
flammation excision  of  the  astragalus  should  be  performed,  otherwise 
amputation  may  become  necessary. 

Tamus,  Metatarsus^  and  Phalanges. — Dislocation  of  any  of  the  sepa- 
rate bones  of  the  tarsus  is  an  accident  of  doubtful  occurrence.  Such  ac- 
cidents have  been  described,  but  the  correctness  of  the  description  is 
still  uncertain,  except  that  the  internal  cuneiform,  it  seems  certain,  is 
sometimes  dislocated  along  with  the  first  metatarsal  bone.  Dislocations 
of  the  metatarsus  affect  either  single  bones,  two  or  more,  or  finally  the 
whole  metatarsus.  Dr.  R.  W.  Smith'  has  recorded  two  cases  in  which 
he  found  old  dislocations  of  the  metatarsus  upwards,  and  has  figured  and 
minutely  described  the  appearances  both  before  and  after  dissection;  and 
Dr.  Hitzig  has  collected  twenty-nine  cases  of  various  dislocations  of  the 
metatarsus,  in  sixteen  of  which  the  whole  metatarsus  was  dislocated,  viz., 
in  eleven  upwards,  in  one  downwards,  in  three  outwards,  and  in  one  in- 
wards. Thus  the  dislocation  upwards  is  seen  to  be  by  far  the  most  com- 
mon.^ These  injuries  are  usually  caused,  according  to  Professor  Smith, 
by  a  fall  or  leap  from  a  height,  but  may  also  be  produced  by  a  weight 
passing  over  the  foot.  The  symptoms  are  obvious ;  the  hinder  part  of 
the  foot  and  the  ankle  are  natural;  in  dislocations  of  single  bones  or  of 
part  of  the  metatarsus  the  toes  are  correspondingly  shortened,  and  the 
projection  of  the  displaced  bones  is  quite  perceptible  ;  in  the  dislocation 
of  the  whole  metatarsus  the  whole  foot  is  shortened  and  the  sole  rendered 
convex  instead  of  concave.  If  the  injur}'  is  recent,  extension  and  coun- 
ter-extension under  chloroform,  with  pressure  on  the  displaced  bones, 
will  probably  succeed  in  reducing  it;  but  Hitzig  wisely  deprecates  too 
violent  attempts  at  reduction,  and  the  accounts  of  several  cases  show 
that  even  if  the  dislocation  be  unreduced  the  foot  in  time  becomes  useful. 

The  toes  are  but  rarely  dislocated,  and  then  it  is  almost  always  the  first 
phalanx,  and  is  always  upwards.  The  great  toe  is  most  commoidy  the 
subject  of  this  lesion,  and  when  it  is  so  the  same  diflficulty  may  be  ex- 
perienced as  in  the  thumb,  and   probably  from  the  same  cause.     As  the 


'  On  Fractures  and  Dislocations,  p.  224. 

*  Berlin  Klin.  Wochenschrift.     See  an  abstract  in    New.  Syd.  See.  Bienn.  Retr., 
1865-6,  p. 273. 


334  GUNSHOT     WOUNDS. 

injury  is  often  compound,  there  would  be  no  hesitation  in  such  a  case  in 
removing  the  head  of  the  bone  ;  but  in  simple  dislocation,  if  there  were 
much  difliculty  in  reducing  it,  it  would  be  better  to  leave  it  alone.  Of 
the  dislocation  of  the  second  rovv  of  phalanges  Malgaigne  could  find  only 
two  examples,  and  in  both  the  dislocation  was  compound  and  was 
reduced. 


CHAPTER    XVL 

GUNSHOT   WOUNDS. 

Gunshot  wounds  are  defined  as  wounds  caused  by  missiles  projected  by 
the  force  of  an  explosion,  and  they  are  therefore  sometimes  divided  into 
those  which  are  direct^  i.  e.,  caused  by  a  body  which  (like  the  bullet  or 
the  fragment  of  a  gun  which  has  burst)  is  projected  by  the  force  of  the 
explosion  itself;  and  indirect^  i.  «.,  caused  by  some  body  (such  as  a  splinter 
or  the  fragment  of  a  wall)  which  has  been  set  in  motion  by  the  projectile. 

Mode  of  Union. — Gunshot  wounds  are  lacerated  and  contused  in  the 
highest  degree,  and  therefore  are  commonly  followed  l>y  sloughing;  but 
this  is  not  always  the  case,  and  Dr.  Simon,  of  Rostock,  has  recorded  some 
instances  of  primary  union  after  such  injuries;'  and  this  possibility  of 
primary  union  has  been  probably  increased  by  the  introduction  of  the 
modern  "  arms  of  precision,"  which  project  their  bullets  at  a  greatly  in- 
creased speed,  so  as  to  cut  tlirough  the  tissues  more  like  a  knife  (a  result 
to  which  the  conical  shape  of  the  bullets  also  contributes),  instead  of 
tearing  and  contusing  them,  as  the  old  bullets  alwaj's  did,  since  these 
latter  rapidly  lost  their  velocity  as  they  traversed  the  tissues.  But  as 
respects  the  fatality  of  gunshot  injuries  any  slight  diminution  in  the  ten- 
dency to  sloughing  in  tlie  track  of  the  wound  which  may  be  occasioned 
by  the  use  of  rifled  arms  is  far  more  than  counterbalanced  by  the  great 
increase  offeree  acquired  by  the  projectiles  used  in  modern  warfare.  It 
is  not  only  that  their  great  speed  enal>les  them  to  pass  through  the  body 
of  one  man  after  another  when  standing  in  a  mass — a  result  to  which 
their  lower  trajectory  also  much  contributes,  and  therefore  that  they  cause 
many  more  wounds  in  proportion  to  the  number  of  bullets  discharged — 
but  also  the  wounds  inflicted  on  each  individual  are  more  grave.  For  the 
old  round  bullets  used  to  be  constantly  deflected  by  the  edge  of  a  bone, 
a  tense  fascia,  a  muscle  suddenly  starling  into  action,  and  thus  the  sub- 
jacent viscera  often  escaped,  so  that  a  ball  might  enter  at  the  front  of  the 
chest  and  pass  out  at  the  back,  and  yet  the  track  might  be  entirely  out- 
side of  tiie  ril)s.  No  such  ol)stacles  avail  to  check  or  turn  aside  the 
course  of  tiie  newly  invented  rif]e-l)alls  ;  the  bones  are  shattered,  and  their 
fragments  are  the  source  of  complicated  misciiief ;  the  viscera  far  more 
rarely  escape,  and  the  l)ullet  often  i)asses  thrcnigli  a  limb  thrown  in  front 
of  the  body  into  the  trunk,  or  vice,  versa.    The  old  distinction  also  which 

'  NewSyd.  Soc.  Bienniul  Kotrospeet,  1807-8,  p.  ;!25.  Deutsclic  Klinik,  1867,  p.  261. 


SYMPTOMS    OF    GUNSHOT    WOUNDS.  335 

used  to  be  made  between  Llie  wounds  of  entrance  and  exit  is  inapplica- 
ble in  those  made  by  such  projectiles  at  their  full  speed.  Bullets  which  are 
moving  at  moderate  speed  are  so  checked  and  slackened  as  they  pass 
through  the  tissues  that  when  tliey  emerge  they  tear  and  turn  outwards 
the  parts  through  which  they  pass.  The  entrance-wound  is  comparatively 
small,  and  either  flat  or  inverted  ;  the  exit-wound  is  much  larger,  more 
lacerated,  and  its  lips  everted. 

Wind  Contusions. — There  are  gunshot  injuries  which  are  unaccom- 
panied b}'  any  skin  wound.  These  used  to  be  called  "  wind  contusions," 
and  were  supposed  to  depend  on  the  mere  windage  of  tlie  ball,  but  now 
they  are  referred  to  oblique  impact,  since  it  has  been  al>undantly  shown 
that  balls  may  pass  so  close  to  the  body  as  to  cut  the  clothes  without 
producing  any  injury,  provided  tiiey  do  not  touch.  These  gunshot  con- 
tusions are  often  very  grave  injuries,  for  though  the  skin  is  not  broken 
the  muscles  and  other  deep  parts  may  be  so  disintegrated  that  traumatic 
gangrene  speedily  follows.  Gunshot  wounds  are  often  complicated  b}'  the 
lodgment  of  the  bullet,  or  of  a  fragment  of  it,  or  of  pieces  of  the  clothes 
or  articles  which  the  patient  has  had  about  him,  or  foreign  substances 
from  without,  or  even  of  portions  of  a  comrade's  body.  Lodged  bullets 
may  travel  to  a  considerable  distance  without  any  obvious  83'mptoms,  or 
the}'  may  remain  quietly  imbedded,  or  encysted,  though  in  the  latter  case 
if  in  tlie  neighborhood  of  important  and  sensitive  organs  (such  as  a  nerve), 
any  slight  movement  or  attack  of  inflammation  may  renew  the  painful 
symptoms  first  produced  bj'  the  injury.  Wounds  from  cannon-balls  and 
from  fragments  of  shells  often  produce  the  most  extensive  and  ghastly 
mutilations. 

Examination  of  the  Wound. — A  common  gunshot  wound  is  divided  into 
the  wound  of  entrance,  the  track,  and  the  wound  of  exit.  Sometimes  the 
bullet  splits,  and  there  is  more  than  one  wound  of  exit,  or  a  portion  may 
lodge  whilst  the  rest  passes  out.  From  this  circumstance,  and  from  the 
much  more  common  lodgment  of  foreign  bodies,  it  is  always  necessary  to 
examine  the  wound,  whether  there  be  an  orifice  of  exit  or  not.  This  is 
best  done  with  the  finger,  if  the  size  of  the  wound  permits  its  introduc- 
tion ;  otherwise  a  probe  must  be  used  proportioned  to  the  length  of  the 
wound.  Balls  and  foreign  l)odies  are  as  a  rule  to  be  removed  at  once, 
unless  in  the  judgment  of  the  surgeon  the  operation  for  their  extraction 
would  cause  greater  mischief  than  the  symptoms  they  might  occasion  if 
left  behind  could  do. 

The  symptoms  of  gunshot  wounds  are  of  course  as  various  as  their  situa- 
tion and  extent,  but  some  general  remarks  may  be  made  on  the  shock, 
the  pain,  and  tlie  hsemorrliage  whicli  are  immediatel}'  caused  by  them. 
The  shock  depends  a  good  deal  on  the  state  of  the  patient's  mind,  and  on 
his  nervous  constitution  as  well  as  on  the  part  injured.  Thus,  though 
sliock  is  usually  and  doubtless  correctly  enumerated  among  the  symp- 
toms of  a  gunshot  wound  of  tlie  lung,  yet  cases  occur  where  the  lung  has 
been  perforated  without  any  marked  collapse,  and  again  others  in  which  the 
most  severe  shock  has  accompanied  a  small  flesh  wound.  The  pain,  again, 
is  very  variable,  and  often  in  the  heat  of  a  battle  is  perfectly  unnoticed  ; 
so  that  a  patient  is  brought  in  as  suftering  from  a  single  wound,  in  whom, 
on  examination,  a  second  wound  is  found  of  which  he  has  been  quite 
unconscious. 

The  pain  is  often  referred  to  the  extremity  of  a  nerve  which  has  been 
injured  at  some  remote  part  of  its  course.  Thus,  Professor  Longmore 
relates  the  case  of  an  officer  who  supposed  the  upper  part  of  his  arm  had 
been  smashed,  and  ran  to  shelter  supporting  the  limb,  which  he  believed 


336  GUNSHOT    WOUNDS, 

was  broken.  On  examination  the  wound  was  found  to  be  confined  to  the 
neck,  and  the  sensations  were  due  to  injury  of  the  brachial  plexus.' 
Hiemorrhage  is  not  a  prominent  feature  of  gunshot  wounds.  The  main  ves- 
sels very  often  escape  injury  altogether,  even  in  wounds  directly  leading 
down  to  their  course,  and  when  they  are  hit  they  are  usually  so  contused 
and  lacerated  that  they  do  not  bleed.  But  to  this  there  are  of  course  many 
exceptions,  and  there  is  an  impression  (which  has  never  been  brought  to 
proof)  that  death  on  the  field  of  battle  very  frequently  occurs  from  wounds 
of  the  large  vessels  of  the  thorax.  When  a  limb  is  torn  off",  whether  by 
cannon-shot  or  otherwise,  the  main  artery  is  generally  seen  pulsating  up 
to  the  point  at  which  it  has  been  torn,  and  often  hanging  beyond  the 
surface  of  the  wound,  exactly  in  the  same  way  as  when  it  is  drawn  out  of 
a  stump  and  twisted. 

Treatment. — In  the  treatment  of  gunshot  wounds  the  first  thing  is  to 
get  the  patient  as  soon  as  possible  into  a  place  of  security.  If  he  is  in 
a  state  of  syncope  it  may  be  proper  to  give  a  little  stimulant  at  once. 
Some  extemporized  support  should  be  arranged  for  a  fractured  limb; 
wounded  arteries  should  be  compressed  or  tied,  if  they  are  exposed,  or 
possibly  a  tourjiiquet  may  be  adjusted.  When  all  this  is  arranged  he  is 
to  be  removed  to  the  place  where  the  definite  treatment  is  to  be  under- 
taken, and  then  a  thorough  examination  is  made,  the  object  of  that  ex- 
amination being  '^  (1)  a  correct  knowledge  of  the  nature  and  extent  of 
the  wound,  (2)  removal  of  any  foreign  bodies  which  may  have  lodged, 
(3;  adjustment  of  lacerated  structures,  and  (4)  application  of  the  pri- 
mary dressings"  (Longmore).  The  examination  is  most  easily  made 
immediately  after  the  injury,  since  then  sensibility  is  numbed,  and  there 
is  less  swelling.  The  patient  should  if  possible  be  put  in  the  attitude  in 
which  he  was  when  he  received  the  wound,  as  this  will  often  give  valua- 
ble hints  as  to  the  possible  course  and  place  of  lodgment  of  the  ball;  his 
clothes  should  be  carefully  inspected,  in  order  to  see  whether  any  pieces 
have  been  carried  in  with  the  l)ullet,  and  the  track  should  be  attentively 
examined  for  fragments  of  the  clothes,  the  bullet,  splinters  from  it  or 
from  the  bones,  and  any  other  foreign  substances.  No  search,  however, 
should  be  made  in  wounds  penetrating  the  great  cavities  of  the  body. 
The  skin  is  only  to  l)e  divided  when  such  division  is  necessary  in  order 
to  extract  bullets  or  fragments  of  siiell  (of  which  very  large  pieces  some- 
times pass  in  through  a  comparatively  small  wound),  or  to  tie  vessels  or 
replace  herniated  viscera.  The  old  plan  of  enlarging  the  orifices  of  gun- 
shot wounds  to  obviate  retention  of  matter  is  (juite  given  up. 

The  detection  of  a  l)ullet  or  lodged  foreign  body  is  by  no  means  eas}'. 
P^ragments  of  clothes  can  hardly  be  detected  by  any  other  means  than 
tlie  linger;  but  very  important  questions  sometimes  occur  (as  in  the  cele- 

Fic.  147. 
Nfclaton's  probe.    The  bulb  iit  the  eiidix  of  white  china. 

bratcd  case  of  Garibaldi)  witii  reference  to  the  detection  of  bullets.  It 
is  for  such  cases  as  these  that  tiie  various  instruments  enumerated  by  Mr. 
Longmore*  have  been  invented  :  Neiaton's  test-probe,  in  wiiich  a  small 
knob  of  biscuit-china  is  |)repare(l  for  taking  an  impression  of  lead  or 


1  Syat.  of  Surg.,  '^d  cd  ,  vol.  ii,  p.  136.  »  lb.,  p.  146. 


TREATMENT    OF    GUNSHOT    WOUNDS.  337 

rust,  on  being  rubbed  against  a  leaden  or  iron  projectile  ;  Lecompte's 
"  stilet-pince,"  in  which  an  arrangement  exists  for  nipping  oft"  and  bring- 
ing away  a  minute  fragment  of  the  foreign  body;  and  the  electric  indica- 
tors of  Rhumkorf  and  De  Wilde,  in  which  contact  with  metal  at  the 
bottom  of  a  wound  is  indicated  by  the  ringing  of  a  bell.  I  believe  I 
should  be  right  in  saying  that  none  of  these  contrivances  have  been 
proved  to  be  of  undoubted  utility.' 

For  the  extraction  of  lodged  bullets  numerous  contrivances  have  been 
invented.  That  which  seems  most  in  favor  with  military  surgeons  is 
Coxeter's  extractor.     Forceps  are  also  contrived  the  blades  of  which  can 

Fig.  148. 


Coxeter's  extractor. 

be  introduced  separate  and  then  connected  together,  as  midwifery  forceps 
are,  while  in  the  wound. 

Parts  torn  by  gunshot  wounds  are  only  to  be  replaced  as  far  as  may  be 
necessary  to  prevent  subsequent  deformity  in  cicatrization  ;  for  since  pri- 
mary union  is  not  to  be  expected,  it  is  useless  to  be  very  exact  in  their 
adjustment;  and  the  dressings  should  be  as  light  and  cool  as  possible,  so 
as  to  moderate  and  allow  for  the  swelling  which  will  ensue.  As  suppu- 
ration comes  on  the  openings  must  be  kept  free.  Gentle  syringing  with 
tepid  water  or  weak  astringent  lotions  is  well  spoken  of  by  Mr.  Longmore, 
as  keeping  the  discharge  free  and  removing  any  torn  fibres  of  cloth  which 
may  have  stuck  inside  the  wound.  Free  incisions  must  be  practiced  when 
the  swollen  condition  of  the  parts  or  the  bagging  of  matter  requires  it, 
and  the  strictest  attention  must  be  given  to  keep  the  wounds  clean,  and 
in  hot  weather  or  tropical  climates  to  keep  them  free  from  flies,  which  are 
not  only  in  such  circumstances  dreadfully  annoying,  but  also  appear  often 
to  act  as  carriers  of  contagion. 

The  constitutional  treatment  should  be  simple  and  supporting.  Iron, 
both  internally  and  as  a  lotion,  often  seems  very  us'eful.  The  wound 
heals  gradually  after  the  separation  of  the  sloughs  from  its  track ;  and 
during  this  separation  secondary  hemorrhage  may  occur,  and  is  the  more 
to  be  apprehended  the  nearer  the  ball  has  gone  to  the  known  course  of  a 
large  vessel.  It  may  sometimes  be  advisable  under  such  circumstances 
to  leave  a  tourniquet,  loosely  applied,  in  charge  of  the  attendant,  with 
instructions  to  screw  it  down  if  the  vessel  should  begin  to  bleed.     If 

1  With  regard  to  the  use  of  N^laton's  probe,  since  much  stress  is  sometimes  laid  on 
using  it — and  in  a  late  trial  at  Dublin  the  surgeon  was  severely  censured  for  not  hav- 
ing done  so— it  mny  he  right  for  me  to  record  an  error  into  which  I  was  led  by  trust- 
ing to  it.  A  man  was  admitted  into  St.  George's  Hospital  under  my  care  in  whom 
the  bullet  of  a  small  j.istol  had  passed  into  the  foot  from  above.  A  small  \youndover 
one  of  the  mi'tatarsal  bimes  exposed  some  smooth,  hard  body.  The  question  in  this, 
as  in  Garibaldi's  case,  was  whether  this  was  the  edge  of  the  bone  or  the  bullet.  To 
settle  this  we  employed  Nelaton's  probe.  This  probe  was  used  in  my  ab.sence  by  two 
gentlemen  on  whose  accuracy  I  relied,  and  who  assured  me  that  the  metallic  film 
which  it  brought  away  was  quite  distinct,  and  this  I  believe  to  have  been  the  case. 
On  repeating  the  experiment  we  could  not  find  any  such  film.  I  then  cut  down  and 
exan)ined  the  parts,  when  it  turned  out  that  there  was  no  bullet  there.  It  had  passed 
down  into  the  soft  tissues  of  the  sole.  I  have  no  doubt  that  in  this  case  the  bullet 
had  If-ft  a  streak  of  lead  on  the  bone,  which  stained  the  probe  and  thus  led  to  the 
error. 

22 


338  GUNSHOT    WOUNDS 

haemorrhage  occurs,  no  time  should  be  lost  in  cutting  down  on  the  artery 
and  tying  it  above  and  below,  if  the  state  of  the  parts  admits.  Should 
it  be  impossible  to  lind  the  artery,  or  should  it  be  so  disorganized  as  not 
to  bear  a  ligature,  tlie  choice  lies  between  compression  in  the  wound, 
tN'ing  the  trunk  artery  above,  or  amputation.  The  surgeon  would  incline 
to  tlie  first  alternative  in  all  ordinary  circumstances  ;  but  if  local  pressure 
carefully  made  has  fiiiled,  and  if  tlie  haemorrhage  is  urgent,  the  second 
alternative,  that  of  tj'ing  the  main  arterj-  at  a  higher  point,  may  be 
adopted  in  the  upper  extremity  in  almost  all  circumstances,  and  in  the 
lower  where  gangrene  does  not  seem  imminent.  In  other  cases  it  would 
be  better  to  remove  the  limb. 

A  few  points  must  be  noticed  in  the  surgery  of  gunshot  wounds  in 
each  region  of  the  body  in  which  their  prognosis,  diagnosis,  or  treatment 
dirters  in  some  respects  from  that  of  the  ordinary  injuries  of  civil  life. 

GunsJiot  icoundi^  of  the  head  are  always  to  be  looked  on  with  grave  ap- 
prehension. Even  simple  contusions  may  be  accompanied  by  fatal  injur}' 
to  the  brain,  and  many  histories  are  on  record  showing  the  rapidly  fatal 
result  of  drinking  or  excitement  after  injuries  which  had  not  been  known 
to  involve  any  deeper  mischief  than  a  mere  bruise  or  a  small  contused 
wound  on  the  head.  Such  is  the  case  quoted  by  Longmore,  from  the 
surgical  history  of  the  Crimean  campaign,  of  a  man  who  was  sent  home 
from  the  Crimea  after  a  superficial  wound  of  the  head,  and  in  whom,  after  a 
drinking  bout,  coma  supervened,  and  he  died  shortly  afterwards.  "Post- 
mortem examination  showed  traces  of  inflammatory  action  in  the  dura 
mater,  and  just  anterior  and  superior  to  the  corpora  quadrigemina  was  a 
tumor  the  size  of  a  walnut  composed  of  organized  fibrin  and  some 
clotted  blood."  In  this  case  the  existence  of  some  mischief  w^as  sus- 
pected in  consequence  of  persistent  headache,  on  account  of  wliich  the 
man  was  invalided  ;  but  a  similar  result  has  been  known  to  take  place 
without  any  symptom  having  been  observed.  The  same  liabilitj^  to  re- 
mote and  unapparent  injur}' of  the  brain  and  other  parts  renders  all  gun- 
shot wounds  of  the  skull  more  serious  than  similar  injuries  are  in  civil 
life.  Thus  fracture  or  fissure  may  extend  far  be3'ond  the  part  struck,  or 
the  internal  table  maybe  fissured  and  driven  in  with  little  or  no  apparent 
injury  to  the  external,  or  the  meningeal  vessels  or  the  brain  itself  may 
be  lacerated.  Fractures  with  depression  are  usually  fatal  unless  the  de- 
pression is  very  slight,  since  the  braiu  is  generally  injured.  And  pene- 
trating wounds  of  the  brain  are  still  more  certainly  fatal.  Out  of  eigiity- 
six  cases  recorded  in  the  history  of  the  Crimean  war  none  survived.  Never- 
theless tliere  are  instances  of  recovery  in  which  either  the  ball  has  passed 
out  again  or  has  become  encysted  in  the  brain,  though  in  the  latter 
instance  it  may  set  up  secondary  inflammation  at  any  subsequent  period. 

The  treatment  is  to  be  conducted  on  the  same  general  rules  as  in  other 
injuries  of  the  head.  In  men  previously  in  strong  health  both  the  general 
and  local  treatment  should  be  strictly  antiphlogistic.  Venesection  is  of 
the  greatest  service  in  such  cases,  and  the  constant  application  of  cold  to 
the  iiead,  strict  rest  in  a  darkened  room,  and  low  diet,  are  also  undeni- 
ably requisite.  Trephining  should,  as  a  general  rule,  be  avoided;  at 
least  this  seems  the  opinion  of  the  most  experienced  militar}'  surgeons. 

Professor  Longmore  speaks  as  follows  on  this  head:  "Two  or  three 
instances  are  known  in  wiiieli  the  course  of  a  ball  has  been  traced  from 
the  site  of  entrance  across  tlie  brain,  and  trei)hining  resorted  to  for  its 
extraction  with  success  ;  but  there  are  also  many  others  in  which  the 
mere  oj)erati(ui  of  the  extraction  of  a  foreign  body  has  apparently  led  to 
the  immediate  occurrence  of  fatal  results.     Moreover,  splinters  of  bone 


OF    THE    SPINE.  339 

are  not  un frequently  carried  into  the  brain  by  balls,  and  these  may  elude 
observation  ;  or  the  ball  itself  may  be  divided  and  enter  tlie  brain  in 
different  directions,  as  was  observed  in  the  Crimea,  when  the  operation 
of  trephining  can  only  be  an  additional  complication  to  the  original 
injury,  without  any  probable  advantage.  Where  irregular  edges,  points, 
or  pieces  of  bone  are  forced  down  and  penetrate — not  merely  press  upon 
— the  cerebral  substance,  or  where  abscess  manifestly  exists  in  any 
known  site,  or  a  foreign  substance  has  lodged  near  the  surface,  and 
relief  cannot  be  afforded  b}'  the  wound,  trephining  may  be  resorted  to 
for  the  purpose;  but  the  application  of  the  operation,  even  in  these  cases, 
will  be  very  much  limited  if  certainty  of  diagnosis  be  insisted  upon.  In 
all  otlier  cases  it  seems  now  generally  admitted  that  much  harm  will  be 
avoided,  and  benefit  more  probably  effected,  by  employing  long-continued 
constitutional  treatment,  viz.,  all  the  means  necessary  for  controlling  and 
preventing  the  diffusion  of  inflammation  over  the  surface  of  the  brain 
and  its  membranes — the  most  careful  regimen,  ver_v  spare  diet,  strict 
rest,  calomel  and  antimonials,  occasional  purgatives,  cold  application 
locally,  so  applied  as  to  exclude  the  air  from  the  wound,  and  free  deple- 
tion by  venesection,  in  case  of  inflammatory  symptoms  arising.  Similar 
remarks  will  apply  in  case  of  lodgment  of  a  projectile  within  the  brain. 
If  the  site  of  its  lodgment  is  obvious,  it  should  be  removed  with  as  little 
disturbance  as  possible,  but  trephining  for  its  extraction  on  simple  infer- 
ence is  unwarrantable." 

Gunshot  icounds  of  the  spine  are  usually  complicated  with  injury  ol 
other  parts,  and  the  mischief  to  the  column  and  cord  is  extensive  and 
probal)ly  fatal.  Little  can,  therefore,  be  done  in  most  cases.  There  are, 
however,  instances  of  the  impaction  of  a  bullet  in  or  near  the  larainre  in 
which  much  good  has  been  done  by  cutting  down  and  extracting  it,  so 
that  in  any  case  where  there  is  reasonable  ground  for  suspecting  that  the 
bullet  has  lodged  in  an  accessible  situation,  it  is  justifiable  to  cut  down 
and  ascertain  whether  this  is  the  case;  and  if  the  bullet  can  be  felt  im- 
pacted near  the  spinous  process  or  laminae,  its  extraction  should  un- 
doubtedly be  attempted. 

A  case  occurred  some  years  ago  in  London  in  which  Mr.  Canton  suc- 
ceeded in  removing  a  bullet  which  was  lodged  in  the  upper  part  of  the 
spinal  column,  and  the  patient  recovered.^  The  case  which  recently 
occurred  in  Dublin  is  also  well  known,  in  which  Mr.  W.  Stokes  made 
an  attempt  to  extract  a  bullet  which  was  lodged  in  tiie  atlas. '^  The  man 
died,  and  the  treatment  was  blamed,  but  most  unjustly,  as  there  is  no 
doubt  that  such  an  attempt  should  be  made  whenever  there  aie  no  special 
counter-indications. 

Gunshot  wounds  of  the  face  are  more  distressing  and  horrible  than 
dangerous,  that  is,  if  they  are  limited  to  the  face.  Large  parts  of  the 
features  may  be  shot  away  and  yet  the  patient  survive.     But  they  are 

1  The  Lancet,  July,  1861.  In  this  case  (the  details  of  which  are  of  a  most  interest- 
ing nature)  the  bullet  had  been  fired  from  a  very  short  distance,  and  struck  against 
the  spinous  process,  or  some  part  of  the  arch,  of  one  of  the  highest  cervical  verlel)rae. 
The  wounded  man  felt  a  momentary  shock,  and  thought  himself  y)aralyzed  ;  but  on 
being  again  shot  by  his  assailant  in  the  face,  and  lo.^ing.  a  good  deal  of  blood,  his 
powers  of  motion  returned,  and  that  to  so  vigorous  a  degree  that  he  was  able  to 
carry  out  successfully  a  dreadful  and  protracted  struggle  for  his  life,  which  ended  in 
the  death  of  his  assailant,  from  repeated  blows  on  the  head.  A  portion  of  bone  ex- 
foliated from  the  injured  vertebrae;  but  the  man  recovered  completely. 

2  Brit.  Med.  Jour.,  1871,  vol.  ii,  p.  716. 


340  GUNSHOT    WOUNDS 

liable  to  be  complicated  with  injury  to  the  skull,  pharynx,  lar3mx,  or 
large  vessels,  which  may  easily  cause  death  ;  and  there  are  often  very 
distressing  though  not  fatal  consequences  from  lesions  of  the  eyes  or  of 
nerves,  ducts,  etc.  These  wounds  are  also  peculiarly  liable  to  secondary 
haemorrhage.  It  is  to  be  noted,  however,  that  much  may  be  done  in  the 
way  of  saving  deformity  by  replacing  parts,  even  if  the  whole  of  the 
part  replaced  may  not  preserve  its  vitality,  so  that  chloroform  should  be 
administered,  the  torn  parts  replaced,  trimmed  up  if  tliey  are  lacerated 
beyond  all  hope  of  union,  and  sewn  together  as  neatly  as  is  possible. 

In  gunshot  wounds  of  the  neck  the  large  vessels  often  escape  injury, 
otherwise  the  case  terminates  fatally  at  once.  When  the  cesophagus  is 
injured  nothing  can  be  done  beyond  supporting  the  patient  with  nutrient 
enemata,  and  when  this  is  no  longer  possible  endeavoring  to  convey  food 
into  the  stomach  through  the  wound  till  the  latter  has  contracted  suf- 
ficiently to  allow  a  tube  to  be  passed  from  the  mouth.  In  wounds  of 
the  trachea  the  opportunity  of  performing  tracheotomy  below  the  wound 
is  sometimes,  though  rarely,  obtained.  li\  however,  the  trachea  is 
wounded,  but  there  are  no  indications  of  portions  of  cartilage  or  foreign 
bodies  being  in  the  trachea,  and  the  patient  breathes  easily,  it  is  better 
to  let  him  alone. 

The  great  nerves  at  the  root  of  the  neck  may  be  wounded  or  contused — 
and  I  have  already  alluded  to  a  case  of  wound  of  the  brachial  plexus — 
but  little  can  be  done  in  the  way  of  treatment.  The  reader  is  referred 
to  the  section  on  Injuries  of  Nerves. 

Gunshot  wounds  of  the  chest  are  divided  into  penetrating  and  non-pene- 
trating, the  latter  being  those  in  which  the  serous  membranes  (pleurre  or 
pericardium)  are  not  opened,  and  the  former  where  the}'  are.  Again,  in 
penetrating  wounds,  tlie  contained  viscera  may  be  injured  or  may  not. 
Non-penetrating  wounds  present  few  peculiarities.  It  may  be  noted  that, 
when  the  ribs  are  fractured,  such  fractures  are  more  comminuted  than  in 
the  injuries  of  civil  life,  and  that  the  fragments  may  wound  vessels  or  be 
driven  into  the  lung  even  when  the  bullet  itself  has  not  penetrated.  And 
it  should  also  be  remembered  that  without  penetration,  and  even  without 
any  fracture  of  the  ribs,  the  lung  may  be  more  or  less  bruised  or  lacerated. 

JHagnosis  of  Wound  of  the  Lung. — In  penetrating  wounds  the  chief 
point  is  to  decide  whether  or  not  the  lung  \\r>,  been  injured.  The  symp- 
toms of  injury  of  the  lung  are  shock,  haemorrhage  from  the  wound,  hfemo- 
thorax,  h8emopt3'sis,  dyspnoja,  traumatopnoea,  and  emphysema.  These 
symptoms  are  of  different  value  in  proving  the  point,  and  any  of  them 
may  be  present  in  cases  where  the  lung  is  not  wounded,  and  absent  in. 
cases  where  it  is,  so  that  it  may  be  said  that  there  is  no  one  symptom 
which  is  absolutely  pathognomonic.  Yet  the  presence  of  all  of  them,  or 
of  the  great  majority,  or  of  the  leading  symptoms  in  a  very  high  degree, 
renders  it  extremely  probable  that  the  lung  is  wounded,  and  justifies  the 
surgeon  in  that  diagnosis. 

Shock  is  a  very  variable  symptom.  Jt  is  frequently  present  to  a  great 
extent  in  cases  where  no  serious  mischief  has  been  done,  and  it  has  been 
often  found  aljsent  where  the  lungs  have  been  perforated.  Its  presence 
could,  thei'efore,  only  strengthen  a  diagnosis  which  has  been  formed  upon 
more  relialile  symptoms. 

External  haemorrhage  from  the  wound,  if  abundant,  and  if  there  is  no 
large  vessel  near  in  the  parietes  (and  there  is  rarely  any  such  vessel), 
must  come  either  from  tlie  lung  or  from  an  intercostal  or  internal  mam- 


OF    THE    CHEST.  341 

raary  artery  within  tlie  chest.  The  direction  of  the  wound,  and  the  result 
of  introducing  a  small  spatula  or  piece  of  card  (if  it  can  be  done  without 
risk)  into  the  inside  of  tlie  parietes,  will  enable  the  surgeon  to  form  an 
opinion  as  to  which  of  these  two  is  the  source  of  the  bleeding.  Still,  by 
itself,  external  haemorrhage  is  only  one  of  the  minor  diagnostic  symptoms 
of  wounded  lung. 

Hivmothorax^  if  considerable,  usually  comes  either  from  the  substance 
or  the  root  of  the  lung;  in  the  latter  case  it  is  almost  certainly  fatal,  and 
in  the  former  very  often  is  so.  Still  a  good  deal  of  blood  may  pass  into 
the  pleura  from  a  wound  of  the  intercostal  arteries  without  wound  of  the 
lung,  so  that  hpemothorax  also  is  not  an  infallible  symptom. 

Hfemopfi/His  may  occur  from  mere  bruising  of  the  lung  without  any 
absolute  penetration,  and  therefore  does  not  by  itself  prove  even  that 
the  wound  has  opened  the  chest.  But  if  haemoptysis  is  very  copious  it 
renders  it  very  probable  that  the  lung  has  been  wounded  ;  and  this  is 
converted  almost  into  a  certaint}'  if  the  blood  is  churned  up  together  with 
air  into  an  abundant  pink  froth,  and  especially  if  a  similar  pink  froth 
escapes  from  the  wound. 

Dyspnoea  is  a  very  variable  sign,  and  depends  in  a  great  measure  on 
the  patient's  previous  condition  and  other  circumstances  which  it  is 
hardly  possible  to  enumerate ;  and  it  is  often  present  in  mere  wounds  of 
the  parietes. 

Traumatopnoea^  or  the  passage  of  air  out  of  the  wound,  is  possible  with- 
out an}'  wound  of  the  lung;  for  the  pleura  having  been  laid  open,  the  air 
may  pass  in  through  the  wound  as  the  parietes  recede  from  the  lung  in 
inspiration,  and  then  be  forced  out  again  as  they  descend  in  expiration. 
It  is,  however,  a  sj'mptom  which  must  always  excite  the  surgeon's  suspi- 
cion; and  it  proves,  at  any  rate,  that  the  wound  is  a  penetrating  one. 

Emphyi<ema  is  rare  in  any  case,  since  the  wound  usually  allows  the  air 
to  pass  freely  out  of  it,  but  otherwise  the  same  observations  apph'  to  it 
as  to  traumatopnoea. 

Treatment. — From  this  it  will  be  seen  that  it  is  usually  possible  to  form  a 
diagnosis  which,  if  not  mathematically  certain,  yet  is  practically  sufficiently 
accurate  to  justify  prognosis  and  treatment  As  to  the  former  the  injury 
is  a  very  dangerous,  but  not  an  absolutely  hopeless  one,  the  dangers  being 
primarily  from  haemorrhage,  and  consequent  exhaustion  or  asphyxia,  and 
secondarily  from  inflammation.  It  is,  tlierefore,  to  the  avoidance  of  these 
dangers  as  far  as  possible  that  treatment  is  to  be  directed.  In  the  first 
place,  collapse,  if  not  so  profound  as  to  threaten  to  prove  fatal,  should 
not  be  interfered  with,  as  it  tends  to  check  bleeding  and  gi^'cs  time  for 
clots  to  form.  Any  vessels  which  may  be  accessible  must  be  tied.  Strict 
quiet  must  be  enforced.  The  application  of  cold  externally  may  be  use- 
ful. Opium  should  be  administered  in  full  doses,  and  internal  stj-ptics 
(such  as  gallic  acid  and  acetate  of  lead),  though  little  to  be  relied  upon, 
may  possibly  be  of  service.  If  the  patient  is  strong  enough  he  may  be 
bled  to  syncope  from  a  large  opening  in  the  vein  ('^pleno  rivo").  No 
probing  or  meddlesome  searching  of  the  wound  is  in  the  least  degree  jus- 
tifiable, but  foreign  bodies  which  are  accessible  must  be  carefully  re- 
moved, and  the  finger  may  be  cautiously  inserted  into  the  wound  to 
replace  depressed  or  comminuted  fragments  of  bone,  when  there  is  good 
reason  to  believe  it  necessary.  The  patient  should  be  put  in  such  a  posi- 
tion as  is  easy  to  him  and  will  not  favor  the  gravitation  of  fluid  into  the 
pleura,  so  that  he  is  usuall}'  placed  on  or  inclining  to  the  injured  side, 
and  the  wound  is  to  be  lightly  dressed.  The  practice  of  sealing  the 
wound  with  a  view  of  repressing  haemorrhage  has  not  proved  successful. 


342  GUNSHOT    WOUNDS 

If  blood  accumulates  in  the  pleura  it  must  be  removed,  either  by  incision 
or  by  tapping. 

Subsequently,  when  symptoms  of  pleuro-pneumonia  come  on,  the  main 
questions  of  treatment  are  as  to  the  administration  of  antimony  and  as 
to  venesection.  Antimony  often  affords  great  relief  in  wounds  of  the 
chest  when  the  patient  is  strong  and  florid,  and  when  he  finds  a  difficulty 
in  expectorating  the  fluid  vvhich  passes  into  the  bronchial  tubes.  If  given 
it  should  be  in  small  but  frequent  doses  (viz.,  n)j  v  :  x  of  the  Vinum  Ant. 
every  three  hours). 

Tlie  use  of  bleeding  in  gunshot  wounds  of  the  lung  was  no  doubt  car- 
ried to  excess  by  Guthrie  and  the  older  surgeons,  yet  there  can  also  be 
no  doubt  that  it  often  affords  the  greatest  relief  and  benefit  in  these  as 
in  other  injuries  of  the  chest.  It  maybe  used,  as  above  stated,  primarily 
in  order  to  induce  an  artificial  collapse,  though  this  is  rarely  done  in  the 
present  day,  since  it  is  believed  that  the  weakness  so  produced  renders 
the  patient  less  able  to  bear  the  subsequent  inflammation.  At  a  sub- 
sequent period  venesection  to  a  moderate  amount  is  indicated  when  the 
dypsnoea  is  in  excess  of  the  shock;  that  is  to  say,  when  the  patient  is 
suffering  much  from  oppression,  with  congested  face  and  lips,  and  the 
pulse  is  firm  or  even  hard,  he  will  derive  great  immediate  relief  from 
losing  about  ten  ounces  of  blood,  and  in  all  probability  will  be  well  able 
to  bear  one  or  even  more  repetitions  of  the  bleeding.  But  when  the  face 
is  pale  and  the  pulse  small,  bleeding  will  probably  only  hasten  his  death. 

Gunshot  wounds  of  the  heart  do  not  differ  from  other  wounds  of  the 
same  organ,  except  in  their  even  more  certain  fatality. 

Wounds  of  the  abdomen,  like  those  of  the  chest,  are  divided  into  non- 
penetrating and  penetrating.  Of  non-penetrating  wounds  nothing  need 
be  said  here.  In  penetrating  wounds  the  viscera  are  usually  injured,  and 
some  collapse  is  generally  present.  The  diagnosis  of  the  exact  nature  of 
the  injury  is  not  always  eas^^,  and  indeed  it  maybe  of  a  very  complicated 
character,  the  bullet  having  passed  through  several  viscera,  or  man}'  coils 
of  intestine,  besides  having  wounded  vessels  or  bones  in  its  course.  The 
diagnosis  of  the  viscus  injured  must  be  made  from  the  same  symptoms 
as  in  other  wounds,  e.  g.,  the  htematemesis  and  pain  in  taking  food  which 
accompanies  wounds  of  the  stomach,  the  escape  of  fiecal  matter  or  gas  in 
injuries  of  the  intestines,  etc.  Penetrating  wounds  of  the  abdomen  are 
not  always  fatal ;  recovery  with  or  without  fjiecal  fistula  sometimes  ensues. 
In  shell- wounds  or  other  large  lacerations  the  viscera  may  protrude,  either 
uninjured  or  wounded.  In  the  former  case  their  prompt  reduction  is 
necessar}'.  If  wounded  intestine  protrudes  the  surgeon  must  decide,  from 
a  careful  examination  of  the  extent  and  nature  of  the  wound,  whether  it 
can  be  sewn  up  and  returned  with  any  |)rospect  of  success,  or  whether  it 
is  necessary  to  attach  it  to  the  wound  and  make  an  artificial  anus.  Pro- 
trusion of  the  solid  viscera  with  wound  hardly  occurs  except  in  injuries 
which  are  necessarily  fatal. 

Tiie  diaphragm  may  be  perforated  by  a  wound,  and  phrenic  hernia  may 
be  thus  caused,  or  the  bullet  may  lodge  in  the  pleura,  in  which  it  may  roll 
al)Out  loose.  Mr.  Guthrie  was  in  the  habit  of  teaching  that  in  such  cases 
the  proper  course  was  to  cut  into  the  pleural  cavity  in  the  last  intercostal 
space  and  extract  the  ball ;'  but  no  case  in  which  that  operation  has  been 
performed  is  as  yet  on  record,  except  where  the  bullet  has  been  felt;  nor 
does  it  seem  that  the  diagnosis  is  quite  so  certain  as  would  be  required  for 


'  Gutlirie's  Commentaries,  1855,  pp.  491-497. 


OF    THE    EXTREMITIES.  343 

SO  grave  an  undertaking.  In  some  cases  the  irritation  of  the  foreign  body 
on  the  diaphragm  has  led  to  constant  and  spasmodic  cough,  but  in  others 
no  swell  sign  of  the  presence  of  the  bullet  has  been  observed,^  and  I  think 
no  one  would  now  feel  justified  in  cutting  down  in  search  of  a  bullet  un- 
less he  had  felt  it. 

Wounds  of  the  Hypogasb-rum. — A  perforating  wound  in  the  hypogas- 
trium  may  involve  the  bladder.  The  bladder  may  be  reached  either  from 
above  tlie  pubes,  through  the  peritoneum,  or  below  the  reflection  of  that 
membrane  or  through  tlie  perineum.  It  may  even  be  reached  in  the 
female  through  the  vagina*  without  any  serious  injury  to  the  soft  parts, 
and  it  would  be  |)ossible  that  it  should  be  wounded  in  the  male  from  the 
rectum,^  though  in  such  a  case  the  perineum  or  ischio-rectal  fossa  must 
be  also  injured.  If  the  ball,  or  a  portion  of  the  clothes,  should  remain 
in  the  bladder  the  usual  symptoms  of  foreign  body  or  stone  will  follow, 
and  the  usual  operation  has  often  been  performed  with  success.*  A  wound 
of  the  bladder  through  the  peritoneum  will,  in  all  probability,  prove  fatal ; 
but  recovery  has  often  been  recorded  in  wounds  which  were  therefore  as- 
sumed not  to  have  implicated  that  membrane.  The  use  of  the  catheter 
in  penetrating  wounds  of  tlie  bladder  is  generally  indicated,  unless  the 
external  wound  is  free  enough  to  provide  complete  exit  for  the  urine. 
Whether  the  catheter  should  be  left  in  or  not  will  depend  on  circumstances, 
such  as  the  ease  or  difliculty  of  its  introduction,  and  the  irritation  which 
it  causes;  but  it  must,  at  an^'  rate,  be  used  often  enough  to  prevent  any 
distension  of  the  bladder,  unless  the  patient  can  pass  water  himself,  which 
is  rarely  tiie  case.  If  any  foreign  body  is  felt  in  the  bladder  its  imme- 
diate extraction  is  imperative. 

Wounds  of  the  penis,  scrotum,  and  testicles  are  rare  as  uncomplicated 
injuries,  and  those  of  the  external  parts  in  the  female  almost  unknown. 
Their  treatment  involves  no  special  points. 

Gunshot  ivounds  of  the  extremities  need  only  be  noticed  here  wiien  com- 
plicated with  lesions  of  bone,  or  presenting  some  other  peculiarity.  The 
general  rules  of  surgery  are  only  modified  in  these  injuries  by  the  exten- 
sive splintering  of  the  bones  which  bullets,  and  especially  the  conical  bul- 
lets, cause,  and  the  osteomyelitis  which  is  so  likely  to  follow,^  by  the 
consequences  of  the  sloughing  which  almost  always  follows  gunshot 
wounds,  and  by  the  circumstances  under  which  the  great  majority  of  these 
injuries  are  treated.     All  these  peculiarities  are  very  unfavorable  for  the 

1  See  the  case  of  Thain,  related  by  Mr.  Poland  in  Syst.  of  Surg.,  vol.  ii,  p.  593, 
2ded. 

2  Emmet,  on  Vesico-vaginal  Fistula,  p.  221. 

3  There  is  a  striking  case  described  by  Mr.  Hewett  in  the  Path  Trans.,  vol.  i,  p. 
152,  and  of  which  a  preparation  is  preserved  in  the  Museum  of  St.  George's  Hospital, 
Ser.  ix.  No.  35,  of  wound  of  the  bladder  through  the  rectum  by  the  broken  upright 
of  a  chair,  on  which  the  patient  fell.  There  is  no  reason  why  a  bullet  should  not 
pass  in  the  same  direction,  though  I  am  not  able  to  refer  to  a  recorded  case. 

*  Mr.  Dixon  gave,  in  the  23d  vol.  of  the  Med  -Chir.  Trans.,  references  to  fifteen 
cases  in  which  this  operation  had  been  performed,  and  with  success  in  a  very  large 
proportion  of  them.  He  also  mentions  one  in  which  a  small  bullet  which  had  passed 
into  the  bladder  was  voided  by  the  urethra. 

5  The  figures  in  the  text  (p.  344)  are  interesting  examples  of  the  great  splintering 
and  extensive  injury  which  conoidal  bullets  inflict  on  the  bones,  as  contrasted  with  the 
more  limited  efiTects  of  round  bullets.  They  also  show  conditions  of  the  articulating 
end  appropriate  for  excision,  at  least  in  the  upper  extremity.  It  seems  doubtful 
whether  excision  of  the  knee  could  be  practiced  successfully  if  the  bone  were  splin- 
tered as  in  Fig.  149 ;  but  it  might  be  ventured  on  if  a  bullet  were  lodged  in  the  head 
of  the  tibia  or  in  the  femur,  and  the  bone  were  not  splintered,  as  in  Fig.  150. 


344 


GUNSHOT    WOUNDS 


success  of  excision,  in  comparison  with  amputation,  in  the  lower  ex- 
tremity- For  the  success  of  excision  of  the  hip  and  tlie  knee  it  seems 
essential  that  the  bone  exposed  should  be  uninjured,  the  soft  parts  pre- 
disposed to  healthy  action,  and,  above  all,  that  the  patient  should  be  left 
undisturbed  for  a  long  period.  None  of  these  things  are  so  essential  in 
excision  of  the  shoulder  or  elbow.     Accordingly  we  find  that  the  two 

Fig.  149. 


Injury  of  the  head  of  the  humerus  by  a  conoidal  bullet.  The  bullet  (shown  by  the  asterisk  *)  has 
entered  apex  first,  and  is  imbedded  in  the  cancellous  tissue,  its  base  being  on  a  level  with  the  surface 
of  the  bone.  Great  splintering  has  followed,  a  and  b  show  the  condition  of  the  head,  and  c  the  fis- 
sured state  of  the  shaft  at  the  part  where  the  operation  of  resection  has  been  performed.  It  is  prob- 
able that  these  fissures  extended  some  distance  in  the  shaft  below  the  line  of  resection, 

latter  operations  were  brought  into  general  acceptance  mainly  in  conse- 
quence of  their  success  in  warfar*',^  while  the  excisions  of  the  hip  and 
knee,  although  they  have  sometimes  succeeded  in  war,  can  count  very 
few  successes  either  in  these  or  in  any  other  primary  injuries.  This  well- 
known  fact  makes  a  great  distinction  in  the  surgery  of  gunshot  injuries 
in  the  u})per  and  lower  extremities. 

The  following  are,  I  believe,  the  main  maxims  of  practice  in  gunshot 
injuries  of  the  extremities:'^ 

I.  In  the  Upper  Extremity. — If  the  lesion  of  the  soft  parts  does  not 
seem  too  extensive  do  not  amputate.  Do  not  perform  any  formal  excision 
unless  the  shoulder  or  elbow  is  opened,  but  remove  loose  fragments  of 
bone,  provide  free  exit  for  discharges,  and  put  the  parts  in  a  favorable 
position  for  union.  In  injuries  of  tlie  shoulder  and  ell)ovv,  however,  the 
patient  has  a  better  chance  of  a  useful  limb  if  the  usual  amount  of  bone 


^  The  success  of  Baron  Larreyin  excising  the  shoulder  in  the  wars  of  the  Kepublio 
and  Empire  was  one  of  the  first  causes  of  the  reception  of  that  operation  ;  while  the 
success  of  Esmarch  in  excisincf  tlx;  elbow  in  the  war  in  Schleswijr-Holstein,  though 
less  striking  from  uocidfntal  cirounistances,  and  although  the  operation  was  already 
a  received  one,  did  mucli  to  pro)>agate  and  extend  its  use. 

*  It  is  a.s.sumed  that  the  u.sual  rules  of  practice  have  been  carried  out  and  foreign 
bodies  if  possible  removed. 


OF    THE    EXTREMITIES. 


345 


be  removed  by  excision  ;  and  the  extension  of  fissures  into  tlie  shaft  of 
the  humerus,  or  into  the  bones  of  the  forearm,  does  not  greatly  prejudice 
tlie  chances  of  the  patient's  recovery,  though  in  tlie  case  of  the  shoulder 
the  frequent  injuries  to  the  scapula  or  axillary  vessels  and  nerves  is 
certainly  a  formidable  complication.     When,  however,  along  with  grave 


Fig.  150. 


A  and  B  show  the  head  of  a  humerus  which  has  been  strurtk  by  a  round  ball  in  nearly  the  identical 
spot  at  which  the  specimen  represented  in  Fig.  149  had  been  struck.  The  round  ball,  like  the  conoidal, 
has  also  entered  to  a  distance  corresponding  with  its  own  depth,  its  surface  being  on  a  level  with  that 
of  the  surrounding  bone.  Although  the  head  of  the  bone  has  been  greatly  shattered,  as  shown  in  A, 
the  rending  asunder,  or  splintering,  is  very  limited  ;  and  the  saw,  in  resecting  the  injured  head,  has 
passed  through  the  shaft  (see  c)  without  crossing  a  single  fissure,  and  this  notwithstanding  the  opera- 
tion has  been  performed  somewhat  nearer  to  the  neck  of  the  bone  than  in  the  preceding  instance.  The 
figures  represent  two  preparations,  Nos.  2926  b  and  2926  D,  in  the  Museum  of  the  Royal  College  of 
Surgeons,  and  are  taken  from  Syst.  of  Surg.,  2d  edit.,  vol.  ii,  pp.  123,  124. 


injuries  to  the  soft  parts,  or  with  comminuted  fracture,  the  main  vessels 
or  nerves  or  both  are  wounded,  it  is  usually  more  prudent  to  amputate. 
Yet  even  in  some  cases  of  wound  of  the  main  artery  in  the  upper  ex- 
tremity complicated  with  fracture,  if  free  from  other  complications,  and 
in  a  young  and  healthy  subject,  the  attempt  to  save  the  limb  may  be 
made. 

II.  In  the  lower  extremity  gunshot  fractures  involving  the  hip-joint  or 
the  upper  third  of  the  femur  are  usually  fatal,  however  treated.  Primary 
amputation  is  so  fatal  in  these  cases  that  it  is  almost  abandoned.  Several 
cases  have  recovered  under  strictly  conservative  treatment ;  a  few  cases 
of  successful  excision  are  on  record  ;  and  secondary  amputation  has  been 
decidedly  more  successful  than  primary.*  The  surgeon  must  use  his  own 
discretion  in  each   case,  but  all  surgeons  nowadays  have  a  well-founded 

1  M.  Jules  Koux,  of  the  S.  Mandrier  Hospital,  at  Toulon,  has  given  a  list  of  no 
less  than  twenty-one  cases  of  recovery  without  amputation  after  gunshot  injuries  of 
the  upper  third  of  the  femur  among  the  soldiers  whom  he  examined  on  their  return 
from  the  Italian  war  of  1859.  Longmore,  op  cit.,  p.  '22Q.  For  a  comparison  between 
primary  and  secondary  amputation  at  the  hip-joint  in  military  surgery  see  pp.  228-9 
of  the  same  essay. 


.346  GUNSHOT    WOUNDS    OF    THE     EXTREMITIES. 

horror  of  primary  ami)utation  at  the  hip,  believing  that  the  operation  is 
almost  necessarily  fatal,  wliile  the  injury  is  not  so. 

In  gunshot  fracture  of  the  lower  part  of  the  femur  amputation  is  the 
rule.  Cases  have  also  been  treated,  when  free  from  other  complications, 
on  the  conservative  method,  all  comminuted  portions  being  removed,  and 
the  parts  put  up  in  the  best  apparatus  which  circumstances  permitted  the 
surgeon  to  make  ;  but  it  seems  the  opinion  of  the  most  experienced  mili- 
tary surgeons  that  in  the  general  run  of  cases  amputation  is  the  best 
course,  though  in  special  instances  the  attempt  to  save  the  limb  may 
justifialily  be  made. 

When  a  bullet  lodges  in  the  knee-joint,  or  passes  through  the  joint, 
splintering  the  bones  yet  not  producing  any  further  discoverable  lesion, 
excision  may  be  resorted  to.  But  hitherto  it  must  be  admitted  that  the 
attempt  has  led  to  disappointment,  or  in  plainer  terms  to  loss  of  life,^ 
and  that  amputation  is  a  far  safer  practice.  In  the  rare  cases  of  such 
accidents  occurring  in  civil  life  at  an  early  age,  and  with  all  the  necessary 
appliances  for  undisturbed  treatment,  it  may  be  justifiable  (though  it  is 
certainly  rather  doubtful  practice)  to  risk  excision;  but  in  common  mili- 
tary practice  no  doubt  can  be  entertained  that  until  we  possess  some 
more  successful  method  of  practicing  excision  the  surgeon's  duty  is  to 
amputate.  There  are,  however,  cases  in  which  the  surgeon  may  very 
reasonably  attempt  the  entire  preservation  of  the  limb,  giving  exit  to 
matter  and  loose  fragments  as  they  present.  Langenbeck  believes,  and 
I  have  no  doubt  with  good  reason,  that  the  success  of  such  attempts 
would  be  much  favored  by  putting  up  the  limb  at  once  in  a  well-fitting 
case  of  plaster  of  Paris. 

In  gunshot  injuries  of  the  leg  the  limb  may  often  be  saved,  and  in 
many  of  these  cases  the  resection  of  the  comminuted  bones,  and  possibly 
of  the  portion  of  the  shaft  around  them,  may  be  advisable.  The  same 
observations  apply  to  those  injuries  in  which  the  ankle  has  been  laid 
open.  In  such  cases  the  removal  of  comminuted  portions  of  bone  is 
often  spoken  of  as  an  "  excision  of  the  ankle,"  and  if  the  term  be  admitted 
the  operation  may  be  said  to  be  a  successful  one.  Langenbeck  is  the 
chief  authority  in  recommending  excision  of  the  ankle  in  military  surgery, 
having  operated  five  times  in  the  Schleswig-Holstein  war  of  1864,  and 
eleven  times  in  the  Austro-Prussian  war  of  ISBB,  with  thirteen  successes 
and  three  deaths.  In  all  the  cases  the  periosteum  was  preserved  as  far 
as  possil)le,  and  the  limb  put  up  in  a  plaster  of  Paris  splint  at  once.  But 
the  operation  differs  from  the  ordinary  excision  of  the  ankle  for  disease 
in  this  vei'y  important  particular,  that  the  bones  of  the  foot  are  not  dis- 
eased and  are  usually  untouched,  and  that  the  patient,  instead  of  being 
a  sufferer  from  chronic  disease,  is  usually  healthy.  The  success  of  the 
excision  of  bones  of  the  leg  (called  excision  of  the  ankle)  for  gunshot 
injury,  even  if  we  allow  that  it  has  been  real — i.  e.,  that  the  same  success 
could  not  have  been  attained  witiiout  operation — does  not  bear  on  the 
question  of  excisions  of  tlie  ankle  for  disease. 

For  wounds  of  the  nerves  of  tiie  limbs  I  must  refer  the  reader  to  a  sub- 
sequent chapter,  in  which  the  affections  of  nerves  are  treated. 


'  In  the  American  Burgeon-General's  report  it  is  stated  that  out  of  eleven  resec- 
tions of  the  knee  all  but  two  terminated  fatally,  aad  a  doubt  is  expressed  of  the  reality 
of  recovery  in  one  of  the  remaining  two. 


TUMORS CLASSIFICATION. 


34- 


CHAPTER   XVII. 


TUMORS. 


Fio.  151. 


There  are  few  parts  of  surgical  pathology  in  which  such  constant 
alterations  have  been  made  ;is  in  the  diagnosis  and  nomenclature  of 
tumors — alterations  which  are  very  puzzling  to  the  student,  and  the 
advantages  of  whicii  have  not  as  yet  become  at  all  evident  to  the  prac- 
tical surgeon.  I  will  endeavor  to  treat  the 
subject  as  practically  and  as  shortly  as  pos- 
sible, without  ignoring  the  theoretical  re- 
finements which  modern  pathologists  have 
introduced,  yet  only  giving  them  such 
prominence  as  their  bearings  on  practical 
surger}'  seem  to  demand. 

A  tumor  is  defined  as  "a  new  formation — 
an  addition  to  some  part  of  the  body  of  a 
substance  organized  or  partly  organized, 
and  not  the  result  of  inflammation  only" 
(Caesar  Hawkins),  and  this  is  probably  the 
best  definition  whicli  can  be  given,  although 
we  must  allow  that  some  genuine  examples 
of  tumor  owe  their  origin  to  inflammatory 
processes — as,  for  example,  the  bursal  tu- 
mors, of  which  an  example  is  figured  here. 

Other  tumors  occur  congenitally,  either 
as  the  result  of  foetal  inclusion,  from  an 
abnormal  and  excessive  formation  of  epi- 
dermal tissues,  or  from  unknown  causes. 
And  it  may  be  stated  generally  that  tlie 
cause  of  formation  of  any  tumor  is  as  a 
rule  entirely  obscure.  Pathologists  and 
statisticians  have  labored  in  A'ain  to  dis- 
cover   any     reason,    either    in    the    local    or         Two  bursal  tumors,  L  e.,  enlarged 

general  condition  of  the  body,  why  the  in-    bur-sse  pateiis,  which  had  become  con- 

5-    •  1       11        111  a-     ^     ^       -li    ii  i.1       verted  into  cystic  tumors  by  the  de- 

dividual  should  be  affected  with  the  growth    ^^^^^^.^^^  J  an  imperfect  fibrous 

of  a    tumor.       Hereditary    tendency  is    often      material  in  their  walls,  leaving  only 

traceable,  especially  in    malignant   tumor;    acavity in  their  centre, with  smaller 

but  this  affords  no  explanation,   since  we 

know  no  reason  for  the  original  occurrence 

of  the  tumor  in  the   first  member  of  the 

family ;   nor,   beyond   the  vague   fact   that 

children  usually  resemble  their  parents  in 

constitution    and    predisposition  to    disease,      cessfully.    (St.  George's  Hospital  Mu 

as  they  do  in  physical  appearance  and  dis-    seum,  ser.  iv,  No.  u  &.) 
position,  do  we  know  any  reason  why  the 

disease  after  it  has  once  originated  should  be  transmitted  to  succeeding 
generations.  The  fact,  however,  that  cancer  is  often  transmitted  from 
parent  to  child  is  one  of  impoi'tance  in  diagnosis. 


alveolar  interspaces  in  the  fibrous 
tissue  composing  their  walls.  The 
cavities  were  filled  with  partially  de- 
colorized blood.  The  enlargement  had 
existed  for  about  two  years.  The 
tumors  were  removed  at  the  same 
operation  from  a  woman  aged  34,  sue- 


348  TUMORS. 

Innocent  and  Malignant  Tumors. — The  most  superficial  acquaintance 
witli  tumors  will  show  that  there  are  two  well-marked  classes  of  them, 
separated  by  broad  distinctions,  both  anatomically  and  clinically.  There 
is  one  class  in  which  the  substance  of  the  tumor  has  an  exact  anatomical 
resemblance  to  some  tissue  of  the  body  (homologoua  tumors),  and  in 
whicii  the  tumor  gradually  increases  in  size,  displacing  the  structures  in 
which  it  grows,  but  not  invading  them,  and  producing  no  other  symptoms 
than  those  caused  by  its  increasing  bulk.  Such  tumors  are  clinically 
termed  innocent^  though,  of  course,  the  increase  in  their  bulk  may  cause 
death,  if  they  are  situated  in  a  vital  part.  There  is  another  class  of 
tumors  which  do  not  present  any  reseml)lance  to  the  normal  tissues,  and 
which  are  therefore  descrilied  as  heterologous.  Clinically  these  tumors 
show  a  strong  local  disposition  to  ulceration ;  they  also  invade  all  the 
textures  of  the  part  in  which  they  grow,  and  they  influence  the  general 
health,  passing  into  the  13'mphatic  system,  appearing  in  remote  parts  of 
the  body,  reappearing  after  complete  removal,  and  affecting  the  mass  of 
the  blood,  so  as  to  cause  profound  cachexia  and  ultimate  death.  Tumors 
of  this  kind. are  therefore  called  malignant. 

Semi-malignant  Tumors. — But  though  there  is  no  difBculty  in  placing 
the  well-marked  examples  of  either  class  under  their  proper  category, 
either  anatomicall}'^  or  clinically,  it  has  long  been  seen  that  in  both  the 
anatomical  and  the  clinical  division  a  third  class  must  be  made,  the 
classification  of  which  is  by  no  means  so  easy.  There  are  some,  such  as 
the  adenoid  tumors  of  the  mammary  and  prostate  gland,  which  very 
nearly  reproduce  the  structure  of  the  part  in  which  they  grow  ;  others, 
such  as  the  "  fibro-plastic "  tumors  of  Lebert,  which  are  formed  in  a 
great  measure  of  tissue  resembling  the  embryonic  state  of  some  natural 
organ  of  the  bod3' ;  and  others,  such  as  the  myxoma  and  glioma  of  Vir- 
chow,  in  which  a  similar,  though  still  more  rudimentary,  resemblance  to 
the  normal  tissues  can  be  traced.  Modern  pathologists,  especially  the 
Germans,  have  revived  for  such  tumors  the  old  designation,  Sarcoma, 
which  had  originallj^  no  certain  meaning,  but  is  now  defined  as  a  tumor 
whose  structure  presents  some  resemblance  to  the  rudimentary  forms  of 
some  natural  tissue  of  the  body.  The  term  Carcinoma  is  then  defined 
anatomically  as  a  tumor  consisting  of  a  congeries  of  cells  resembling 
those  of  epithelium,  and  in  some  cases  nearly  identical  with  them,  lying 
in  the  interstices  of  a  connective  tissue,  in  which  aaain  other  cellular 
elements  are  to  be  found.  But  the  cells  of  carcinoma  have  no  structural 
connection  with  the  connective  tissue,  nor  do  they  appear  to  undergo  any 
transformation  into  higher  stages  of  development. 

Looking,  again,  at  these  so-called  ''sarcomatous"  tumors  clinically, 
we  find  that  among  them  are  well-marked  examples  of  a  third  class,  be- 
sides the  innocent  and  the  malignant,  above  spoken  of.  There  are 
tumors  which  will  recur  after  their  complete  removal ;  others  which 
gradually  spread  to  all  the  tissues  in  their  neighborhood,  and  others 
which  ultimately  destroy  life  by  their  iilceration,  although  they  have  not 
the  other  features  of  malignnncy;  that  is,  they  do  not  affect  the  lym- 
phatic system,  nor  make  their  appearance  in  remote  parts  of  the  body. 
To  such  tumors  the  terms  semi-malignant,  locally  vialignant.,  and  cancroid 
have  been  applied.  The  class  of  sarcomata  is  largely  formed  of  tumors 
of  this  kind  ;  but  what  renders  the  subject  so  complicated  and  difficult,  and 
prevents  us  from  accepting  the  lal)ors  of  modern  pathologists  in  this  direc- 
tion as  holding  out  any  hope  of  finality,  is  that  this  same  class  contains 
some  tumors  wliich  are  perfectly  innocent,  and  many  others  which  are  more 
truly  malignant  than  tliose  classed  anatomically  among  the  carcinomata. 


CYSTS.  349 

Amidst  all  this  confusion  there  is  one  important  point  to  which  Mr. 
Savory  has  recently  called  attention  in  a  very  suggestive  paper  in  the 
Brit.  Med.  Jour..,  Dec.  19tli,  1874,  viz.,  that,  speaking  generally,  "the 
less  the  structures  of  which  a  tumor  is  composed  tend  to  ciiange  from 
their  primary  or  embryonic  form  tlie  more  abundantly  will  they  multiply; 
so  that  lliose  tumors  whose  structures  retain  most  nearly  their  primary 
.  form  are  the  most  malignant.  And  as  the  structures  of  a  tumor  are 
capable  of  transformation  so  tliey  lose  their  power  of  repetition  ;  so  that 
those  tumors  wliicli  consist  most  completely  of  fully  formed  tissue  are 
the  most  innocent."  Thus  the  most  lowl}'  formed  tumors  are  the  carci- 
nomatous, the  cells  of  which  show  no  tendency  to  grow  into  any  higher 
forms,  and  wliich  consist  in  great  measure  of  juice,  which  is  partly,  in- 
deed, the  product  of  the  disintegration  of  the  cells,  but  parti}'  is  a  new 
morbid  formation  ;  and  these  tumors  show  all  the  characters  of  malig- 
nancy most  plainly'. 

Next  in  order  are  the  sarcomatous,  in  which  an  attempt  has  been  made 
at  the  formation  of  tissue,  although  imperfet^t  and  embryonic,  and  these 
tumors,  though  unstable  in  their  composition,  prone  to  ulceration,  prone 
to  recur  after  removal,  and  occasionally  making  their  appearance  in  dis- 
tant parts  of  the  body,  have  all  these  characters  in  a  far  less  degree  than 
the  carcinomatous  tumors  have;  wliile  the  best  examples  of  the  purely 
innocent  tumors  are  sucli  as  consist  throughout  of  a  highlj'  developed 
tissue,  such  as  l»one.  Many  of  the  latter  kind  of  tumors  are  as  stable 
and  as  little  prejudicial  to  the  health  of  the  individual  as  if  they  had 
been  original  portions  of  his  organism. 

Jt  remains  to  describe,  as  well  as  our  present  knowledge  permits,  the 
kinds  into  which  the  purely  innocent,  the  sarcomatous,  and  the  carci- 
nomatous tumors  are  now  usually  divided. 

Innocent  tumors  are  subdivided  into  cystic  and  solid.  The  cystic 
tumors  are  again  subdivided  into  simple,  or  purely  cystic  tumors,  and 
proliferous  cysts,  in  which  a  growth  springs  from  the  cyst-wall  and  fills 
tile  cavity  more  or  less  completely. 

The  simple  cysts,  which  consist  merely  of  a  fibrous  envelope  filled  with 
fluid,  are  classified  according  to  the  nature  of  the  fluid  they  contain. 
They  are  serous,  synovial,  raucous,  sanguineous,  and  seminal.  Milk- 
cysts,  oily  and  colloid  C3'sts,  may  be  added,  but  the  milk-cysts  will  come 
under  notice  with  tlie  diseases  of  the  breast,  and  the  others  are  merely 
pathological  curiosities,  for  which  the  reader  must  consult  some  of  the 
manuals  of  Pathology.  Nor  will  anytliing  further  be  said  here  about  the 
synovial  cysts  or  enlarged  bursje,  nor  the  seminal  cysts  or  encysted 
hydroceles  of  the  epididjmis.  These  will  be  found  described  in  tlieir 
proper  places. 

BerouH  cijsta  occur  very  commonly  in  the  neck,  constituting  what  is 
called  hydrocele  of  the  neck.,  and  this  is  the  best  example  of  their  inde- 
pendent formation.  The  hydrocele  of  the  neck  forms  a  large  encysted 
tumor  (occupying  sometimes  the  whole  side  of  the  neck,  and  falling  like 
a  dewlap  over  tlie'  cliest),  containing  clear  or  sliglith'  tinged  serum,  grow- 
ing slowly,  and  producing  no  definite  symptoms.  I  have  seen  such  a 
cyst  completely  transparent  like  a  common  hydrocele.  These  cysts  are 
generally  supposed  to  be  formed  by  accuuiulation  of  fluid  in  the  cellular 
spaces,  which  then  produces  by  its  pressure  the  stratification  of  the 
areolar  membrane,  and  thus  becomes  encapsuled.  Most  of  the  other 
serous  cysts,  such  as  those  whicli  occur  in  the  thyroid  body,  in  the  tunica 
vaginalis  (common  hydrocele),  in  the  testicle  (the  uou-malignant  form  of 


350 


TUMORS. 


Fig.  152. 


cystic  (iisejise  of  the  testis),  in  tlie  breast,  or  in  tlie  kidne}',  are  formed 
by  effusion  of  serum  into  spaces  naturally  existing  in  the  organ,  and 
their  contents  have  some  resemblance  to  that  of  the  part  in  which  they 
are  formed.  Thus,  the  serum  filling  these  cysts  is  of  the  most  various 
color  and  composition,  in  some  cases  almost  watery,  at  others  nearly  the 
consistence  of  honey,  and  of  ever}'  color — sometimes  black  or  nearly 
black,'  at  others  perfectly  colorless.  More  or  less  fat,  cholesterin,  or  • 
some  of  the  elements  of  the  blood,  may  frequently  be  found  in  it. 

Mucous  cysts  are  such  as,  being  formed  in  or  in  tlie  neighborhood  of  a 
mucous  surface,  contain  a  fluid  similar  to  that  secretion,  but  usually  more 

concentrated.  Their  cause  appears 
to  be  the  obstruction  of  a  mucous  fol- 
licle. They  are  found  most  commonly 
in  the  antrum,  in  the  mouth  (ranula), 
in  the  glands  of  Naboth  and  Cowper, 
and  in  the  muciparous  glands  of  the 
vulva  and  vagina. 

Sanguineous  cysts  occur  either  as 
a  consequence  of  haemorrhage  into  a 
serous  cyst,  which  seems  common  in 
the  neck  (htematocele  of  the  neck),  or 
possibly  in  connection  with  a  vein, 
the  orifice  of  communication  having 
afterwards  become  obliterated,  or  from 
effusion  of  blood  into  a  tumor,  the 
substance  of  which,  expanded  over  the 
collection  of  blood,  appears  like  a 
<;yst.  This  was  the  case  in  the  in- 
stance from  which  the  annexed  illus- 
trations were  taken.  The  patient,  a 
man  tet.  30,  was  under  my  care  at  St. 
George's  Hospital,  in  consequence  of 
repeated  hcemorrhages  from  the  large 
tumor  which  is  shown  growing  from 
the  outer  side  of  the  leg,  and  which  is 
seen  to  be  ulcerated  in  several  places. 
The  whole  mass  was  excised,  and  was 
at  first  thought  to  be  a  simple  cyst 
filled  with  l)lood;  but  minute  cxami- 
A  blood-cyst  .situated  on  the  leg.  The  pa-  nation  by  Mr.  Beck  and  Mr.  Arnott 
tient  was  a  healthy  man  aged  30.   The  tumor  showcd  a  thill  layer  of  Sarcomatous 

had  hei'n  noticed  about  two  years,  and  had  been     ,.  ..      ,i  „     I'l      „^    i.i,„4.     +1,,,    ,  „„„ 

the  .seat  of   repeated    and  severe    luemorrhage     ^ISSUC    Ul    the     wall,    SO    that    the    CaSC 

during  the  last  three  months.    The  drawing    was  really  onc  of  an  cuormous  efl[u- 

shows  thcMli'ip  fissures  in  the  tumor  from  which  sion  of  blood  intO  the  SUl)Stance  of  a 
this  ha.-morrl.age  proceeded.  It  shows  also  the  g^j^jj  t^„^jor.  TllC  man  did  Well,  and 
shape  of  the  tumor,  springing  from  a  broad  base,  ,  1.1        .  .1 

pendulous,  and  overhangingthe  healthy  skin  for  "O    recurrence     has    hithcrto    taken 

some  distance.     It  wa.s  removed,  together  with     plaCC.       Again,    blood-CystS     are    Very 

the  skin  around  -  ■• 

March, 

the  cicatrization  of  the  wound  being  assisted  by 

ceed  in  size  the  solid  growth  in  wiiich 
they  form,  so  tliat  surgeons  are  alwa3's 
lalher  appreliensive  of  more  serious 
mischief  when  dealing  with  these  cysts. 


sme  aistaiice.    it  wa.s  removes,  logeiner  wiin  piacc.      71  gam,    uiouu-cysis     art;    vtiiy 

le  skin  around   its  Ijase  for  some  distance,  in  fVcqucntlv    formed    Hu    "malignant    tU- 
[arch,  187:i.    The  patient  made  a  good  recovery,  "1,1  .•  1 

le  cicatrization  of  the  wound  being  assisted  i,;  mors,  and  they  sometimcs  mucli  ex- 


skin-grafting.  lie  was  seen  in  good  health  two 
years  afterwards.  On  examination  of  th(!  tumor 
its  walls  wiTe  found  to  be  composid  of  a  tliiri 
layer  of  sarcomatous  tissue,  the  cells  from  which 
are  represenled  in  Fig.  153. 


•   A.S  in  soini'  fluid  from  a  mammary  cyst  preserved  by  Sir  B.  Brodie  in  the  Museum 
of  St.  Gi'orgc's  Hospital. 


SEBACEOUS    TUMORS. 


351 


Fui.  15;{. 


The  diagnot;is  of  f^imple  ci/sts  rests  on  several  considerations.  The 
synovial,  seminal,  and  mucous  cysts,  forming  as  they  do  definite  diseases 
of  the  parts  in  which  they  occur,  are  recognized  mainly  by  tlieir  position. 
Cysts  in  general  are  distinguished  from  solid  tumors  (a  distinction  not 
easy  to  make  when  the  cyst  is  very  tense  and  deeply  seated)  by  tlieir 
elasticity  and  perfectly  rounded  outline — from  chronic  abscess  by  the 
absence  of  all  pain  and  inflamma- 
tory infiltration  of  the  tissues 
around  ;  and  when  any  doubt  is 
felt  an  exploratory  puncture  can 
never  do  any  harm,  gives  hardly 
any  pain,  and  will  at  once  settle 
the  question. 

Treatment. — Serous  cysts  may 
often  be  treated  successfully  by 
iodine  injection,  exactly  as  in 
hydrocele,  or  they  may  be  oblit- 
erated by  a  seton,  tliough  this 
sometimes  sets  up  dangerous  in- 
flammation, especially  in  the 
neck.  I  once  saw  death  occur 
in  a  week  through  the  insertion 

of  a  seton  into  a  CVSt  of  the  thy-        Cells  from  the  sarcomatous  envelope  of  the  hlood- 

roid  body.     Any  form  of  simple  ^^^^  ^''°^»  '»  ^'--  ^^--  ^he  large  oval  cells  shown 

,  '  ,  ,  ,".'  ,   ,        ,      .  below  formed  the  bulk  of  the  tumor.    Smaller  spindle- 

cyst  may  be  obliterated  by  being  ^^^^^^^  ^ells    are  shown   at  a.    The   sarcoma  tissue 

freely     incised     and     the    incision  formed  a  thin  layer,  not  perceptible  to  the  naked  eye, 

kept    open     until     the     cavity    has  in  some  parts  arranged  in  slight  bands  shooting  up 

arinnlated     un  •     but     tllis     ^,.p„^.  into  the  papill*  of  the  skin   or  spreading  beneath 

gianuiaiea    up,    out   iriis    neat-  ^j^g,^^.  i^  ,j(,^g^gp^„j.^,gg^j,y  ,^^5^^^^  ^,p  ^;^,^  ji^gj^j^^^, 

ment      is      hardl}'      applicable     to    clot  which  filled  tlie  cyst.    From  Path.  Soc.  Trans., 

blood-cysts,  on    account   of  the  "s'oi.  xxiv,  pp.  208,  211. 
danger  of  renewed   haemorrhage 

or  of  violent  inflammation  of  their  walls.  They  are  better  removed  en- 
tire, in  which  case,  if  truly  simple,  they  will  not  recur;  but  if  their  wall 
is  formed  bj'  sarcomatous  tissue  such  recurrence  is  probable,  and  if  by 
cancer  material  is  nearly  certain. 

Compound  cy.s^.s  are  (1)  such  as  contain  the  elements  of  the  skin — cu- 
taneous cysts  and  dermal  cysts  ;  and  (2)  such  as  have  growing  from  their 
lining  membrane  secondary  cysts,  or  masses  of  solid  substance,  which 
nltimatel}'  either  partly  or  entirely  fills  the  original  cavitj' — proliferous 
cysts. 

Sebaceoum  Tumors. — Of  the  former  kind  the  commonest  are  the  seba- 
ceous, whicli  are  found  mainly  on  the  head  and  face,  though  most  other 
parts  of  the  surface  may  be  affected,  the  axilla  being  remarkably  exempt. 
Sir  J.  Paget  describes  them  under  two  classes — one  marked  by  a  dark 
point  on  the  summit,  indicating  the  opening  of  a  hair-follicle,  and  show- 
ing that  the  tumor  was  formed  by  the  obstruction  of  such  follicle ;  the 
other  presenting  no  sucli  opening,  and  probably  formed  in  tlie  same  man- 
ner as  any  simple  cyst.  They  contain  usually  inspissated  sebaceous 
matter  of  a  peculiarly  offensive  odor,  more  rarely  fluid  of  various  colors, 
mixed  with  epidermal  scales  and  cholesterin.  The3'  grow  often  to  a 
very  large  size,  and  appear  in  very  large  numbers  in  tiie  scalp,  and  then 
the  operation  for  their  removal  becomes  a  serious  one,  on  account  of  the 
great  liability  to  erysipelas  in  such  cases  ;  but  there  is  some  risk  of  this 
complication  even  after  the  removal  of  the  smallest  tumor,  and  pyoemia 


352  TUMORS. 

may  also  follow.  I  well  remember  the  death  of  an  apparently  healthy 
young-  man  from  pyremia  very  shortly  after  the  removal  of  a  little  seba- 
ceous tumor,  the  operation  being  a  most  trifling  one,  over  in  a  minute, 
and  of  which  neither  the  surgeon  nor  the  patient  thought  much.  Hence 
it  is  always  desirable  before  performing  any  such  operation  to  take  all 
adequate  precautions  to  see  that  the  patient  is  in  good  health,  and  after- 
wards to  take  care  that  he  does  not  expose  himself  injudiciously  to  any 
risk  of  cold  or  indulge  in  excess  of  any  sort.  The  oi)eratiou  is  usually 
a  very  simple  one.  The  whole  cyst  being  freely  cut  across  and  its  con- 
tents allowed  to  escape,  it  may  be  seized  with  a  pair  of  forceps  and 
dragged  out,  while  the  skin  is  held  with  the  fingei'-nail  or  another  pair 
of  forceps  ;  or,  in  the  case  of  smaller  tumors,  the  skin  only  may  be 
divided,  separated  from  the  surface  of  the  tumor  with  a  few  touches  of 
the  knife,  and  the  bag  turned  out  with  the  spoon-end  of  a  director  or  the 
handle  of  the  knife.  When  the  skin  is  firmly  united  to  the  surface  of  the 
tumor,  as  haijpens  in  many  regions  from  pressure,  the  surgeon  will  be 
unable  to  pull  out  the  cyst,  and  more  or  less  dissection  is  necessary.' 
Great  care  should  always  be  taken  to  remove  such  cysts  entire.  If  a 
portion  be  left  it  may  reproduce  the  secretion,  prevent  the  healing  of  the 
wound,  and  set  up  a  chronic  form  of  ulceration  with  foul  discharge  much 
resembling  that  which  accompanies  epithelial  cancer. 

If  there  is  any  especial  reason  to  dread  erysipelas  the  caustic  treatment 
is  believed  to  be  safer,  i.  e.,  to  destroy  the  skin  over  the  tumor  to  a  suffi- 
cient extent  with  some  caustic,  so  as  to  make  a  free  opening  into  the  cyst, 
and  then  either  to  leave  it  to  discharge  itself,  draw  it  out,  or  procure  its 
elimination  by  renewed  applications  of  the  caustic  to  its  interior. 

Congenital  cutaneous  cysts  are  not  of  very  rare  occurrence.  A  very 
common  situation  for  congenital  cysts  is  at  the  outer  upper  angle  of  the 
orbit,  forming  a  little  round  tumor,  slowly  increasing  in  tliat  situation. 
Its  early  removal  is  necessary,  or  at  least  expedient,  since  tlie  deformity 
it  causes  will  ultimately  render  the  operation  inevitable,  when  it  would 
require  a  larger  wound  and  be  more  difficult ;  but  the  operation  is  never 
so  eas}'  as  it  would  at  first  sight  ai)pear,  since  the  cyst-wall  is  very  thin, 
and  it  may  extend  very  deeply  into  the  orbit,  lying  constantly  in  close 
proximity  to  the  periosteum,  and  even  (as  in  a  case  which  I  once  saw) 
perforating  the  bone  and  lying  in  contact  with  the  dura  mater.  Tlie  dis- 
section, therefore,  sliould  be  conducted  very  carefully,  all  possible  care 
being  taken  not  to  open  the  cyst — an  accident  which  will  much  embarrass 
the  dissection.  If  this  has  occurred  it  is  perhaps  best  to  lay  the  whole 
cyst  freely  open,  and  after  evacuating  its  contents,  dissect  it  all  carefully 
from  the  i)arls  lying  below  it.  Any  little  fragment  of  the  cyst  wiiich  has 
been  left  l)eliind  may  prove  a  source  of  very  serious  trouble.  Tliese  cysts 
usually  contain  thin  fluid  and  liairs. 

Cutatuous  cijsfs  in  the  scalp  are  often  congenital,  and  tliey  may  then 
perforate  one  or  both  tables  of  the  skull.  But  cysts  have  also  been  found 
in  the  interior  of  the  skull,  having  l)een  included  within  it  in  the  process 
of  its  ossification.  Such  congenital  sebaceous  tumors  are  matters  of  sin- 
gular interest,  on  account  of  the  mistakes  in  diagnosis  to  which  they  may 
give  rise.  Many  cases  of  meningocele  or  encephalocele  have  been  mis- 
taken for  such  sebaceous  tumors  and  operated  on,  usually  with  a  fatal 
result,  though  sometimes  the  patient  has  been  lucky  enougii  to  escape 

'  It  will  oftf-n  bc!  founil  ciisicr  to  disspct  out  one  of  these  cysts  after  it  has  been  laid 
open,  if  the  dissection  be  beijiin  from  below,  whei'e  Ihi^  cyst  lies  lot>sely  in  the  ccillular 
tissue,  rather  than  abuve,  where  the  skin  is  firmly  united  to  it. 


CYSTIGEROUS    CYST.  353 

with  life.  The  greatest  care,  therefore,  should  be  taken  in  examining  a 
case  of  supposed  sebaceous  tumor  lying  in  one  of  the  usual  situations  of 
encephalocele  to  ascertain,  in  the  first  place,  whether  it  is  congenital,  and 
secondly,  whether  pressure  on  it  reduces  it  either  wholW  or  partly,  or 
causes  any  cerebral  symptoms.  If  the  tumor  be  reducible  it  can  hardly 
be  sebaceous,  and  there  can  be  no  doubt  that  it  should  be  left  alone.  If 
pressure  cause  cerebral  sjanptoms  it  may  doubtless  nevertheless  be  a 
sebaceous  tumor  lying  on  the  dura  mater ;  yet  even  so  the  risks  of  its 
I'emoval  would  be  too  great  to  render  the  operation  under  ordinary  cir- 
cumstances justifiable.  If,  however,  an  operation  be  undertaken,  the 
tumor  must  on  no  account  be  opened.  It  must  be  exposed  by  very  free 
incisions  and  careful  dissection,  and  its  base  must  then  be  separated  with 
all  imaginable  care  from  the  subjacent  membrane. 

The  other  dermal  cysts  are  most  familiar  to  us  in  the  ovary,  and  next 
to  that  in  the  scrotum.  They  contain  masses  of  hair,  portions  of  skin 
with  cutis  and  cuticle,  and  frequently  one  or  more  teeth,  mixed  often  with 
a  large  quantity  of  fat ;  and  sometimes,  besides  these  truly  dermal  struc- 
tures, irregular  pieces  of  well-formed  bone  are  present  in  them.  They 
seem  to  be  often  if  not  always  congenital,  though,  like  other  congenital 
tumors,  they  may  have  remained  for  a  very  long  time  without  growing. 
They  used  to  be  regarded  as  instances  of  foetal  inclusion,  i.  e.,  the  elements 
of  which  they  are  composed  were  regarded  as  fragments  of  a  blighted 
twin  foetus  which  had  been  included  in  the  body  of  the  one  which  grew  to 
maturity.  But  there  is  no  reason  whatever  for  such  a  supposition,  in  the 
case  of  the  ordinary  dermal  cysts  of  the  ovary  or  scrotum.  The}'  seem 
to  be  merely  tumors  growing  in  the  foetus,  just  as  any  other  cutaneous 
tumor  may  in  the  adult.  There  are,  of  course,  cases  of  well-marked  foetal 
inclusion,  in  which  a  portion  of  the  body  of  one  foetus  is  buried  in  the 
other,  while  the  lower  limbs  protrude,  but  these  rare  cases  will  form  the 
subject  of  a  future  section.  The  dermoid  cysts  are  now  universally 
allowed  to  be,  if  not  always,  yet  at  least  as  a  rule,  quite  independent  of 
twin  impregnation.  Their  diagnosis  can  only  be  conjectural  before 
removal,  resting  on  the  long  existence  of  the  tumor,  its  irregularity  and 
heterogeneous  consistence.  After  removal  no  recurrence  need  be  antici- 
pated. In  the  scrotum  the}'  have  been  known  to  be  spontaneously  ex- 
truded by  suppuration. 

Proliferous  cysts  are  those  in  which  some  solid  substance  springs  from 
the  interior  of  the  cyst-wall,  which  may  entirely  fill  it  up.  They  occur 
frequently  in  the  ovary,  and  still  more  often  in  the  female  breast.  The 
proliferating  solid  portion  of  the  tumor  is  a  vascular  tissue  which  springs 
from  the  wall  of  the  cyst,  generally  at  one  definite  part,  but  not  uncom- 
monly from  a  great  part  of  the  lining  membrane,  filling  it  up  more  or  less 
completely,  and  ultimately  making  its  way  through  the  cyst,  and  then 
through  the  skin  out  of  which  it  fungates.  Such  are  the  sero-cystic.  tubero- 
cystic,  or  cystic-sarcomatous  tumors.  The,y  are  almost  confined  to  the 
neighborhood  of  glands,  and  are  far  more  common  in  the  female  breast 
than  in  any  other  gland.  I  think,  therefore,  it  will  save  space  and  time  if 
I  refer  the  reader  to  what  is  said  in  the  chapter  on  Diseases  of  the  Breast 
as  to  the  diagnosis,  pathology,  and  treatment  of  these  tumors. 

Cystigerous  Cyst. — Another  kind  of  compound  or  proliferous  c^-st  is 
the  cystigerous.,  in  which  the  lining  membrane  of  the  parent  cyst  becomes 
the  seat  of  the  formation  of  a  number  of  secondary  cysts.  In  the  ovary 
such  compound  cystic  tumors  are  very  common  ;  and  in  tumors  which 
before  removal  appear  to  be  simple  cysts  secondary  cysts  will  sometimes 
be  discovered.     But  I  do  not  know  that  there  is  much  importance  in  the 

23 


354 


TUMORS. 


diagnosis  of  this  from  the  other  form  of  compound  cystic  tumor  or  from 
the  simple  cysts. 

The  fat ti/  are  amongst  the  most  common  examples  of  purely  innocent 
tumors.     They  spring  in  almost  all  cases  from  the  natural  fat  of  the  sub- 
cutaneous   membrane,    or 
Fi«- 154.  i,^  connection  with  deeper- 

seated  fat.  In  some  rare 
instances  fatty  tumors 
have  been  found  in  parts 
naturally  destitute  of  any 
growth  of  fat,  and  fatty 
tumors  have  sometimes 
been  found  in  patients  who 
had  died  of  exhausting 
diseases,  and  who  had  lost 
the  natural  fat  from  all 
parts  of  the  bod}'.  They 
may  grow  to  any  size  ;  and 
if  developed  in  ver}^  early 
life  (which,  however,  is  not 
common),  they  sometimes 
attain  enormous  propor- 
tions, as  was  the  case  in  a 
child,  then  aged  seven 
years,  from  whom  Mr.  Pol- 
lock removed  a  fatty  tu- 
mor which  had  been  mis- 
taken for  a  spina  bifida, 
being  situated  in  the  mid- 
dle line  of  the  luml)ar  re- 
gion, and  had  therefore  been  allowed  to  grow.  When  removed  it  weighed 
12|  Ibs.^  I  saw  her  many  years  after,  in  perfect  health.  Fatty  tumor 
does  not  often  appear  at  so  early  an  age  as  in  this  instance.  In  other 
respects  the  case  illustrates  the  common  history  of  fatt}'  tumors :  their 
gradual  growth  to  a  large  size,  without  any  tendency  to  suppuration  or 
to  degeneration  of  an}'  kind,  or  to  ulceration  of  the  skin,  their  size  being 
the  only  inconvenience,  and  the  complete  restoration  of  health  on  their 
removal.  The  illustrations  (Figs.  154,  155)  show  the  characteristic  forms 
of  fatty  tumor,  the  former  a  collection  of  deeply  lobulated  masses,  the 
latter  a  lai-ge  globular  mass  of  fat,  both  of  them  inclosed  in  a  capsule 
formed  by  the  condensed  areolar  tissue,  and  therefore  easily  separated 
from  the  parts  around.  The  skin  is  generally  attached  to  the  surface  of 
a  fatty  tumor  by  numerous  strings  of  areolar  tissue;  and  when  the  skin 
is  moved  on  the  tumor  dimples  are  ))roduced  in  it  by  the  tension  of 
these  attachments,  a  point  somewhat  characteristic  of  fatty  tumor.  The 
lobulated  surface,  soft,  solid  feeling,  and  slow  growth  are  tlie  other 
characters  of  this  form  of  tumor,  and  are  usually  sutlicient  for  its  diag- 
nosis. Occasionally  this,  like  other  forms  of  tumor,  is  the  seat  of  neu- 
ralgic pain,  and  this  is  especially  the  case  in  young  women,  who  often 
have  fatty  tumors  in  the  shoulder  or  in  the  neighborhood  of  the  breast. 
In  rare  cases  cysts  are  formed  in  fatty  tumors,  and  in  still  rarer  instances 
abscesses  may  form  in  them. 


A  large  mass  of  fat  under  the  skin  of  the  scrotum,  collected 
into  lobules,  and  continuous  with  the  fat  of  the  abdomen.  The 
patient  died  of  phthisis,  and  the  rest  of  his  body  was  much  ema- 
ciated. The  case  is  described  at  length  by  Mr.  H.  Gray,  in  the 
Path.  Trans.,  vol.  vi,  p.  230. — (St.  George's  Hospital  Museum, 
Ser.  xiii.  No.  14.) 


'  Path.  Soc.  TraiLS.,  vol.  viii,  p.  360. 


FIBROUS    TUMORS. 


355 


Fatty  tumors  generally  form  after  the  period  of  maturit}',  but  in  some 
rare  cases  they  occur  congenitally,  as  was  probably  the  case  in  a  remark- 
able instance  of  fatty  tumor,  growing  in  the  interior  of  the  spinal  canal, 
which  I  assisted  Mr.  Athol 
Johnstone  to  remove,  and 
the  history  of  which  will 
be  found  in  the  Path.  Soc. 
Trans.,  vol.  viii,  pp.  16, 
28. 

Besides  the  definite  and 
encapsuled  collections  of 
fat  which  deserve  the  name 
of  tumors  there  are  often 
met  with,  especially  in  very 
fat  elderly  people,  enor- 
mous ill-definedoutgrovvths 
of  fat  and  cellular  tissue — 
such  as  used  to  be  called 
"lipoma."  These  have  no 
capsule,  but  graduall_y  pass 
into  the  fat  of  the  part.  It 
may  become  necessary  to 
remove  them  on  account 
of  the  inconvenience  they 
cause ;  but  the  operation 
should  not  be  lightly  un- 
dertaken. In  order  to  be 
efficient  for  its  purpose  it 
must  involve  a  verv  large       .         ,       , ..   .  .     ,„  ^   „  •    ..  ^i 

-     .            ■  .        S  A  very  large  fatty  tumor,  moasuring  12  by  8  niches,  removed 

incision,  and  the  patient  is  f^^^^  ^,,g  j,^^^  of  the  thigh,   it  extended  from  the  trochanter  to 

generally  not    a  very  good  the  middle  of  the  back  of  the  leg,  and  was  freely  movable.    It 

Subiect  for  operation.  was  invested  by  thick  areolar  tissue.    The  darker  parts  consist 

1^    X.      .                       ^      ^4-      „  of  tissue  in  which  blood  seems  to  have  been  accidentally  extrava- 

ratty  tumors  are  not  1111-      .  ^      j    u- »,  •  i     v.    i      /■ 

•^  ,   .    ,  sated,  and  which  is  more  or  less  broken  down. 

commonly  multiple. 

The  removal  of  a  fatty  or  any  other  perfectly  innocent  tumor  is  merely 
a  question  of  convenience.  The  tumor  must  be  expected  to  increase 
slowly;  but  if  the  patient  is  out  of  health,  or  there  is  any  other  special 
reason  for  dreading  an  operation,  it  may  be  better  to  advise  him  to  bear 
what  is  after  all  only  a  deformity  and  an  inconvenience,  rather  than 
incur  any  real  danger.  But  in  most  cases  the  operation  involves  such 
trifling  risk  that  it  should  be  at  once  performed.  If  the  tumor  has  not 
been  irritated,  its  attachments  will  be  so  loose  that  if  it  is  lifted  in  one 
hand  from  the  subjacent  fascia,  while  with  the  other  hand  the  surgeon 
makes  a  free  incision  across  the  whole  of  the  mass,  he  can  turn  it  out  of 
its  capsule  with  his  fingers  in  a  moment,  without  any  dissection.  If,  on 
the  other  hand,  the  tumor  has  been  irritated  or  compressed — as,  for 
instance,  is  often  the  case  in  the  common  tumor  on  the  shoulder  by  the 
pressure  of  braces  or  shoulder-straps — the  skin  will  adhere  to  it,  and  it 
will  require  formal  dissection. 

Fibrous  Tumors The  purely  fibrous  tumors  are  also  typical  examples 

of  the  innocent  class.  Their  external  characters  are  not  always  easy  to 
distinguish  from  those  of  fatty  tumors,  when  they  grow  in  the  subcuta- 
neous tissue ;  and,  indeed,  in  this  situation  the  two  textures  are  frequently 


356 


TUMORS. 


Fig.  156. 


intermingled,  so  as  to  form  a  fihro-fatty  tumor ;  but  the  true  fibrous 
tumors  are  harder,  rounder,  and  less  adherent  to  the  skin  than  the  fatt_y. 
Fibrous  tumors  occur  in  connection  with  the  uterus,  with  the  nerves,  the 
bones,  especially  the  lower  jaw  and  the  base  of  the  skull,  where  they 
form  the  "naso-pharyngeal  polypus,"  the  testicle,  the  lobe  of  the  ear,  and 
in  many  other  parts.  The  fibrous  is  often  mixed  with  other  texture,  as 
in  the  uterus,  where  an  admixture  of  the  unstriped  muscular  tissue  is 
constant  (fibro-muscular).  In  the  nerves  the  disease  forms  a  special 
aflfection,  which  will  be  described  in  a  future  chapter  under  the  name  of 
"Neuroma."  The  progress  of  a  true  fibrous  tumor  is  usually  slow; 
those  of  the  uterus  are  prone  to  a  retrogressive  change,  in  which  they 
calcif}'^  more  or  less  completel}^ ;  ^  the  others  usually  advance  slowl}'  till 
they  protrude  through   the    skin   or   mucous    membrane    and  ulcerate. 

Sometimes  cysts  form  in 
their  substance — "  fibro-cys- 
tic  tumors" — as  is  not  un- 
common in  the  bones  (see 
Diseases  of  Bones).  The 
true  fibrous  tumors  are  usu- 
ally inclosed  in  a  capsule, 
rendering  their  removal  both 
easy  and  safe ;  and  after  re- 
moval, if  the  tumor  be  found 
to  be  composed  of  perfect 
and  well-formed  fibrous  tis- 
sue, no  recurrence  need  be 
apprehended.  There  have, 
it  is  true,  been  a  few  in- 
stances in  which  tumors 
supposed  to  be  purely  fibrous 
(and  that  by  competent  ob- 
servers) have  afterwards  run 
the   course  of  cancer ;    but 


remained  free  from  any  recurrence  at  least  for  eighteen 
months,  during  wliich  time  she  was  repeatedly  seen.  The 
tumor  was  removed  from  the  subperitoneal  tissue  of  the  iliac 
fossa.  The  patient  was  a  woman,  aged  41,  who  had  borne 
children.  The  case  is  reported  in  Path.  Trans.,  vol.  xv,  p.  211. 
Neiaton  has  also  called  attention  to  the  occasional  growth 
of  fibroid  tumors  in  the  iliac  fossa  in  child-bearing  women. — 
St.  George's  Hospital  Museum,  Ser.  xvii.  No.  42. 


A  specimen  of  fibro-cellular  tumor,  showing  its  perfect 
identity  in  external  appearance  with  the  common  fibrous 
tumor.    On  microscopical  examination,  however,  oat-shaped    tllCSC    exceptional    instances 
nuclei  and  fibre-cells   were  readily  detected.     The  patient    ^^  ^^^^^  perhaps  WaS  after  all 

only  an  accidental  error  of 
observation  need  not  inter- 
fere with  the  general  state- 
ment that  a  slowly  growing 
tumor  definitely  separated 
from  the  surrounding  parts, 
and  composed  of  well-formed 
fibrous  tissue  onl}^  will  not  recur  after  complete  removal.  The  more 
rapid  the  growth  is,  the  more  embryonic  or  ill-formed  the  fibres,  and  the 
more  they  are  mixed  with  cells,  and  especially  cells  of  variable  sliape  and 
size,  the  more  is  recurrence  to  be  dreaded.  And  this  leads  us  to  speak 
of  i\\Q  fibro-cellular  tumors. 

Fihro-cellular  Tamom. — These  contain,  along  with  the  fibrous  element, 
a  more  or  less  large  proportion  of  cells.  They  grow  more  rapidly  than 
the  purely  fibrou^  tumor,  tliey  occupy  more  variable  positions,  and  are 
often  more  deeply'  situated,  and  they  are  less  definitely  marked  off  from 
neighboring  parts  and  less  frequently  encapsuled ;    they  often  contain 


^  See  the  chapter  on  Diseases  of  the  female  Generative  Organs. 


CARTILAGINOUS    TUMORS. 


357 


glandular  elements,  when  they  grow  in  or  in  the  neighborhood  of  glands. 
Each  of  these  circumstances 

has  its  value  in  the  prognosis  fig.  157. 

of  the  disease ;  but  in  the 
present  state  of  our  knowl- 
edge it  is  very  difficult  to 
estimate  that  value,  or  to 
give  a  consistent  and  intel- 
ligible account  of  the  tu- 
mors grouped  under  the  term 
"fibro-cellular."  Some  of 
them  are,  as  far  as  can  be 
judged,  as  purely  innocent  as 
the  typical  examples  of  fib- 
rous tumor,^  others  are  of  a 
very  malignant  nature.  The 
latter  are  such  as  will  be 
found  described  below  un- 
der the  names  of  round- 
celled  and  spindle-celled  sar- 
coma, myxoma  and  glioma. 
The  innocent  fibro-cellular 
growths  are  those  in  which 
both  the  fibres  are  well- 
formed  and  have  attained 
their  perfect  development, 
and  the  cells  are  homoge- 
neous, generally  round  or 
oval,  and  display  little  ten- 
dency either  to  growth  into 
fibres,  to  proliferation,  or  to 
decay.  Such  are  tlie  cells 
frequently  found  in  the  fib- 
rous epulis  on  the  jaw,  and  in  the  firm  fibro-cellular  growths  of  the  skin. 
The  cells  usually  bear  only  a  small  proportion  to  the  bulk  of  the  fibrous 
tissue. 

The  diagnosis  between  the  firmer  fibro-cellular  and  the  true  fibrous 
tumors  is  only  possible  after  removal,  and  the  looser  kinds  are  again 
ver}^  difficult  to  distinguish  in  many  situations  from  cancerous  tumors. 
Their  removal  is  urgently  indicated,  and  in  the  less  well-defined  speci- 
mens the  surgeon  will  do  well  to  cut  as  wide  of  the  disease  as  prudence 
permits. 

Ca7-tilagi7ious  himors  (enchondromata)  are  far  more  common  as  out- 
growths from  bone  than  in  any  other  part,  and  they  will  accordingly  be 
described  furtlier  among  the  Diseases  of  Bones,  where  also  will  be  found 
some  illustrations  of  their  most  characteristic  forms.  But  they  do  occur 
also  in  the  soft  parts,  frequently  in  the  parotid  gland,  occasionally  in  the 
testicle,  and  very  rarely  in  the  subcutaneous  tissue,  in  the  thyroid  body, 

^  Paget,  in  speaking  of  flbro-cellular  tumors,  says  :  "  What  has  been  said  of  the 
excision  of  fatty  tumors  might  be  repeated  hero,  and  so  might  the  statements  as  to 
the  very  favorable  prognosis  after  removal  ;  but  with  this  reserve,  that  if  a  fibro- 
cellular  tumor  be  incompletely  developed,  soft,  looking  like  little  more  than  size  or 
other  soft  gelatin,  or  presenting  a  great  preponderance  of  its  elemental  structures  in 
an  embryonic  state,  it  is  likely  to  prove  recurrent." — Syst.  of  Surg.,  vol.  i,  p.  525, 
2ded. 


A  mass  of  fibro-cellular  tumors,  removed  from  the  labium 
pudendi,  weighing  1}4  ft>s.  avoirdupois.  They  were  removed 
by  operation,  and  only  one  vessel  required  the  ligature. 
They  had  given  the  patient  (a  widow,  aged  40)  very  little 
inconvenience  during  the  three  years  they  had  been  grow- 
ing, until  one  burst  and  discharged  a  thin  sanious  fluid. 
a  refers  to  the  skin  and  fat  of  the  labium  ;  b  to  the  pendulous 
fibro-cellular  outgrowths. — Museum  of  St.  George's  Hospital, 
Ser.  xvii.  No.  47. 


358  TUMORS. 

and  in  other  parts.  The}'  are  distinguished  from  the  harder  fibrous 
tumors,  which  they  much  resemble,  mainly  by  their  firmer  consistence 
and  deei)er  lobulation.  Tliey  are  as  a  general  rule  purel}'  innocent,  and 
if  once  removed  entire  will  never  recur.  Sir  J.  Paget  has,  however,  re- 
corded' a  single  instance  in  which  a  cartilaginous  growth  originating 
in  the  testicle,  and  presenting  ever}^  character  of  an  ordinary  enchon- 
droma,  i)assed  up  the  lympliatic  vessels,  pressed  upon  and  perforated  the 
vena  cava  inferior,  and  was  thus  conveyed  into  the  lungs,  where  it  at- 
tained so  large  a  size  as  to  prove  fatal.  The  case  is  a  very  striking  and 
instructive  one  ;  it  does  not,  however,  show — nor  does  Sir  J.  Paget 
record  it  as  showing — that  enchondroraa  is  ever,  when  occurring  un- 
mixed, a  malignant  disease,  but  as  proving  that  the  elements  of  any 
growing  tissue  if  they  pass  into  the  blood  ma}-  become  multiplied  there 
to  an  indefinite  extent. 

Besides  the  purely  cartilaginous  tumors — ^.  e.,  those  which  consist  of 
cartilage  and  nothing  else — there  are  a  great  number  of  tumors,  some 
innocent  and  others  malignant,  which  consist  partly  of  cartilage;  but  as 
the  cartilage  in  these  tumors  forms  only  a  part,  and  that  a  subordinate 
part  of  the  growth,  and  does  not  give  its  character  to  the  disease,  it 
seems  to  me  erroneous  to  classify  such  tumors  as  enchondromata.  Thus 
cartilage  is  often  found  in  osteoid  cancer,  and  the  recurrent  growths  in 
tlie  lung  often  consist  in  great  measure  of  cartilage.  This  illustrates  the 
presence  of  cartilage  in  cancer,  while  the  common  fibrous  tumor  of  the 
parotid  or  the  ordinary  fibrous  epulis  will  often  be  found  to  contain  more 
or  less  cartilage  ;  and  these  may  be  used  to  illustrate  its  formation  in  in- 
nocent tumors.  But  such  tumors  should  be  classified  under  the  name  of 
their  principal  constituent,  and  the  name  enchondroma  siiould  be  reserved 
for  those  growths  which  consist  entirely  or  almost  entirely  of  cartilage. 
/  Cartilaginous  tumors  degenerate  in  various  ways.  Some  break  down 
in  the  centre,  so  as  to  form  large  cysts  (cystic  enchondroma),  others 
soften  througliout,  others  become  converted  into  a  calcareous  mass,  in 
which  it  is  difficult  to  discover  any  definite  organization.  Many  ossify, 
but  this  is  far  more  common  in  those  which  are  attached  to  bone  than  in 
those  formed  in  the  soft  parts,  and  it  will  be  spoken  of  along  with  Diseases 
of  the  Bones  in  connection  with  the  subject  of  exostosis. 

The  free  removal  of  an  enchondroma  is  all  that  is  necessar}'  for  tlie 
patient's  future  safety.  Amputation  may  be  indicated  if  the  size  and 
connections  of  the  tumor  demand  it,  and  in  cases  of  multiple  enchon- 
dromata on  the  fingers  or  toes  it  may  be  the  only  resource  available;  but 
such  cases  will  be  discussed  hereafter. 

Bony  lumom  are  not  absolutely  unknown  in  the  soft  parts.  There  are 
some  rare  cases  in  which  the  muscles  ossify,  as  in  a  skeleton  preserved 
in  the  Museum  of  the  Royal  College  of  Surgeons,  in  which  many  of  the 
bones  are  connected  immovabl}'  by  masses  of  bone  which  have  replaced 
some  of  tlie  largest  muscles  in  the  body;  and  otlier  singular  cases  occur 
like  that  recorded  liy  Mr.  Caesar  Hawkins,'-'  in  which  masses  of  bone  were 
formed  loose  in  the  cellular  tissue  of  the  muscles.  But  such  cases  are  so 
very  uncommon  and  have  so  little  bearing  on  practice  that  exostosis  may 

'  Mod.-Chir.  Trans.,  vol.  xxxviii,  p.  247. 

2  C(jiitril)Ution.s  to  Palliolouy  unci  SurtijtTy,  vol.  ii,  p.  193.  Mr.  Hawkins  describes 
the  forniation.s  of  bone  in  the  case  which  he  relates  as  the  result  of  ossification  of  tho 
muscular  fibres  in  consequence  of  inflammation,  and  refers  to  some  similar  instances  ; 
though,  as  he  observes,  "  we  cannot  say  why  the  muscles  inflame,  nor  why  the  com- 
mon results  of  inflammation  are  modified  .«o  that  bone  is  formed  in  the  cellular  tissue 
of  the  muscles." 


VASCULAR    TUMORS. 


359 


be  regarded  as  a  disease  of  the  bones,  and  will  accordingly  be  treated  of 
in  that  chapter. 

Vascular  Tumors. — The  only  other  form  of  innocent  tumor  is  the  vas- 
cular, in  which  the  bulk  of  the  disease  is  composed  of  eidarged  vessels, 
these  vessels  being  either  arterial,  capillary,  or  venous.  The  tumors 
which  are  formed  chiefly  of  enlarged  arteries  are  called  aneurisms  by 
anastomosis.  They  are  large,  irregular  lobulated  pulsating  masses,  in 
which  a  considerable  bruit  can  often  be  heard,  and  numerous  large  ves- 
sels can  be  traced  into  them  on  all  sides.  The  capillaries  share  in  the 
enlargement,  and  the  veins  thus  receive  the  pulsation.  As  the  arteries 
enlarge  their  coats  become  thinned,  so  that  the  distinction  between  the 
arteries  and  veins  around  the  tumor  becomes  impossible.  The  growth  of 
the  tumor  sometimes  causes  ulceration  of  the  skin,  and  severe  or  even 
fatal  haemorrhage ;  but  ai)art  from  this  there  is  not  much  danger,  and  I 
have  seen  cases  which  have  gone  on  for  an  unlimited  time  without  material 
change.  Sometimes,  however,  when  the  disease  occurs,  as  it  usually  does, 
on  the  head,  the  constant  noise  is  so  distressing,  and  the  increase  of  the 
tumor  so  threatening,  that  the  surgeon  is  compelled  to  interfere. 

The  diagnosis  is  usually  obvious.  At  the  same  time  I  have  seen  a  pul- 
sating cancer  of  the  skull  mistaken  for  aneurism  by  anastomosis  and 

Fig.  158. 


Aneurism  by  anastomosis  of  the  upper  lip.    From  a  drawing  presented  by  Sir  B.  Brodie  to  the  Museum 

of  St.  George's  Hospital. 

operated  on,  the  patient  being  with  difficulty  saved  from  death  on  the 
table.  A  more  accurate  examination  would  have  shown  in  this  case  that 
the  skull  was  perforated,  for  pressure  on  the  tumor  produced  vertigo,  loss 
of  consciousness,  and  partial  hemiplegia. 

The  favorite  seats  of  this  disease  are  the  scalp  and  the  lip.  In  the 
scalp  they  are  commonly  close  to  the  ear,  and  the  disease  often  extends 
into  and  implicates  the  vessels  of  the  ear. 

They  have  been  treated  by  all  kinds  of  operations.  When  small  they 
might  possibly  be  cured  by  setons  or  by  ligature  applied  as  to  an  ordi- 
nary nsevus.     The  larger  tumors  are  best  treated  by  the  galvanic  cautery.. 


360  TUMORS. 

The  wire  being  passed  througli  the  mass  at  its  base  is  tlieii  attached  to 
the  battery,  so  as  to  bring  it  to  a  wliite  heat,  and  is  drawn  slowly  out  to 
the  surface,  cutting  the  tumor  into  two  parts  and  searing  the  divided  sur- 
face as  it  cuts,  so  that  no  hjemorrhage  occurs.  This  may  be  repeated  la 
several  places,  and  so  the  tumor  will  be  divided  b}^  several  cicatrices,  by 
which  the  vascular  tissue  will  be  obliterated.  As  fresh  parts  threaten  to 
grow  tliey  must  be  treated  in  the  same  way.  Bleeding  may  occur  during 
the  sei)aration  of  the  sloughs,  and  must  be  combated  either  by  the  lio;a- 
ture  or  actual  cautery. 

The  total  removal  of  the  tumor  is  a  still  more  certain  method  of  treat- 
ment, but  the  operation  is  highly  dangerous  when  the  growth  is  large. 
An  incision  is  made  around  a  part  of  the  base  of  the  tumor,  cutting 
across  several  large  vessels,  which  are  then  tied.  If  the  patient  has  not 
lost  too  much  blood  the  cut  is  then  extended  around  another  part  or  the 
whole  of  the  circumference,  and  again  the  divided  vessels  are  tied.  When 
the  whole  circumference  has  thus  been  dealt  with  the  mass  is  rapidly 
removed  and  all  vessels  at  its  base  secured.  In  large  tumors  it  is  often 
necessary  to  divide  this  operation  into  several,  allowing  an  interval 
between  each  for  the  recovery  of  the  patient  from  the  results  of  haemor- 
rhage. The  ligature  of  the  main  trunk  artery  (the  common  or  external 
carotid j  has  often  been  practiced  in  aneurism  b}'  anastomosis;  even  the 
common  carotids  on  both  sides  have  been  tied,  with  a  due  interval.  But 
I  cannot  discover  that  the  practice  has  been  so  successful  as  to  justify 
the  operation.  Mr.  Southam  has  published  a  successful  case,^  but  here 
the  seton  was  also  employed.  On  the  other  hand,  I  remember  a  remark- 
able case  in  which  the  patient  had  been  in  great  danger  from  repeated 
haemorrhage.  This  had  been  suppressed  and  the  patient  restored  to 
heallli  and  comfort  by  the  persevering  use  of  the  galvanic  cauter}-.  Three 
years  afterwards  the  bleeding  recurred,  and  a  surgeon  was  sent  for,  who, 
unluckily  for  the  patient,  tied  the  common  carotid.  The  man  bled  to 
death  fifteen  days  afterwards,  while  the  ligature  was  still  firm  on  the  ves- 
sel.^ At  the  same  time  cures  are  claimed  after  this  operation  the  reality 
of  which  I  am  not  concerned  to  dispute.  All  that  I  would  say  is  that  I 
believe  local  cauterj'  to  be  safer  and  more  efficient. 

NxvuH. — Capillary  and  venous  tumors  are  called  naevi,''  and  n?evi  are 
also  divided  into  cutaneous  and  subcutaneous,  the  purely  venous  nnevi 
being  usually  subcutaneous,  those  entirely  confined  to  the  skin  being 
always  capillary  only  ;  while  those  in  vvhicli  the  skin  and  cellular  tissue 
are  affected  simultaneously  are  usually  of  the  mixed  kind  ;  and  in  all 
such  cases  large  veins  will  l)e  seen  running  away  from  the  tumor. 

Tiie  nature  of  the  common  ntevus,  or  mother-mark,  is  obvious  at  first 
sigiit,  and  in  some  more  serious  cases  the  whole  or  great  part  of  the  side 
of  the  face  is  iini)licated  in  a  similar  dilatation  of  tlie  capillaries,  called 
•'^  port  wine  stain,"  or  along  with  the  enlarged  vessels  there  is  a  pigment- 
ary foi-mation,  and  often  an  overgrowth  of  hair.  But  I  do  not  know 
that  anytliing  has  yet  been  successfully  attempted  for  the  relief  of  this 
deformity.  The  ordinary  capillary  n.nevus  is  very  common  indeed;  and 
as  a  great  many  i\  tiiink  the  majority)  of  such  n.'cvi  remain  without  an}' 
growth  indefinitely,  tiicy  should  Ite  left  alone,  unless  from  their  situation 
they  occasion  any  unpleasant  dcfornuty,  or  from  their  growtii  it  becomes 
necessary  to  treat  tiiein,  in  wiiich  case,  if  they  are  in  a  position  where  a 
scar  is  of  no  consequence,  they  siiould  be  removed  either  by  ligature  or 

I  M(!fl..Chir.  Trans.,  vol.  xlviii,  p.  (55.  *  Lancet,  1858,  vol.  ii,  pp.  75,  339. 

'  Some  authors  also  speak  of  nn(!uri.sm  by  anastomosis  under  the  name  of  "  arterial 
nffivus." 


N^vus.  361 

with  the  knife.  The  latter  is  safe  enough  if  the  tumor  be  avoided,  but 
as  the  former  is  quite  free  from  all  risk  of  haemorrhage  it  is  more  com- 
monly used,  especially  in  private  practice.  Two  stout  harelip  needles 
being  passed  beneath  the  nievus  at  right  angles  a  strong  ligature  is  tied 
beneath  them  as  tightly  as  i)ossil)le.  If  the  mass  is  large  it  is  well  to 
cut  a  groove  in  the  skin  from  each  needle  to  the  one  next  it  for  the  liga- 
ture to  lie  in.  The  great  point  is  to  tie  the  ligature  tight  enough,  in 
which  case  there  is  no  pain  afterwards.  The  surgeon  may  be  certain 
that  the  tumor  is  completely  strangulated  if  he  pricks  it  with  a  needle 
here  and  there  while  the  ligature  is  drawn  tight  and  sees  that  at  last  onl}^ 
a  little  serous  fluid  oozes  from  the  punctures.  The  points  of  the  needles 
should  be  cut  off  with  pliers  made  for  the  purpose,  and  a  strip  of  lint 
wound  under  them  and  round  their  ends.  When  the  mass  has  turned 
black  the  needles  may  be  removed  and  a  poultice  applied  till  the  slough 
drops  oft".  The  subcutaneous  nrevi  may  be  removed  like  any  other  sub- 
cutaneous tumor,  by  dissecting  the  skin  from  above  them  and  removing 
them  without  opening  the  capsule  in  which  they  are  contained  ;'  or  if  at 
any  stage  of  the  operation  the  surgeon  should  meet  with  alarming  iijemor- 
rhage  the  ligature  ma}'  be  substituted.  And  in  naevi  which  are  only  partly 
subcutaneous  a  similar  operation  may  be  performed,  i.  e.,  the  skin  may  be 
dissected  from  the  mass  below,  generally  without  much  hfemorrhage,  and 
the  latter  be  thus  removed.  But  I  cannot  say  that  in  the  few  trials  I  have 
made  of  this  method  I  have  seen  much  use  in  the  skin  so  preserved.  It  is, 
in  fact,  so  thin  and  ill-nourished  that  it  generally  sloughs  or  withers  away. 

The  caustic  treatment  of  small  njevi  is  very  satisfactory.  The  caustic 
generally  used  is  nitric  acid,  or  the  acid  nitrate  of  mercury,  which  will 
remove  a  small  mother-mark  in  two  or  three  applications,  leaving,  how- 
ever, a  small  depressed  cicatrix  very  like  that  of  vaccination.  The  actual 
cautery  by  means  of  a  white-hot  needle,  or  a  point  of  white-hot  metal  with 
a  bulb  above,  by  which  the  heat  is  prevented  from  too  suddenly  being 
quenched,  is  also  often  used,  and  successfully.  But  many  of  these  small 
naevi  may  be  removed  with  less  deformity  by  the  application  of  tiie  elec- 
trolytic current ;  i.  e.,  a  current  of  electricity  of  very  low  power  continued 
for  some  time,  so  as  to  disintegrate  the  tissues  without  cauterizing  them. 

Another  plan  which  should  be  mentioned  is  vaccination.  If  the  child 
has  not  been  previously  vaccinated  he  may  be  vaccinated  on  the  nrevus, 
the  vaccine  being  introduced  in  a  great  many  places  very  close  together. 
The  object  is  to  obliterate  the  va,scular  tissue  by  the  inflammation  pro- 
duced around  the  vaccine  pustules.  But  the  plan  is  not  one  which 
deserves  recommendation.  It  is  very  uncertain,  since  the  vaccine  may 
be  washed  away  b}'  the  blood,  and  it  has  usually,  if  not  always,  failed  in 
the  cases  which  I  have  seen  ;  and  when  vaccine  pustules  are  produced,  it 
by  no  means  follows  that  the  nsevus  is  cured,  or  that  the  child  has  obtained 
the  proper  immunity  from  small-pox. 

Coagulaling  Injection. — Again,  subcutaneous  nrevus,  especially  those 
large  ntevi  which  sometimes  occur  in  the  parotid  region,  may  be  treated 
by  the  injection  of  perchloride  of  iron.  The  method,  however,  is  a  dan- 
gerous one,  one  case,  at  least,  being  on  record  in  which  instant  death 
was  caused,  probably  by  coagula  carried  into  the  heart.^  If  it  is  employed 
the  solution  should  be  used  in  small  quantity,  three  or  four  drops  being 
injected  through  the  hypodermic  syringe  first  in  one  place  and  then  in 

1  See  Teale,  in  Med.-Chir.  Trans.,  vol.  1,  p.  57.  The  existence  of  a  complete  capsule 
subdividiniz;  the  growth  into  lobules  is  very  distinctly  described  in  the  account  which 
Mr.  Birkett  has  given  of  the  structure  of  a  nsvus  in  the  Med.-Chir.  Trans.,  vol.  xxx, 
I).  193. 

2  Teale,  Med.-Chir.  Trans.,  vol.  1,  p.  62. 


362 


TUMORS. 


another. 


Fig.  159. 


Some  surgeons  first  break  down  the  tissue  of  the  nrevus  with  a 

broad  cutting  needle,  and  then 
introduce  the  coagulating  injec- 
tion into  the  cavity  so  produced. 

Subcutaneous  Ligature.  —  The 
larger  nsevi  require  complicated 
forms  of  ligature  for  their  strangu- 
lation. Those  that  are  entirely 
subcutaneous  are  generally  treat- 
ed by  the  subcutaneous  ligature. 
The  needle  (which  should  be  a 
large  curved  one)  is  armed  with  a 
strong  piece  of  whipcord.  This 
is  entered  at  one  point  of  the  cir- 
cumference and  carried  round  the 
base  as  far  as  possible,  when  it 
emerges  through  the  skin.  The  lig- 
ature having  been  drawn  through 
as  far  as  necessary  is  re-entered  at 
the  same  puncture  and  carried 
round  another  portion  of  the  circle, 
and  so  on,  till  at  length  it  reaches 
the  original  point  of  entrj'^,  through 
which  its  two  ends  now  protrude, 
and  must  be  tied  as  tightly  as  pos- 


Subcutaneous  ligature  of  nreviis.  The  upper  figure 
shows  a  single  ligature  carried  round  the  tumor. 
The  lower  (iu  which  no  tumor  is  depicted)  shows  a 
double  string  carried  below  the  centre  of  the  base, 
then  divided  into  two,  a  a'  and  b  b',  and  each  of  the 
two  carried  subcutaneously  round  half  of  the  naeviis, 
and  then  tied. 


Fig.  160. 


1.  The  threaded  needle 
passed  under  the  centre  of 
the  base  of  the  tumor;  one 
thread  divided  near  the 
needle. 


2.  The  other  end  of  the  divided  thread  passed  3.  The  needle  withdrawn  and  the  nsDvus  stran- 

into  the    needle's  eye.     Both   threads   carried  gulated  iu  quarters, 

round  a  quarter  of  thecircumfereuce  and  passed 
under  the  base  alright  angles  to  their  former 
direction. 

Fio.  160.— "Fergusson's  knot,"  for  the  strangulation  of  large  ntcvi,  or  other  tumors.  In  order  to  keep 
the  diagrams  of  a  convenient  size  the  tumor  has  been  represented  relatively  much  smaller  than  it  is  in 
practice;  and  in  Fig.  3  the  incisions,  which  are  usually  made  through  the  skin  from  each  puncture  to 
the  next,  have  been  omitted,  to  avoid  complication.  They  are  not  absolutely  necessary,  if  the  mass  is 
not  very  large,  but  they  reduce  the  quantity  of  ti.ssue  which  is  to  be  cut  through  by  the  ligature,  and 
promote  the  success  of  the  operation,  besides  very  probably  saving  the  patient  some  pain  while  the 
ligature  is  separating. 


NJiiVUS. 


363 


Fig.  IGl. 


sible.  Or  if  the  mass  is  too  large  to  be  dealt  with  in  this  way  the  ligature 
may  first  be  carried  under  the  middle  of  the  tumor,  and  may  then  be  di- 
vided into  two,  which  is  applied  as  before  subcutaneously  to  eacli  half. 
Another  excellent  knot  for  a  large  n?evus  is  that  which  goes  by  Sir  W. 
Fergusson's  name,  and  which  is  represented  in  Fig.  160. 

In  otlier  cases,  where  the  tumor  is  of  an  elongated  form,  the  form  of 
ligature  represented  in  Fig.  161  is  more  appropriate.  The  tumor  is 
strangulated  in  pieces  by  passing  a  double  ligature  under  its  base  from 
side  to  side,  as  there  shown.  The  ends  of  the  ligature  are  colored  differ- 
ently— sa}'  one  white  and  the  other  black.  Eacii  loop  is  left  long,  so  that 
the  whole  ligature  must  be  of  great  length.  Then  the  white  loops  are 
divided  on  one  side  and  the  black  on  the  other,  and  the  pairs  of  white 
and  black  strings  are  tied  tightl}'.  The  whole  tumor  will  thus  be  found 
to  be  strangulated. 

The  two  latter  methods  necessarily  involve  the  death  of  the  skin,  and 
even  although  the  purely  subcutane- 
ous ligature  does  not,  perhaps,  in- 
volve the  death  of  the  skin  by  abso- 
lute necessity,  since  enough  nutrition 
ma}'^  be  provided  by  the  vessels  which 
pass  into  tiie  skin  between  the  punc- 
tures to  avert  gangrene,  j^et  sucli  a 
fortunate  result  is  often  obtained. 
More  commonly  the  subcutaneous 
ligature  sets  up  extensive  inflamma- 
tion, in  which  the  whole  tissue  per- 
ishes, including  the  skin. 

Mr.  Barwell  has  lately  described  a 
process  for  the  "  scarless  eradication" 
of  nsevus*  by  means  of  an  instrument 
whereby  a  wire  conveyed  subcutane- 
ously around  the  base  of  the  tumor 
is  gradually  tightened  bj'  means  of 
an  appropriate  mechanism  until  it 
comes  away,  and  so  divides  all  the 
vessels  which  nourish  the  subcutane- 
ous part  of  the  nsevus.  After  this  the 
subcutaneous  ntevus  can  be  treated 
with  nitric  acid  if  necessary,  but  often  withers  away  and  disappears  spon- 
taneously. ♦ 

Another  plan  which  will  often  check  the  growth  of  large  naevi,  and 
which  is  eminently  useful  in  situations  where  their  complete  removal  is 
impossible  or  very  dangerous,  is  to  cut  them  into  pieces  by  ligatures  con- 
veyed under  their  base  and  tied  tightl}'^  round  tlie  entire  tissue.  If  the 
growth  be  so  large  that  the  first  ligature  will  not  ulcerate  through  it,  a 
second  can  be  introduced  into  the  groove  which  the  ulceration  of  the  first 
has  caused,  and  thus  when  the  Matures  have  come  away  the  tumor  will 
be  divkled  into  portions  by  wounds,  in  which  l)ands  of  cicatrix  will  form, 
and  so  its  growth  will  be  arrested.  A  case  of  venous  nsevus  in  the  scro- 
tum treated  successfully  in  this  w^ay  will  be  found  described  and  figured 
in  the  Path.  Soc.  Trans.,  vol.  xv,  p.  95. 

There  are  other  methods  of  treatino-  naivi  too  numerous  to  mention. 


Ligature  for  strangulating  a  large  naevus. 
The  white  loops  are  divided  on  one  side,  and 
the  black  on  the  other,  and  the  corresponding 
ends  (as  a  a',  b  b')  tied  together.  The  termi- 
nal strings  c  c  may  be  either  tied  or  withdrawn, 
as  the  surgeon  thinks  best. 


1  Lancet,  May  8,  1875. 


364 


TUMORS. 


I  need  only  add  that  ver}'  large  njevi  are  often  cured  by  the  introdnction 
of  setons.  Some  surgeons  steep  the  seton-threads  in  perchloride  of  iron. 
Degeneration. — Na?vi  which  do  not  grow  may  remain  stationary,  or 
ma}'  disappear,  or  may  degenerate.  In  some  cases,  usually  after  an  attack 
of  some  gi'ave  illness,  such  as  scarlet  fever  or  hooping-cough,  even  large 
noevi  have  been  known  to  disappear  altogether.  Thus  in  the  discussion 
on  Ml'.  Teale's  proposal  for  enucleating  the  large  ntevi  which  sometimes 
form  in  the  parotid  region,  Mr.  Prescott  Hewett  related  an  instance  in  his 
own  family  where  a  nrevus  of  this  kind  had  entirely  disappeared  soon 
after  one  of  the  common  affections  of  childhood.  In  other  cases  the 
tumor  after  ceasing  to  grow  degenerates  into  a  c^'stic  mass,  and  this  is  a 
well-known  cause  of  congenital  cystic  tumor.  The  contents  of  the  tumor 
nia}^  vary  very  much  from  the  composition  of  the  blood,  though  they 
generally  show  some  trace  of  their  origin. 

Sarcovm. — Sarcomatous  tumors  are  defined  to  be  such  as  in  their  for- 
mation and  growth  present  some  resemblance,  though  an  imperfect  one, 
to  the  formation  and  growth  of  the  normal  tissues.  The  class  of  semi- 
malignant  or  locally  malignant  tumors  belong  to  the  sarcomata,  but  many 
sarcomata  are  innocent,  and  others,  on  the  contrary,  are  extremely  malig- 
nant. The  classification,  therefore,  does  not  seem  to  me,  I  own,  a  good 
one,  or  likel}''  to  be  permanent ;  but  as  it  has  lately  come  much  into  vogue 
it  seems  better  for  the  present  to  adhere  to  it.  The  general  characters  of 
sarcomata  are,  that  they  consist  of  fibrous  tissue  more  or  less  perfectly 
formed,  and  of  cells  which  display  some  resemblance  to  the  normal  cells 

of  either  embryonic  or  adult  fibres, 
Fi"- 1*52.  membrane,  muscle,  bone,  cartilage, 

or  nerve,  the  cells  and  fibrous  tis- 
sue having  an  organic  connection, 
and  the  former  showing  a  tendency 
to  higher  development. 

The  class  of  sarcomata,  there- 
fore, embraces  a  considerable  num- 
ber of  those  tumors  which  have 
been  described  above  as  "  fibro-cel- 
lular,^'  and  it  very  nearly  coincides 
with  the  tumors  described  formerly 
as  "  fibro-plastic,"  the  only  differ- 
ence being  that  under  the  term 
sarcoma  man}''  tumors  have  been 
included  by  the  German  patholo- 
gists which  are  of  a  truly  malig- 
nant clinical  nature,  and  which 
used  to  be  described  as  cancer. 
Taking  this  definition,  the  follow- 
ing are  the  tumors  which  are  ar- 
ftingcd  by  Billroth  under  the  head 
of  sarcoma  :  • 

a.  Round  felled  or  granulation  sarcoma,  in  which  the  chief  constitu- 
ents are  small  round  cells  like  lymph-cells,  such  as  are  found  in  granula- 
tions, the  intercellular  substance  being  either  distinctly  fibrous  or  libril- 
lated  or  perfectly  homogeneous,  as  in  the  neuroglia  or  transparent  sheaths 
of  the  nerve-tubes  (glioma). 

h.  Spindle-celled  sarcoma,  which  is  composed  of  small  elongated  cells 
(oat-  or  awn-shaped),  sometimes  without  any  intercellular  substance,  at 


Round  or  oval-celled  sarcoma.  From  a  tumor 
of  the  female  breast,  de.scribcd  in  I'ath.  Tran.s., 
vol.  xix,  pp.  394-^97,  and  figured  in  the.  same  vol- 
ume as  pi.  xii,  Fig.  6. 


SARCOMA, 


365 


other  times  united  by  a  homogeneous,  fibrillar,  or  fibrous  tissue.  The 
cells  are  variously  regarded  as  embryonic  connective  tissue  (Lebert),  or 
embryonic  nervous  or  muscular  tissue  (Billroth). 


t,^)^  *"  o  -6  »^  -OO- ^ 

Section  from  a  spindle-celled  sarcoma  of  the  femur,  taken  from  the  exterior  of  the  tumor,  a  shows 
the  "indifferent  granulation  material"  or  "  adenoid  tissue"  stretching  out  from  the  tumor  structure 
(6)  into  the  adipose  tissue  (c)  separating  its  cells.  The  tumor  was  of  a  malignant  character,  and  con- 
tained in  other  parts  of  its  substance  cartilaginous  and  osteoid  material.  Path.Soc.  Trans.,  vol.  xxi, 
p.  341,  and  pi.  viii,  Fig.  1. 

c.  Giant-celled  sarcoma,  or  myeloid  tumor,  in  which  the  cells  distinc- 
tive of  the  form  of  tumor  are  very  large,  contain  numerous  nuclei  (some- 

FlG.  164. 


'  Giant-celled  sarcoma,"  or  myeloid  tumor. — After  Billroth,    a  points  to  a  part  where  cysts  were  being 
formed  by  the  softening  of  the  tissue  of  the  tumor;  6,  to  a  focus  of  ossification. 


366 


TUMORS. 


times  as  many  as  twenty  or  thirty),  and  are  often  provided  with  numerous 
offshoots.  These  cells  are  likened  to  those  which  occur  in  the  marrow  of 
fa?tal  bones.  Such  cells  are  found  mixed  up  with  the  tissue  of  any  of 
the  other  forms  of  sarcoma,  but  they  are  most  common  in  tumors  which 
spring  from  bone,  and  they  will  be  further  spoken  of  in  the  chapter  on 
Diseases  of  Bone. 

d.  Mucvus  or  net-celled  sarcoma  (myxoma.  Yirchow),  characterized  by 
the  development  of  caudate  branching  cells,  communicating  with  each 

Fig.  165.  Fig.  166. 


U 


ni 


4 IS 


Fig.  165. — Section  of  myxoma,  a.  Angular  or  stellate  bodies,  the  prolongations  of  which  anastomose 
so  as  to  form  a  network  traversing  the  whole  section,  h.  Small  round  cells,  having  no  apparent  con- 
nection with  the  angular  corpuscles,  c.  Corpuscles  having  much  resemblance  to  mucous  corpuscles, 
but  smaller,  contained  in  the  prolongations  of  the  branching  or  angular  bodies.  These  prolongations 
had  double  outlines,  and  appeared  to  form  canals,  in  which  the  mucous  corpuscles  were  contained. 
Some  fatty  tissue  was  mingled  with  the  structure  of  this  tumor.    (From  Path.  Trans.,  vol.  xx,  p.  344.) 

Fio.  166.— "Alveolar  sarcoma."— After  Billroth. 


other,  and  lioaring  a  resemblance  to  the  structure  of  the  gelatinous  tissue 
of  tlie  umbilical  cord  or  that  of  the  vitreous  body.  Mixed  with  tliis  is 
commonly  a  variable  quantity  of  soft  mucous  substance  (colloid)  or  soft 
tissue,  more  or  less  resembling  cartilage  ;  and  bone  may  also  be  found 
in  these  mucous  sarcomata. 

e.  Billrotli's  next  class  of  sarcomata  is  the  alveolar,  in  which  he  allows 
the  great  difficulty  of  distinguishing  the  structure  from  carcinoma,  and 
in  wiiich  his  description  hardly  shows  any  difference.  The  cells  are 
round,  larger  than  the  lymph-cells,  with  one  or  more  large  nuclei,  con- 
taining glistening  nucleoli,  and  about  the  size  of  cartilage-cells,  or  mod- 
erately large  flat  epithelium.  The}'  lie  in  the  interstices  of  a  beautifull}' 
alveolar  cellular  tissue. 

f.  Finally,  we  have  the  pigmenfarij  or  melanotic  sarcoma,  in  which  one 
or  other  of  tlie  above  forms  of  sarcoma  is  colored  black  or  dark-brown 
by  the  deposit  of  granular  pigment,  which  almost  always  occurs  in  the 


SARCOMA.  367 

cells,  and  more  rarely  in  the  intercellular  substance  also  (Fig.  HI,  p. 
373). 

I  have  thus  given  the  anatomical  division  of  this  class  of  tumors  from 
one  of  the  most  recent  and  most  authentic  of  the  German  pathologists, 
in  order  to  place  before  the  reader,  as  intelligibl_y  as  I  can,  the  views 
which  have  recently  prevailed.  Not  that  sui-geons  or  pathologists  are 
by  any  means  agreed  upon  those  views.  For  instance,  Billroth's  alveolar 
sarcoma  is  not  recognized  by  otlier  authors,'  and  seems  to  me,  according 
to  his  own  description,  to  belong  ratlier  to  carcinoma;  and  mt'Ia» otic 
tumors  are  certainly  in  the  human  subject  often  regarded  as  carcinoma- 
tous ;  but  the  other  members  of  Billroth's  series  are  usually  admitted  as 
distinct  anatomical  forms  of  tumors,  and  classified  as  sarcoma. 

Their  clinical  characters  are  unfortunately  very  varial)le.  We  only 
know  of  glioma  as  occurring  in  the  interior  of  the  eye  and  in  the  brain. 
In  the  latter  position  its  separate  clinical  history  cannot  be  traced,  since 
it  causes  death  by  its  situation.  For  its  description  as  it  occurs  in  the 
eye  I  must  refer  to  the  chapter  on  Diseases  of  the  Eye.^ 

Some  of  the  other  sarcomatous  tumors  ai"e  among  the  "  recurrent,"  or 
"  locally  malignant  "  type,  and  many  others  are  decidedly  cancerous  in 
their  clinical  history.  The  spindle-celled  sarcoma  is  in  some  of  its  forms 
identical  with  the  recurrent  fibroid  of  Paget,  or  the  fibro-plastic  tumor  of 
Lebert.  Such  tumors  will  when  removed,  however  completely,  occasion- 
ally but  not  always  recur  in  the  cicatrix  of  the  operation,  and  their  con- 
stant recurrence  will  cause  death.  Thus,  the  Museum  of  St.  George's 
Hospital  contains  specimens  from  a  case  of  this  kind,  in  which  a  fibro- 
plastic tumor,  or  fibre-celled  sarcoma,  originally  developed  in  the  female 
breast,  was  removed  ten  times,  until  at  length  the  extent  of  tissue  impli- 
cated bv  it  became  too  great  for  adequate  removal,  and  the  patient  died 
exhausted  bj'  its  ulceration,  eighteen  years  after  its  first  appearance.* 
Further,  there  are  cases,  though  not  so  numerous,  in  which  tumors  of 
this  sort  recur,  not  in  the  cicatrix,  or  not  there  only,  but  in  the  internal 
viscera,  usually  the  lungs  or  the  liver,  very  much  after  the  manner  of 
cancer.  For  example,  Mr.  Mitchell  Henry*  man}'  years  ago  related  a 
case  in  which  a  myeloid  tumor  amputated  at  the  shoulder-joint  recurred 
both  in  the  stump  and  in  the  lungs;  and  I  have  myself  recorded  a  case 
in  which  a  fibro-plastic  tumor  of  the  thigh,  recurring  after  imperfect  re- 
moval, was  amputated  at  the  hip-joint,  and  the  patient  died  some  months 
afterwards,  with  a  similar  growth  in  the  pelvi^s,  in  the  lungs,  the  brain, 
and  in  other  still  more  remote  parts  of  the  body — viz.,  the  spine  and  the 
thorax — the  stump  of  the  amputation  being  all  the  time  quite  sound  and 
healthy.  The  structure  of  the  tumor  in  this  case  was  minutelj'  examined 
both  before  and  after  recurrence  by  several  experienced  microscopists, 
so  that  its  nature  cannot  be  doubted.^  In  another  case,  where  the  breast 
had  been  removed  for  a  large  fibro-plastic  tumor,  the  growth  recurred  in 
the  cicatrix,  and  afterwards  in  the  opposite  breast,  which  I  also  removed; 
but  the  recurrence  was  not  checked,  and  it  ultimately  proved  fatal. 

There  is  no  question  that  when  these  sarcomatous  (myeloid  and  fibro- 

'  See  the  very  useful  and  practical  account  of  the  anatomy  of  tumors  by  Dr.  Moxon 
in  Bryant's  Practice  of  Surgery,  chap.  Ixv. 

2  Since  glioma  is  only  connected  with  the  neuroglia,  it  is  often  described  as  a  dif- 
ferent form  of  tumor  from  the  ordinary  sarcoma,  which  springs  from  connective 
tissue,  and  this  is  the  view  tal^en  in  the  chapter  on  Diseases  of  the  Eye. 

*  St.  George's  Hospital  Museum,  Ser.  xvii,  Nos.  58  to  60. 

*  Path.  Soc.  Trans.,  vol.  ix,  p    367 

6  Path.  Soc.  Trans.,  vol.  xvii,  pp.  217,  '2dO.  See  also  the  woodcuts  and  report  on 
p.  292. 


368  TUMOES. 

plastic)  tumors  are  thus  diffused  into  remote  parts  of  the  body  the  ele- 
ments of  their  diffusion  are  sometimes  carried  by  the  veins  ;  and  Billroth 
claims  to  have  been  one  of  the  first  to  show  that  sarcoma  (contrar^^  to 
what  is  very  common  in  carcinoma)  never  attacks  l^'mphatic  glands,  and 
he  therefore  believes  that  it  is  through  the  venous  system  tliat  such  in- 
fection proceeds  in  sarcoma.  This  is  probable,  but  it  is  a  matter  of  sec- 
ondary importance.  Wliat  is  more  important  to  tlie  surgeon  is  to  know 
whether  sarcoma  can  be  diagnosed  from  other  less  dangerous  forms  of 
tumor,  and  whether  after  removal  any  prognosis  can  be  arrived  at — ?'.  p., 
whether  the  surgeon  can  saj^  with  any  approach  to  accuracy  whether  the 
tumor  will  recur  or  not. 

With  regard  to  the  diagnosis  between  sarcoma  and  carcinoma  at  an 
earl}'  stage — i.  e.,  before  any  glandular  affection  has  been  developed  and 
before  the  skin  has  given  wa}'^ — it  can  hardly,  I  think,  be  established 
definitely.  The  diagnostic  signs  which  Billroth  points  out  are  as  follows  : 
"  Sarcomata  develop  with  peculiar  frequenc}'  after  previous  local  irrita- 
tions, especially  after  injuries;  cicatrices  also  are  not  unfrequently  the 
seat  of  these  tumors  ;  black  sarcomata  (melanosis)  may  come  from  irri- 
tated moles.  Skin,  muscles,  nerves,  bone,  periosteum,  and,  more  rarely, 
glands  (among  these  the  mamma  most  frequently)  are  the  seats  of  these 
tumors.  Sarcomata  are  rarest  in  children,  rare  between  ten  and  twenty 
3'ears,  most  frequent  in  middle  life,  and  rarer  again  in  old  age.  .  .  .  The 
growth  is  sometimes  rapid,  sometimes  slow ;  the  consistence  varies,  so 
that  it  can  rarely  be  used  as  a  point  in  diagnosis"  {lib.  cit.^  p.  618).  To 
these  diagnostic  signs  Billroth  adds  that  sarcomata  are  usually  encap- 
suled,  and  carcinomata  are  not ;  but  as  it  is  certain  that  the  more  rapidlj'^ 
growing  sarcomata  are  not  encapsuled,  this  can  hardly  be  regarded  as 
diagnostic.  And  I  need  scarcel}^  say  that  the  above  diagnostic  signs  are 
far  indeed  from  estahlisliing  any  reliable  distinction  b}^  which  sarcoma 
and  carcinoma  can  in  all  cases  be  distinguished  ;  in  fact,  this  is  often 
hardh'  possible,  even  after  removal  and  careful  examination. 

Tlie  rapidity  of  their  growth  is  that  w^iich  more  than  anything  else 
distinguishes  the  sarcomatous  from  the  purely  innocent  tumors;  and  the 
only  indication,  as  far  as  we  know  as  yet  of  the  probability  of  recurrence, 
is  drawn  from  this  rapidity  and  from  the  succulence  of  the  growth. 
Rapidly  growing  soft  tumors  are  regarded  with  much  more  apprehension 
than  those  of  firmer  consistence  and  slower  increase.  In  any  case  the 
l^rognosis  is  better  if  th^  tumors  have  been  very  early  and  ver}^  freely 
removed.  Even  after  one  or  more  recurrences  the  case  is  not  absolutely 
hopeless.  Cases  are  on  record  where,  after  the  second  or  third  removal, 
no  further  development  of  the  disease  has  taken  place,  and  such  cases 
render  it  the  plain  duty  of  the  surgeon  to  interfere,  and  at  the  earliest 
possil)le  moment,  when  recurrence  is  ascertained  ;  though,  as  a  rule,  a 
tumor  which  has  once  recurred  will  go  on  doing  so  ;  and  the  more  rapidl}'' 
it  recurs  the  more  rapidly  it  will  in  all  probabilit}^  ulcerate  ;  and,  as  a 
general  rule,  the  oftener  it  has  been  removed  the  shorter  will  be  the  pa- 
tient's next  respite.  Sarcomatous  or  fibro-i)lastic  tumors  when  ulcerated 
much  resemljle  cancer;  but  as  there  is  certainly  more  hope  of  successful 
removal  in  the  former  than  the  latter,  it  is  important  to  draw  the  distinc- 
tion ;  and  tliis  is  made  chiefly  by  the  amount  of  infiltration  of  the  sur- 
rounding skin.  A  tumor  which  fungates  out  of  a  cleanly  cut  hole  in  the 
skin  is  probably  sarcomatous  ;  one  in  which  the  tissue  of  the  skin  around 
tlie  hole  is  redematous,  hardened,  and  studded  with  nodular  masses,  is 
in  all  likelihood  cancerous;  and  the  diagnosis  of  cancer  becomes  estab- 
lislied  if  tlie  glands  are  implicated. 


CARCINOMA.  369 

Carcinoma. — The  words  "  cancer  "  and  "carcinoma"  are  sometimes 
used  as  synonymous  and  equivalent  to  the  term  "  malignant  tumor;"  by 
other  authors  this  use  is  made  of  the  word  "cancer"  only,  by  which  is 
then  meant  a  tumor  presenting  the  clinical  characters  of  malignancy, 
while  the  term  "  carcinoma  "  is  made  to  be  strictly  anatomical.  In  the 
latter  terminology,  which  is  perhaps  now  the  more  common,  all  carcinom- 
atous tumors  are  also  cancerous  or  malignant,  but  the  term  cancer  ap- 
plies also  to  many  of  the  sarcomatous  tumors,  as  will  have  been  seen  from 
the  above  description  of  the  latter.  Carcinoma  is  defined  anatomically 
as  a  tumor  which  is  composed  of  an  areolar  framework  of  fil)rous  tissue, 
within  which  areohie  are  contained  collections  of  cells  bearing  a  consider- 
able resemblance  to  those  of  the  epithelium,  and  believed  by  most  modern 
pathologists  to  be  developed  from  that  structure,  so  that  they  deny  the 
possibility  o^  carcinoma  taking  its  origin  anywhere  except  upon  the  sur- 
face of  the  body,  whether  external  or  internal,  including,  of  course,  in  the 
surface  the  deeper  layers  of  the  epithelium  and  all  the  involutions  formed 
by  ducts,  follicles,  etc.;  though  no  one  denies  tiiat  cancer  or  malignant 
disease  originates  in  situations  such  as  the  interior  of  bones,  in  the  sub- 
stance of  the  brain,  and  innumerable  other  localities  far  away  from  any 
pre-existing  epithelium. 

Taking  this  definition  of  carcinoma,  it  would  be  defined  as  consisting 
of  a  network  of  fibres  in  which  may  be  found  the  nuclei  peculiar  to  con- 
nective tissue,  and  contained  in  these  areolae  a  mass  of  cells  varying  in 
shape,  size,  and  special  characters  in  different  examples  and  even  some- 
times in  the  same  example  of  the  disease,  but  all  of  them  bearing  some 
resemblance,  more  or  less  distinct,  to  the  normal  epithelium.  The  cells 
show  no  tendenc}^  to  pass  into  a  higher  stage  of  development,  as  those  of 
sarcoma  do,  nor  have  they  any  organic  connection  with  the  fii)rous  stroma. 
On  the  contrary,  they  are  marked  by  a  tendency  to  fatty  degeneration 
and  often  contain  oil-globules,  and  the  whole  tumor  tends  more  or  less 
rapidly  to  degeneration  and  ulceration. 

Carcinoma  is  prone  to  aflTect  the  hmphatics  leading  from  the  part  in 
which  it  was  originally  developed;  so  that  the  glands  next  in  order  are 
very  commonly  found  to  be  the  seat  of  a  similar  tumor,  and  this  glandu- 
lar formation,  when  confined  to  the  glands  immediately  connected  with 
the  primary  tumor,  is  by  many  surgeons  considered  rather  in  the  light  of 
a  portion  of  that  tumor  than  as  an  extension  of  the  disease.  And  cer- 
tainly the  disease  often  stops  for  a  time  at  these  first  glands.  But  from 
this  first  range  of  glands  it  will  pass  either  to  more  remote  glands  or  will 
infect  the  mass  of  the  blood  and  reappear  in  the  remotest  parts  of  the 
body.  Meanwhile  the  primary  tumor  has  been  locallj'  infecting  the  tissues 
in  its  neighborhood,  and  thus  making  its  way  to  the  surface  either  of  the 
skin  or  of  a  neighboring  serous  or  mucous  cavity.  In  its  course  it  breaks 
down,  as  above  stated,  so  that  its  structure  presents  traces  of  fatty  de- 
generation in  the  form  of  small  dots  of  a  yellow  chees^^  consistence,  visi- 
ble to  the  naked  eye,  and  in  the  presence  of  a  creamy  juice  (so-called 
"  cancer-juice  ")  which  can  be  scraped  or  squeezed  from  its  section.  The 
cancer-juice,  however,  is  not  entirely  formed  b}' the  breaking  down  of  the 
tumor.  In  some  cases  it  certainly  must  be  so,  in  great  part — as  shown 
by  the  quantity  of  oil  and  debris  which  it  contains — but  in  other  cases  it 
shows  only  well-formed  and  perfect  cancer-cells,  and  is  regarded  with 
great  probability  by  many  pathologists  as  the  medium  in  which  the  cells 
grow,  and   by  which  they  are  propagated  to  the  parts  around.'     When 

'  See  Savory,  Brit.  Med.  Journal,  Dec.  19,  1874. 
24 


370  TUMORS. 

the  disease  has  made  its  wa}-  to  the  surface  an  indolent  ulcer  is  formed, 
with  hard,  elevated  edges,  the  cancerous  material  being  infiltrated  into 
the  integument  for  a  variable  distance,  tlie  surface  of  the  ulcer  varying 
in  character  according  to  the  form  of  the  disease.  These  cancerous  ulcers 
are  ver}-  prone  to  hii^morrhage,  and  the  patient's  life,  if  not  cut  short 
otherwise,  is  gradually  worn  out  by  the  bleeding  and  the  exhaustion  of 
the  discharge.  Carcinoma  kills,  however,  in  many  other  ways.  The 
growth  of  the  primary  tumor  interferes  witli  the  functions  of  vital  organs  ; 
or  the  disease  is  propagated  into  one  of  the  great  viscera  ;  or  it  infects  the 
mass  of  the  blood,  causing  a  peculiar  cachexia,  which  sometimes  proves 
fatal  without  any  obvious  mechanical  cause. 

The  forms  into  which  carcinoma  is  divided  are  as  follows : 

1.  Hard  cancer  or  scirrhus — carcinoma  fibrosum — very  common  in  the 
female  breast.  This  is  distinguished  by  its  stony  hardness  (hence  popu- 
larly called  stone-cancer)  ;  it  feels  \\ke  a  lump  of  some  hard  foreign  sub- 
stance let  into  the  part;  in  its  growth  its  structure  often  shrivels,  so  as 
to  draw  the  neighboring  tissues  to  it,  producing  an  apparent  loss  of  size, 
gluing  the  integument  to  its  surface,  and  causing  the  dimple  of  the  skin 
so  often  seen  in  this  form  of  cancer,  and  the  retraction  of  the  nipple  which 
so  commonly  occurs  when  it  is  situated  in  the  breast.  Stretching  out 
from  the  main  tumor  may  often  be  found  indurated  strings,  being  the 
cellular  tissue  infiltrated  and  drawn  in  towards  the  tumor.  It  was  these 
projections  which,  being  fancifully  likened  to  a  crab's  claws,  gave  its 
name  to  the  disease. 

When  cut  into,  scirrhus  presents  a  characteristic  hardness,  feeling  like 
a  raw  potato  does  when  cut ;  its  section  is  whitish  or  grayish,  dotted  with 
minute  yellow  points,  and  its  surface  often  presents  a  concavity  caused 
by  the  shrinking  of  the  tumor.  The  tissue  of  its  exterior  passes  into  that 
of  the  healthy  structures  by  no  exact  or  defined  margin. 

Examined  microscopically  it  shows  a  stroma  which  is  often  extremely 
definite — the  cells  are  ''of  an  epithelial  type,  of  varying  size  and  shape, 
but  with  tolerably  uniform  (and  usuall^^  single)  large  nuclei,  closely 
packed  in  the  meshes  of  a  stout  fibrillated  stroma,  without  au}^  visible 
intercellular  elements."  ^  The  stroma,  which  man}'  pathologists  regard 
as  merely  the  compressed  connective  tissue  of  the  part,  is  believed  by 
Mr.  Arnott  to  be,  often,  at  any  rate,  a  new  formation. 

Tills  form  of  scirrhus,  collected  into  a  se})arate  nodule,  is  called  the 
tuberous  form  ;  the  other  is  the  infiltrating,  in  which  the  cancer  appears 
more  as  a  general  induration  of  all  the  tissues  in  the  neighborhood,  the 
skin  Ijcing  tliickened,  tense,  and  livid,  and  adhering  closely  to  the  parts 
below  ("liidebound  cancer");  the  disease  spreads  slowly  and  superfici- 
ally, ulcerating  in  one  part,  and  possibly  afterwards  healing  there  while 
spreading  in  other  parts. 

The  ulceration  of  a  scirrhus  tumor  leaves  a  sluggish  sore,  with  sharp 
edges,  bounded  to  a  variable  distance  by  cancer-tissue,  sometimes  with  a 
nearly  flat  surface,  at  others  with  prominent  granulations,  and  with  a 
peculiar  fetid  discharge,  the  smell  of  which  much  distresses  the  patient, 
and  which  is  mixed  with  more  or  less  blood  from  time  to  time.  Such 
ulcers  may  heal  for  a  time,  leaving  a  thin  livid  scar  very  prone  to  break 
down  again. 

Scirrhous  cancer  may  be  operated  upon,  whenever  tlie  skin  is  unaffected 
and  the  glands  are  not  implicated,  with  a  tolcrabl}'  certain  prospect  of 
benefit  from  the  cessation  or  prevention  of  the  stabbing  pain  which  often 


H.  Arnott,  in  Syst.  of  Surgery,  2tl  cd.,  vol.  i,  p.  G14. 


CARCINOMA. 


371 


accompanies  the  growth  of  the  tumor,  and  from  the  removal  of  what  is  a 
source  of  constant  annoyance  and  apprehension  to  the  patient.  Cases  are 
also  unquestionably  on  record  in  which  the  tumor  has  never  recurred, 
but  these  are  so  rare,  especially  if  we  insist  on  anatomical  evidence  of  the 
correctness  of  the  diagnosis,  that  they  need  hardly  be  taken  into  account, 
and  as  a  general  rule  the  return  of  the  disease  must  be  anticipated.  Xor 
is  there,  as  far  as  I  know,  any  conclusive  evidence  that  the  operation  pro- 
longs life,  for  it  must  be  remembered  that  the  course  of  scirrhus  is  some- 
times very  slow,  and  against  the  few  cases  in  which  no  return  has  takeu 


Fig.  167. 


Fig.  168. 


//■f' 


Fig.  167. — Microscopical  appearances  of  scirrhus  of  breast  (after  H.  Arnott).  "  The  typical  form  of 
hard  cancer.  To  one  side  of  the  section  are  drawn  a  few  detached  and  larger  cells  from  another  speci- 
men of  undoubted  scirrhus  of  the  breast,  showing  more  clearly  the  varying  size  and  shape  of  these  cells 
and  their  occasional  multiple  nuclei."    (Syst.  of  Surg.,  vol.  i,  Fig.  13,  opposite  p.  614,  2d  ed.) 

Fig.  168. — Cancer  stroma  (after  H.  Arnott).  "A  very  thin  section  was  made,  through  a  tolerably  firm 
pink-white  cancerous  nodule,  in  the  liver  of  a  patient  dying  with  hard  cancer  of  the  breast,  and  the 
cells  brushed  away  with  a  camel's  hair  pencil  under  water.  There  is  thus  left  the  typical  stroma  dimly 
fibrillated  and  granular,  inclosing  meshes  which  have  been  closely  tilled  with  cells."  (Syst.  of  Surg., 
ibid.,  Fig.  18.) 

place  for  many  yeai's  after  the  operation  may  be  set,  perhaps,  as  many  in 
which  the  tumor,  having  never  been  interfered  with,  has  remained  indo- 
lent and  innocuous  for  a  very  long  time,  until,  perhaps,  the  patient  h.as 
died  of  old  age  or  of  some  other  affection,  or,  after  this  long  interval, 
cancer  has  shown  itself  in  other  parts  of  the  body.'  But  there  is  certainly 
no  reason  to  say  that  operations  shorten  life  ;  and  as  they  give  a  period 
of  immunity,  and  usually  with  ver}'  little  danger,  they  should  be  per- 
formed in  all  appropriate  cases. 

Even  when  ulceration  has  occurred  to  a  considerable  extent  I  have 
known  the  operation  successful  in  procuring  a  considerable  period  of 
health,  and  avoiding  impending  death  from  haemorrhage. 

The  question  of  operating  when  the  glands  are  affected  is  a  doubtful 
one.  If  all  the  affected  glands  can  be  removed,  there  seems  no  reason 
why  the  operation  should  not  be  as  successful  as  in  any  other  case,  since 
the  glands,  as  was  said  above,  are  rather  a  part  of  the  primary  disease 
than  a  propagation  of  it ;  but  it  must  be  allowed  that  in  the  axilla  espe- 
cially it  is  extremely  difficult  to  remove  them  all,  without  a  most  formid- 
able and  frequently  fatal  operation  ;  those  that  are  obvious  being  only  a 
superficial  part  of  a  chain  of  glands  which  often  stretch  deep  into  the 
axilla,  and  where  a  second  chain  (as,  for  example,  the  cervical  glands  in 
cancer  of  the  breast)  has  become  involved  it  is  unjustifiable  to  operate. 

1  In  the  Path.  Trans.,  vol.  xi,  p.  220,  is  the  account  of  a  case  in  which  the  scir- 
rhous tumor  had  existed  for  more  than  thirty  years,  and  then  deposits  of  cancer  took 
place  in  various  parts  of  the  skeleton. 


372 


TUMORS. 


"When  there  is  a  second  tumor  perceptible  in  a  remote  part  of  the  body, 
or  any  symptoms  of  the  formation  of  such  a  tumor,  the  operation  is  inad- 
Tnissii)le,  as  also  when  the  presence  of  general  cachexia  testifies  to  the 
infection  of  the  mass  of  the  blood. 

2.  ^leduJJary  Cancer. — The  next  variety  of  carcinoma  is  the  encepha- 
loid,  medullary,  or  soft  cancer,  in  which  the  cells  are  more  plump, 
rounded,  and  usuall^^  more  uniform  in  size  and  shape,  and  the  alveolar 
stroma  less  distinct.  This  form  of  cancer  is  often  secondary  to  scirrhus, 
so  that  a  primary  scirrhous  tumor  in  the  breast  will  be  accompanied  by 
the  growth  of  medullary  carcinoma  in  the  glands  or  viscera.  It  grows 
much  more  rapidly  than  scirrhus,  is  often  exceedingl}-  vascular,  so  that 
large  blood-cysts  are  formed  in  the  interior  of  the  tumor,  and  its  surface 
is  very  commonly  permeated  by  large  veins.  To  the  most  vascular  exam- 
ples of  this  form  of  cancer  Mr.  Hey's  name,  "  Fungus  hfematodes,"  is  still 
occasionally  applied.  This  form  of  cancer  differs  from  scirrhus  in  the 
greater  softness  of  the  whole  mass  (whence  the  name),  in  tlie  relatively 
smaller  proportion  of  the  intercellular  substance,  in  the  greater  juiciness 
of  the  tumor,  and  the  more  rounded  shape,  larger  size,  and  more  varying 
form  of  the  cells. 

The  favorite  seats  of  encephaloid  cancer  are  the  bones,  the  female 
breast,  the  eye,  the  testicle,  and  less  frequently  the  uterus,  bladder,  and 
other  viscera  ;  but  any  tissue  of  the  body  may  be  affected  by  it.  It  occurs 


Fig.  169. 


Fig.  169. — Medullary  cancer.  "From  a  lymphatic  gland — secondary  to  hard  cancer  of  the  hreast. 
This  form  of  cancer  differs  from  the  scirrhus  only  in  the  proportion  of  the  cell  element  to  the  fibrous 
stroma — the  cells  heinj,'  here  seen  to  be  still  of  the  cpitlielial  type,  and  lying  close  together  withoutany 
visible  intercellular  substance." — From  Arnott,  ibid.,  Fig.  LO. 

Fig.  170. — Melanosis,  springing  from  the  mucous  lining  of  the  urethra,  a,  the  urethra  laid  open.  6, 
the  prepuce,  c,  the  section  of  the  corpora  cavernosa.  The  disease  was  removed  by  amputation. — St. 
George's  Hospital  Mus(!um,Ser.  xiii,  No.  10  a. 


very  commonly  in  young  people  in  blooming  health,  and  its  nature  is 
often  overlooked  at  first,  it  being  mistaken  for  innocent  tumor,  or  for 
abscess,  from  its  extreme  softness  when  not  covered  by  any  hard  tissue, 
or  for  clironic  inflammation  in  the  testicle  when  bound  down  by  the  firm 
tunica  albuginea.    It  rapidly  affects  the  glands,  and  when  removed  it  gen- 


MELANOSIS  —  OSTEOID. 


373 


erally  rapidly  recurs,  so  that  the  prognosis  is  even  more  unfavorable  than 
in  scirrhus.  Nevertheless  operations  are  eminently  justifiable  in  this  form 
of  cancer.  They  certainly  tend  to  prolong  life,  and  usually  they  restore 
the  patient  for  a  time  to  complete  health.  When  left  to  itself  tiie  tumor 
speedily  makes  its  way  through  the  skin,  ulcerates,  and  bleeds  copiously. 
If  death  is  not  caused  in  this  way  it  is  occasioned  by  the  rapid  growth  of 
the  tumor. 

Some  peculiarities  in  encephaloid  cancer  as  it  exists  in  bones  deserve 
especial  notice,  viz.,  its  tendenc}^  to  ossify  and  its  occasional  pulsation. 
The  reader  is  referred  to  the  section  on  cancer  in  bones  later  on. 

MeIa7}osi,<. — As  subvarieties  of  encephaloid  I  would  name  melanosis 
and  osteoid  cancer.  Melanosis,  or  black  cancer,  is  usually  developed 
from  parts,  such  as  the  eye  or  the  skin,  where  pigment  is  always  or  com- 
monly found  in  the  natural  state.  When  occurring  in  the  skin  it  seems 
often  to  originate  in  a  mole.  The  liver,  again,  is  a  tolerably  common  seat 
of  melanosis,  and  it  is  found  comparatively  often  as  a  secondary  forma- 
tion in  many  other  parts  of  the  body,  such  as  the  brain  or  the  i)ones.  It 
also  sometimes  originates  in  parts  where  no  pigment  naturall}'  exists 
(Fig.  170).  The  pigment  is  deposited  chiefly  in  the  cells  and  also  to  a  cer- 
tain extent  in  the  intercellular  substance. 

That  melanosis  is  clinically  a  malignant  disease  in  man  is  a  fact  to 
which  I  have  not  as  yet  met  with  any  well-marked  exception.^  But  that 
the  disease  is  always  of  the  character  which  would  be  technically  called 
carcinoma  by  all  pathologists  is  a  very  dilferent  matter.  The  anatomical 
characters  of  the  tumor  may  either  be  those  of  soft  cancer,  as  shown  in 
Fig.  17  of  Mr.  Arnott's  plates,-  or  of  spindle-celled  sarcoma,  as  in  a  re- 
markable instance  under  my  own 
care  of  melanosis  of  the  urethra, 
here  figured. 

Odtoid  cancel'  is  a  xary  rare 
form  of  the  disease.  Its  primary 
seat  is  almost  always  in  the  bones  ; 
but  it  presents  the  remarkable  pe- 
culiarity of  forming  secondary  de- 
posits of  bou}'  cancer  in  the  glands 
and  in  the  viscera,  and  of  recurring 
as  a  bony  mass  in  remote  parts  of 
the  body.  In  all  cases  that  I  have 
seen  the  lungs  have  been  the  seat 
of  the  secondary  growth.  The 
primary  tumor  is  usually,  as  Mr, 
Moore  describes  it,  "  a  mass  of 
the  hardest  enamel  or  ivory-like 
bone,"  mixed  with  which  are  the 

materials  of  ordinary  encephaloid  cancer,  and  often  a  considerable  pro- 
portion of  cartilage.  And  sometimes  the  primary  tumor  has  been  judged 
to  be  of  the  common  encephaloid  nature,  while  the  recurrent  growth  in 
the  lunffs  has  been  osteoid.^ 


Fig.  171. 


The  cells  which  were  found  in  the  microscopic 
exainiiiiition  of  the  tumor  shown  in  tlie  previous 
figure,  a.  Section  from  the  peripheral  part  of  the 
growth,  showing  "indifferent"  or  "granulation 
tissue,"  with  isolated  j)igment-cells  among  it.  At 
one  point  a  l)loodvessel  is  seen.  6.  A  portion  of 
the  growth  more  highly  magnified,  showing  large 
spindle-shaped  branching  cells,  many  of  them  quite 
filled  with  pigment— From  a  drawing  l>y  Dr.  T.  H. 
(heen  in  the  Path.  Soc.  Trans.,  vol.  xxiii,  p.  17G. 


^  In  exceptional  cases,  however,  recurrence  after  operation  may  be  long  delayed. 
Mr.  Pollock  removed  a  melanotic  tumor  from  the  thij^h,  and  afterwards  one  which 

showed  itself  in  an  inguinal  gland      '''' ^~^  *"''""   "'"'^"  fl(-t„„.,   „^o,.o 

afterwards 


^  Even  in  this  plate  it  is  doubtful,  as  Mr.  Arnott  say 
characters  are  not  rather  those  of  round-celled  sarcoma. 
^  Syst.  of  Surg.,  2d  ed.,  vol.  i,  p.  574. 


No  recurrence  had  taken  place  fifteen  years 
whether  the  anatomical 


374 


TUMORS. 


Fig.  172 


The  diagnosis  of  osteoid  cancer  is  sometimes  rendered  self-evident  by 
the  presence  of  bony  masses  in  the  glands,  otherwise  it  can  only  be 
formed  by  anatomical  examination  or  by  the  nature  of  the  recurring 
tumor.  I  would  refer  the  reader  to  the  chapter  on  Disease  of  the  Bones 
for  further  particulars  with  regard  to  this  form  of  cancer. 

EpithcJioma. — The  other  indubitable  form  of  cancer  is  the  epitiielial, 
or  epithelioma.     This  form  of  cancer  takes  its  origin  from  the  epithelium 

of  the  part  in  which  it  grows, 
and  is  therefore  always  de- 
veloped from  the  surface,  or 
from  the  parts  in  contact  with 
the  surface  of  the  skin,  or  mu- 
cous membrane.  A  favorite 
seat  of  epithelioma  is  the 
orifice  of  some  cavity  (mouth, 
anus,  vagina,  urethra),  where 
the  skin  and  mucous  mem- 
brane become  continuous.  It 
usually  appears  as  a  hard  flat- 
tened lump,  the  surface  of 
which  easily  breaks  down  and 
ulcerates,  and  which  readily 
affects  the  nearest  glands.  Its 
connection  with  simi)le  in- 
flammation is  very  close  ;  the 
continuous  irritation  of  some 
foreign  substance  is  an  un- 
doubted cause  of  the  disease, 
as,  for  example,  that  of  a  clay 
pipe  in  causing  epithelioma 
of  the  lip  or  tongue,  of  soot 
in  the  rugse  of  tiie  scrotum 
in  causing  chimney-sweep's 
cancer,  of  retained  secretion 
under  a  phimosed  prepuce  in 
causing  epitlielioma  of  tlie 
penis.  And  the  enlargement 
of  the  glands  is  often  due 
merel}'  to  ordinary  inflammation,  and  will  subside  completely  after  the 
removal  of  the  tumor.'  On  microscopic  examination  tlie  epithelial  ele- 
ments are  very  distinct,  in  the  form  of  large  nucleated  cells,  often  bearing 
a  very  close  resemblance  to  those  of  the  ei)idermis,  frequently  arranged 
in  concentric  lamiii.'c  like  the  layers  of  a  bird's  nest,  while  in  other  cases 
the  cells  liave  no  definite  arrangement,  but  lie  heaped  confusedly  together 
among  the  fibres  of  tlie  stroma.  Epithelioma  is  esi)ecially  prone  to  break 
down  and  ulcerate,  and  is  the  fortn  of  cancer  which  usually  gives  rise  to 
the  cancerous  ulcer  (lescrii)ed  in  a  subse(pient  chapter. 

Epithelioma,  although  it  appears  to  me  to  realize  moi'e  exactl}'  than 
any  of  the  other  forms  of  cancer  the  anatomical  descriptions  of  carcinoma 


Epithelioma.  "A  section  through  a  chimney-Sweep's 
cancer  of  tlie  scrotum,  representing  two  nests  ('laminated 
capsules'  'globes  epidermiques'),  the  larger  one  display- 
ing the  structure  of  these  bodies — plump  epithelial  cells  in 
the  midst,  surrounded  by  drier  and  flattened  scales;  whilst 
the  smaller  shows  a  more  common  appearance,  tlie  cells 
being  so  flattened  and  alterc  d  as  to  resemble  a  ball  of  hair ; 
both  nests  were  imbedded  with  numerous  others  in  the 
subcutaneous  tissue." — I'rom  Arnott,  ibid.,  Fig.  21. 


'  Mr.  Arnott  puy.'' :  "  Theso  bodies  are  commonly  mot  with,  in  greater  or  less 
number,  in  all  epithelial  eancer.«i,  thoii<i^h  not  fieculiar  to  this  di.«easc  ;  and  it  would 
appear  that  whore  the  epith('lioma  nfl'ect.-^  a  mucous  surface  witii  C3-Iindricai  epithelium 
(as  the  inte.-tinej  the  cells  are  of  a  cylindril'orm  type  rather  than  of  the  more  usual 
squamous  variety." 


COLLOID. 


375 


wliicli  are  accepted  at  the  present  day,  in  the  distinct  derivation  of  its 
cell-forms  from  the  epidermal  tissues,  and  the  completeness  of  its  fibrous 
stroma,  yet  is  commonly  much  less  "malignant"  than  the  other  forms  of 
cancer — i.e.,  it  destro3^s  life  less  quickly,  and  after  removal  it  returns 
much  less  speedil}^,  and  often  as  it  seems  does  not  return  at  all.  Its 
removal,  therefore,  is  a  matter  of  urgent  necessity,  and  a  more  encoui*- 
aging  prognosis  may  be  given  than  we  can  honestly  give  in  scirrhus  or 
soft  cancer. 

Colloid. — There  are  two  other  forms  of  tumor  which  are  by  some  clas- 
sified as  cancers,  while  others  deny  their  cancerous  nature,  viz.,  colloid 
and  villous.  It  appears  probable  that  colloid  at  any  rate  is  very  fre- 
quently cancerous,  or  at  least  malignant.    Its  synonym  is  alveolar  cancer, 


Fin.  173. 


Colloid  cancer,  a.  From  a  drawing  by  Mr.  Arnott,  in  Path.  Soc.  Trans.,  vol.  xxiii,  pi.  10.  It  shows 
clusters  of  cells  of  the  epithelioid  type  (those  at  the  right  hand  of  the  drawing  very  large  and 
irregular  in  shape),  floating  in  spaces  bounded  by  a  delicate  fibrous  network,  which  forms  large  oval 
and  spherical  meshes.  This  stromal  tissue  is  closely  beset  with  elongated  oval  nuclei.  6.  Also  from 
Arnott,  in  Syst.  of  Surg.,  Fig.  23,  shows  .some  cells  which  are  very  characteristic  of  colloid  cancer — 
"round  or  oval,  mono-nucleated,  and  having  within  the  outer  cell-wall  several  very  delicate  concentric 
lines,  giving  to  the  cell  somewhat  of  an  oyster-shell  appearance." 


derived  from  the  arrangement  of  the  fibres  of  its  stroma  in  large  open 
meshes  of  transparent  fibres,  in  which  are  seen  rounded  or  oval  nuclei. 
Lying  in  the  interstices  of  these  fibres  is  a  transparent,  jelly-like  sub- 
stance, in  which  will  be  seen  under  the  microscope  cells  of  various  sizes 
and  shapes,  the  most  characteristic  being  large,  round,  and  flat,  formed 


376  TUMORS. 

of  a  mic'leus,  around  which  are  numerous  concentric  laminae,  very  mnch 
lilve  an  oyster-shell,  besides  whicli  there  are  others  which  approach  more 
or  less  closely  to  tiie  forms  usually  seen  in  epithelioma.  The  favoritc'seat 
of  colloid  is  the  peritoneum,  especially  its  omenta,  though  it  is  found  also 
in  the  female  breast,  in  the  limbs,  the  rectum,  and  the  face.  Many  of  the 
cases  whicli  are  now  described  as  myxoma  would  formerly  have  been 
classed  as  colloid.  The  title  of  colloid  to  the  designation  of  cancer  has 
been  much  questioned,  and  more  particularly  of  late  _years  b}^  Mr.  Sibley 
{Med.-Chir.  Trant>.^  vol.  xxxix),  who  speaks  of  it  as  never  infecting  the 
glands,  as  not  prone  to  affect  the  liver  and  lungs,  as  true  cancer  peculiarly 
is,  and  as  not  prone  to  recur  after  complete  removal.  The  anatomical 
characters  of  colloid,  however,  certainly  seem  to  agree  in  essentials  with 
those  of  carcinoma,  and,  as  far  as  can  be  judged  by  the  rather  rare  cases 
which  become  the  subjects  of  surgical  operation,  it  is  quite  as  prone  to 
recur  as  epithelioma  is,  and  cases  in  which  the  glands  have  been  affected 
are  not  wanting.  It  appears  probable,  as  Mr.  Croft  has  said,'  that  "some 
tumors  are  colloid  in  character  from  the  outset,  others  appear  to  undergo 
a  colloid  change,"  and  it  may  be  possil)le  that  the  nature  of  the  developed 
tumor  may  depend  on  that  of  the  one  which  it  has  replaced. 

Villous  tumors,  or  papillomata,  are  now  almost  universally  allowed  to 
be  in  general  not  cancerous.  They  spring  from  mucous  surfaces,  and  the 
situations  in  which  thej'  are  most  commonly  found  are  in  the  bladder  and 
rectum.  Very  striicing  instances  have  been  put  on  record  of  the  differ- 
ence which  generally  marks  their  course  from  that  of  cancer.'^  Nor  is  the 
anatomy  of  the  disease  that  of  cancer.  The  tumor  consists  usually  of  a 
loose  floating  mass  of  processes  with  a  dendritic  arrangement,  springing 
from  a  base,  in  which  no  cancerous  elements  can  be  detected.  The  vil- 
lous processes  are  composed  "  of  a  fine  membranous  envelope  like  the 
finger  of  a  glove,  inclosing  a  quantity  of  granular  matter  in  which  nu- 
merous cells  are  imbedded,  which  are  chiefly  spheroidal  in  form,  and  can- 
not be  distinguished  from  those  of  the  membrane  adjacent  to  the  villous 
growth."  These  villi  bear  the  most  exact  resemblance  to  the  villi  of  the 
chorion.'  It  appears,  however,  undeniable  that  cancers  may  be  covered 
b}'  a  similar  villous  growth.  The  anatomical  diflerence,  therefore,  between 
a  sim[)le  and  a  cancerous  villous  growth  would  rest  on  the  presence  or 
absence  of  cancer  underlying  the  villous  surface.  Clinicallj'  the  rapidit}"^ 
of  growth  and  acuteness  of  symptoms  would  enable  the  surgeon  to  form 
a  diagnosis,  which,  however,  in  many  cases  would  be  only  conjectural. 

These  are  all  tlie  new  growths  which  appear  to  me  to  require  separate 
description  as  coming  within  our  definition  of  tumors.  For  the  other 
forms  of  growth  which  are  described  in  some  systematic  treatises  under 
the  head  of  tumors,  I  would  refer  to  other  parts  of  this  work.  Thus  the 
reader  will  fiml  Lymphoma  or  Lymphadenonia  spoken  of  under  the  Dis- 
easesofthe  Absoi-bent  System;  Neuroma  under  those  of  nerves;  Adenoma 
under  tliose  of  the  breast,  prostate  and  other  organs  where  polypi  of  that 
kind  are  met  with. 

1  In  the  account  of  the  case  from  which  Fig.  173  is  taken,  Path.  Soc.  Trans.,  vol. 
xxiii,  p.  2fi8. 

*  Hini  below,  in  the  chapter  on  diseases  of  the  bhiddcr,  jui  ilhistration  taken  from 
a  typical  case  of  villous  tumor  in  that  oru;;in  ;  and  see  Patii.  Trans.,  vol.  xii,  p.  120, 
for  a  striking  example  of  villous  tumor  of  the  rectum.  In  both  these  cases  the  tumor 
was  clearly  of  an  innocent  nature. 

»  See  a  "jia|)er  by  Mr.  Sibley  in  Path.  Trans.,  vol.  vii,  p.  '212,  where  the  villi  from 
tumors  of  the  intestine  and  bladder  are  figured  side  by  .side  with  those  of  the  chorion. 


SCROFULA. 


377 


CHAPTEE  XVIII. 


SCROFULA. 


The  terms  "struma"  and  "scrofula"  are  usually  regarded  and  em- 
ployed as  synonymous  ;  but  some  writers  make  a  diiierence,  and  a  very 
important  one,  between  the  two.  In  the  most  intelligible  sense  of  the 
words,  and  in  the  class  of  cases  which  are  most  easy  to  diagnose,  scrof- 
ula or  struma  is  the  constitutional  diathesis  which  leads  to  (or  which 
tends  to  lead  to)  the  deposit  of  a  substance  called  "  tubercle"  in  various 
organs  of  the  body.  Tubercle  is  described  as  being  of  two  kinds,  the 
gray  or  miliary,  and  the  yellow  or  crude.  The  latter  is  now  regarded  by 
most  authors,  following  the  authority  of  Virchow,  as  a  secondary  stage 
of  the  former.  Gray  or  miliary  tubercle  is  "  a  grayish-white,  translucent 
nonvascular  body  of  firm  consistence  and  well-defined  spherical  outline, 
usually  about  the  size  of  a  mil- 
let-seed. Although  in  its  earlier  fig.  174. 
stage  it  is  uniformly  translucent, 
its  central  portions  quickly  be- 
come opaque  and  yellowish,  ow- 
ing to  the  retrograde  metamor- 
phosis of  its  component  ele- 
ments. In  structure  tubercle, 
like  the  other  '  l3Miiphomata,' 
consists  of  lymphatic  cells  con- 
tained in  the  meshes  of  a  very 
delicate  reticulum.  The  cells 
are  mostly  round,  or  roundly 
oval,  colorless,  transparent,  and 
slightly  granular  bodies,  much 
resembling  lymph  -  corpuscles  ; 
and,  like  these,  varying  consid- 
erabl}'  in  size ;  many  of  them 
contain  a  small  distinct  nucleus. 
In  addition  to  these  there  are  a 
few  larger  cells,  containing  two 

or  even  three  nuclei."^  These  minute  gray  granulations  are  often  aggre- 
gated together  into  larger  masses,  and  then,  though  the  granulations 
themselves  are  essentially  nonvascular,  vessels  may  be  found  in  the  inter- 
stices of  the  aggregate  mass  belonging  to  tissues  interposed  between 
the  component  parts  of  the  mass.  The  deposit  of  miliary  tubercle  is  pe- 
culiarly apt  to  follow  the  course  of  the  small  arteries  and  capillaries,  and 
seems  first  to  occur  in  the  "  adventitia,"  or  fibrous  envelope  of  the  ves- 
sels."    This  aggregation  of  tubercle  softens  into  a  yellow  caseous  sub- 


Elements  shown  by  teasing  out  a  miliary  tubercle, 
after  Rindfleisch.  1.  The  large  tubercle-cells.  2.  The 
small  tubercle-cells.  3.  Endogenous  cell  development. 
4.  Delicate  recticulum  from  the  interior  of  a  miliary 
tubercle,  the  cells  partly  removed  by  pencilling. 


^  Green's  Pathology,  pp.  146-7. 

^  See  Rindfleisch,  op.  cit.,  p.  137,  and  Wilson  Fox,  On  the  Artificial  Production 
of  Tubercle,  where  beautiful  representations  of  its  microscopic  structure  will  bo 
found. 


378  SCROFULA. 

stance,  and  in  that  condition  forrns  the  yelloiv  or  crude  tnbercle.^  Be- 
sides the  cells  floured  above  as  typical  of  tubercle,  all  sorts  of  debris  are 
met  with  in  microscopical  examination — "ill-formed  epithelial  cells, 
masses  of  pigment,  crystals,  and  plates  of  cholesterin,  remnants  of  in- 
closed and  distintegrating  tissue"  (Savory).  As  the  yellow  tubercle  de- 
generates it  undergoes  one  of  two  forms  of  metamorphosis.  In  most 
cases  it  softens  and  breaks  down,  and  in  this  degeneration  the  tissues 
around  are  involved.  They  become  disintegrated  by  low  inflammation, 
and  thus  a  strumous  abscess,  vomica,  or  strumous  ulcer  is  formed.  It 
seems  that  this  softening  may  either  commence  in  the  centre  of  the  tuber- 
cle, and  thence  gradually  spread  to  the  tissues,  or  else  the  inflammation 
of  the  latter  may  involve  the  destruction  of  the  tubercle. 

In  other  cases  the  tubercles  harden  as  they  degenerate,  the  fluid  parts 
are  absorbed,  leaving  a  hard,  chalky  mass,  the  cretaceous  tubercle,  and 
this  change  may  affect  the  gray  granulation  as  well  as  the  crude  tubercle.'^ 
In  this  condition  the  withered,  dried-up  mass  generally  remains  innocu- 
ous, though  sometimes,  as  Sir  J.  Paget  points  out,  renewed  suppuration 
is  set  up  around  it  ("  residual  abscess"),  and  thus  it  is  cast  out.  It  is 
indisputable,  however,  that  cases  described  as  scrofula  are  often  nnasso- 
ciated  with  any  visible  deposit  of  tubercle,  and  this  leads  to  two  ques- 
tions: 1.  Is  there  anything  essentially  peculiar  in  tubercle,  or  is  it  merely 
a  form  of  chronic  inflammatory  deposit?  and,  2.  Is  the  presence  of  tu- 
bercle, or  a  tendenc}' to  its  development,  a  necessary  characteristic  of 
scrofula,  or  is  there  a  distinct  class  of  scrofulous  affections  in  which  there 
is  no  such  tendency?  To  the  first  question  there  is  much  reason  for 
giving  a  negative  answer.  The  researches  of  Drs.  A.  Clark,  Burdon 
Sanderson,  and  Wilson  Fox  have  shown  that  by  the  inoculation  of  non- 
tubercular  products,  or  by  artificial  irritation  of  the  tissues  in  the  lower 
animals,  products  indistinguishable  from  tubercle  may  be  generated  ; 
and  this  doctrine  lends  strong  support  to  the  belief  which  experience 
justifies,  and  which  has  been  expressed  by  myself  and  others,'^  that  tuber- 
culosis in  the  human  subject  is  often  the  result  and  not  the  cause  of  some 
exhaustive  suppurative  lesion  which,  being  described  as  "scrofulous,"  is 
often  regarded  as  being  dependent  on  the  diathesis,  of  which,  on  the 
contrary',  it  is  itself  the  cause.  If  we  assume  that  these  experiments 
made  on  the  lower  animals  are  exactly  applicable  to  man  Ave  shall  conclude 
that  the  deposit  of  tubercle  is  only  a  more  definite  form  of  chronic  inflam- 
matory lymph;  or,  in  Dr.  C.  J.  B.  AVilliams's  words,  that  tubercle  is  "  a 
degraded  condition  of  the  nutritive  material  from  which  old  textures  are 
removed  and  new  ones  formed,  and  that  in  its  origin  it  differs  from  the 
normal  jjlasma  or  coagulable  lymi)h,  not  in  kind  but  in  degree  of  vitality 
and  ca[)acity  of  organization."  If  we  regard  tubercle  in  this  light,  the 
difficulty  which  has  always  been  felt  in  distinguishing  between  a  crude 
tul)ercle  and  a  mass  of  old  13'niplio-pus  is  easily  accounted  for,  and  the 
occurrence  of  cases  in  wliicli  there  is  a  constitutional  predisposition  to 
low  inflammation,  though  no  characteristic  masses  of  tubei'clc  are  de- 
tected anywhere  in  the  body,  is  )iatnral  enough. 

Two  forms  of  struma  are  spoken  of  both  liy  Mr.  Savory*  and  by  Sir 

1  Chfiraotoristio  illustrations  of  tho  nikod-cye  appearance  of  crude  tuburclfi  will  be 
found  in  tlio  ctiajjtc^r  oti  Discuses  of  IJono. 

2  lioUitansky,  who  7-ci,Mrd('d  tlic  two  kinds  of  tubercle  as  independent,  speaks  of 
this  as  the  only  metannorphosis  which  the  gray  granulation  undergoes. 

8  See  Wilson  Fox,  op.  cit.,  pp.  27,  28. 
*  Syst.  of  Surg.,  vol.  i. 


FORMS    OF    SCROFULA.  379 

W.  Jenner/  The  former  speaks  thus  of  the  two  forms  :  "  In  the  first, 
distinguished  as  the  sanguine  or  serous,  there  is  a  general  want  of  mus- 
cular development;  for,  although  the  figui'e  maybe  sometimes  plump  and 
full,  the  limbs  are  soft  and  flabl\y  ;  tlie  skin  is  fair  and  thiti,  showing  the 
blue  veins  beneath  it;  the  features  are  very  delicate;  often  a  brilliant 
transparent  rosy  color  of  the  cheeks  contrasts  strongly  and  strikingly 
with  the  surrounding  pallor:  the  eyes,  gray  or  blue,  are  large  and  humid, 
with  sluggish  pupils,  sheltered  by  long  silken  lashes;  hair  fine,  blonde, 
auburn,  or  red  ;  teeth  white  and  often  brittle ;  there  is  frequently  a  ful- 
ness of  the  upi)er  lip  and  ala?  nasi ;  the  ends  of  the  fingers  are  commonly 
broad,  with  convex  nails  bent  over  their  extremities.  Such  persons  usu- 
ally possess  much  energy  and  sensibility,  with  elasticity  and  buoyancy 
of  spirits;  they  often  possess,  too,  considerable  beauty.  In  this  variety, 
with  the  same  delicac3',  the  skin  and  eyes  are  sometimes  dark. 

"  In  the  second,  distinguished  as  the  phlegmatic  or  melancholic,  the 
skin,  pale  or  dark,  is  thick,  muddy,  and  often  harsh,  the  general  aspect 
dull  and  heavy  ;  hair  dark  and  coarse  ;  the  mind  is  often,  but  not  always, 
slow  and  sluggish. 

"Children  especially,  in  whom  the  diathesis  is  strongly  marked,  are 
often  distinguisiied  by  the  narrow  and  prominent  chest,  the  tumid  and 
prominent  abdomen,  and  the  pastelike  complexion  ;  the  limbs  are  vvasted  ; 
the  circulation  languid  ;  chilblains  are  common  on  the  extremities  ;  the 
mucous  membranes  particularly,  and  above  all  of  them  the  digestive,  are 
liable  to  morbid  action  ;  tlie  breath  is  often  sour  and  fetid  ;  the  tongue  is 
furred,  and  the  papillae  towards  the  apex  red  and  prominent;  the  bowels 
act  irregularly,  and  the  evacuations  are  unusually  offensive;  the  diges- 
tion weak,  the  appetite  variable  and  capricious.  In  Dr.  Todd's  opinion, 
'  the  strumous  dyspepsia  presents  a  more  characteristic  feature  of  this 
habit  of  body  than  any  physiognomical  portrait  which  has  yet  been  drawn 
of  it.'  The  relation  of  disorder  of  the  digestive  organs — the  subject  upon 
which  Abernethy  was  so  wont  to  insist — to  scrofula  was,  many  years  ago, 
particularly  dwelt  upon  by  Lloyd.  There  is  often  a  singular  assumption 
of  age  both  in  character  and  appearance — in  mind  and  manners  they  are 
prematurely  old. 

"  Moreover,  persons,  and  especially  children,  possessing  this  diathesis 
are  ver^'  subject  to  certain  atfections  which  are  regarded  by  many  as  mani- 
festations of  scrofula  ;  such,  for  instance,  as  various  erui)tions,  frequently 
seen  behind  the  ears;  chronic  inflammation  of  the  eyelids  and  conjunc- 
tivae ;  a  certain  form  of  ophthalmia,  described  as  strumous ;  chronic  ulcers 
of  the  cornea,  etc."     {Op.  cit.,  p.  363.) 

Sir  W.  Jenner  also  divides  the  strumous  diathesis  into  two  forms:  1. 
Tuberculosis,  the  leading  pathological  changes  of  which  are  "  fattj'  de- 
generation of  the  liver  and  kidneys,  deposits  or  formations  of  tubercle 
and  their  consequences,  inflammation  of  the  serous  membranes;"  and  (2) 
scrofulosis,  the  leading  pathological  tendencies  of  which  are  "inflamma- 
tion of  the  mucous  membrane,  of  a  peculiar  kind  ;  so-called  strumous 
ophthalmia,  inflammation  of  the  tarsi,  catarrhal  inflammation  of  the  mu- 
cous membrane  of  the  nose,  pharynx,  bronchi,  stomach,  and  intestines  ; 
inflammation  and  suppuration  of  tlie  lymphatic  glands  on  trifling  irrita- 
tion, obstinate  diseases  of  the  skin,  caries  of  bone."  I  would  prefer  to 
substitute  for  "caries  of  bone  "  "low  inflammation  of  bones  and  joints." 
Sir  W.  Jenner  attributes  to  his  "  tuberculous  "  class  the  same  general 
characters  which  Mr.  Savory  specifies  as  characteristic  of  the  "sanguine 

1  Lectures  on  Rickets,  Med.  Times  and  Gaz.,  1860,  vol.  i,  p.  259. 


380  SCROFULA. 

or  serous  "  type  of  serofula.  and  to  the  "  scrofulous  "  those  which  charac- 
terize the  "i)hle<>ii)atic  or  nielaucholic "  type.  No  doubt  the  distinction 
pointed  out  by  Sir  W.  Jenner  in  the  tendencies  of  these  two  forms  or 
types  of  scrofula  is  very  generally  true,  and  is  important  to  bear  in  mind; 
but  I  do  not  tliink  that  the  two  types  are  so  far  distinct  from  each  other 
as  to  justify  us  in  regarding  them  as  different  diathetic  conditions.  If  we 
do  so  regard  them  we  should  use  the  word  "struma"  as  the  general  term 
for  both  the  diatheses — the  one  in  which  tubercle  is  met  with  being  called 
tuberculosis,  and  the  one  in  which  only  low  inflammations  are  developed 
scrofulosis. 

From  what  has  gone  before  it  will  result  clearly  that  the  diagnosis  of 
scrofula  cannot  be  a  very  decided  one.  If  we  agree  that  tubercle  itself, 
which  is  the  most  recognizable  anatomical  peculiarity  of  the  diathesis, 
may  after  all  be  onl^'  a  modification  of  ordinary  inflammatory  lymph,  it 
cannot  surprise  us  that  many  cases  which  one  practitioner  will  denomi- 
nate as  "strumous  "  another  will  regard  as  examples  of  chronic  inflam- 
mation. My  own  impression,  derived  from  a  tolerably  extensive  experi- 
ence of  cases  of  so-called  "  strumous  "  disease  of  joints,  is  that  the  great 
majority  of  them  are  usually  the  results  of  slight  injury,  and  have  no 
connection  of  anj^  sort  with  any  constitutional  peculiarity  ;  and  I  am  glad 
to  see  this  view  of  the  case  gaining  ground  and  obtaining  the  support  of 
eminent  practical  surgeons.  The  question,  indeed,  of  the  causation  and 
of  the  prognosis  of  struma  is  of  the  most  essential  importance  when  we 
come  to  give  advice  about  the  treatment  of  any  case  diagnosed  as  "  stru- 
mous." If  struma  were,  as  we  conceive  cancer  to  be,  a  general  blood 
disease,  or  a  tendency  in  the  constitution  which  has  indeed  local  mani- 
festations, but  these  only  subordinate,  and,  as  it  were,  accidental,  the 
inference  is  irresistible:  that  the  way  to  cure  the  complaint  must  be 
by  modifying  the  general  disorder,  so  as  to  restore  the  blood  or  the  S3^s- 
tem  to  a  health}^  condition,  and  that  the  local  conditions  are  of  subordi- 
nate importance:  and  this  is  the  view  which  has  prevailed  hitherto,  and 
wliich  is  still  most  extensively  entertained.  If,  on  the  contrar}'^,  we  be- 
lieve that  these  strumous  diseases  are  often  only  instances  of  common 
inflammation,  and  that  their  relation  to  the  general  disease  is  often  that 
of  cause,  not  that  of  effect,  the  motive  for  curing  the  disease  b}'  surgical 
interference  at  the  earliest  possible  moment  becomes  even  stronger  than 
in  other  cases. 

Causes. — The  causes  of  scrofula  are  not  very  easy  to  ascertain.  It  is 
undouI)t{'dly  true  tliat  hereditary-  predisposition  plays  a  very  great  part 
in  tlie  prcjduction  of  the  disease  ;  and  it  is  also,  I  think,  indubitable  that 
it  may  be  caused  l)y  any  permanent  source  of  malnutrition,  such  as  bad 
air,  insufficient  clothing,  bad  or  scanty  food,  and  I  would  add,  the  de- 
pressing influence  of  prolonged  suppuration  and  confinement. 

Trealmcnl. — The  treatment  of  scrofula  must  be  regulated  according  to 
our  views  of  its  causes.  We  cannot  act  upon  the  liereditar^^  predisposi- 
tion further  than  by  enforcing  increased  caution  in  tlie  management  of 
such  children  and  young  persons  as  are  clearly  under  its  influence,  so  as 
to  witlidraw  tiiem  as  far  as  may  be  possil)le  from  all  the  agencies  by  which 
the  diathesis  may  be  subsequently  acquired.  When  tlie  disease  is  once 
develoi)ed  every  condition  which  can  improve  the  patient's  general  health 
must,  as  far  as  possible,  be  secured.  Fresh  air,  moderate  exercise,  the 
free  action  of  tiie  skin  and  bowels,  an  c(iuable  and  temperate  climate, 
residence  by  the  seaside,  a  bght,  nutritious,  iinstimulating  diet,  are,  as  a 
general  rule,  of  more  importance  than  medicines,  and  routine  practice  is 
as  bad  in  strumous  as  in  other  cases.    But  there  can  be  no  question  of  the 


TREATMKNT.  381 

great  advantages  which  are  obtained  by  the  judicious  administration  of 
cod-liver  oil  in  cases  accompanied  by  emaciation  witlioiit  much  dyspepsia, 
of  iron  in  those  where  anjemia  is  a  prominent  feature,  of  the  syru|)  of  the 
iodide  of  iron  where  the  patient  is  weak,  fat,  pale,  and  flabby  ;  of  bark 
and  mineral  acids  in  cases  where  hectic  is  present;  of  alkalies  in  combi- 
nation with  sarsaparilla  or  milk,  along  with  the  moderate  use  of  i)urga- 
tives,  where  the  secretions  are  disordered  and  the  digestion  fault3\  Of 
these,  by  far  the  most  important  agent  in  the  treatment  of  scrofula  is  the 
cod-liver  oil ;  and,  although  there  is  no  space  in  tliis  work  for  details 
which  more  fitly  belong  to  a  treatise  on  therapeutics,  yet  I  must  state  the 
most  necessary  precautions  in  the  use  of  this  drug.  The  chief  objection 
to  its  use  is  the  nausea  whicii  it  produces,  especially  at  first.  This  is 
much  diminished  by  commencing  with  small  doses,  and  by  giving  the  oil 
on  a  full  stomach — about  a  quarter  of  an  hour  after  meals.  The  full  dose 
for  a  child  would  be  about  two  teaspoonfuls  and  a  tablespoonful  for  an 
adult.  The  taste  may  be  very  successful!}'  disguised  by  floating  the  oil 
on  orange  wine  or  tincture  of  orange,  or  steel  wine  ;  or  by  mixing  it  with 
five  or  six  drops  of  Liq.  Strychnitie,  or  a  little  mineral  acid.  Often,  if  the 
patient  can  be  induced  to  persevere,  his  repugnance  to  the  oil  will  wear 
off;  and  as  the  oil  will  have  to  be  taken  for  many  months,  if  it  agrees,  it 
is  well  worth  some  trouble  to  establish  this  tolerance.  After  a  time  pa- 
tients, and  particularly  children,  can  take  it  as  an  ordinary  article  of  diet, 
not  only  without  disgust  but  with  pleasure. 

I  should  be  sorry  if  anything  which  I  have  said  above  as  to  the  neces- 
sity for  eradicating  strumous  diseases,  or  diseases  reputed  strumous, 
before  they  permanently  impair  the  health,  should  mislead  the  reader 
into  the  idea  that  I  advocate  hasty  operative  interference  in  such  cases. 
They  are  essentially  chronic  maladies,  whether  we  regard  them  as  local 
or  constitutional  in  their  origin,  and  the  great  majority  of  them  can 
usually  be  brought  to  a  successful  issue  by  the  mildest  treatment,  i.  e., 
by  laying  open  any  suj)purating  cavities,  dressing  exposed  surfaces  with 
mildly  stimulating  lotions  or  ointments,  and  keeping  the  parts  at  rest. 
It  is  only  when  prolonged  suppuration,  or  this  conjoined  with  enforced 
deprivation  of  air  and  exercise,  is  breaking  down  the  health,  or  when 
extensive  disease  of  the  bony  or  other  structure  of  the  part  holds  out  no 
hope  of  natural  cure  in  any  reasonable  time,  that  I  advocate  the  removal 
of  the  affected  organ  by  excision  or  amputation;  and  I  tliinkthat  I  have 
had  abundant  experience  even  in  my  own  practice  to  show  that  such 
operations  are  usually  followed  by  complete  and  permanent  recovery  in 
cases  which  would  by  every  one  be  classed  as  strumous.^ 

Scrofula  is  generally  a  disease  of  youth ;  but  similar  symptoms  appear 
sometimes  after  middle  age,  and  have  lately  been  more  especially  described 
by  Sir  J.  Paget  {Clinical  Lectures^  1875)  as  "Senile  scrofula."  The  dis- 
ease at  this  age  holds  out  little  prospect  of  cure,  but  the  general  indica- 
tions of  treatment  are  the  same. 

1  See  a  paper  in  the  Lancet,  Feb.  24th,  1866,  on  The  Sequel  in  some  Cases  of 
Excision  and  Amputation. 


382  HYSTERIA. 


CHAPTEK   XIX. 

HYSTERIA  AND  NERVOUS  DISORDERS. 

Hysteria  is  a  disease  which  it  is  very  difficult  to  speak  of  intelligibly 
and  adequately  within  the  compass  of  a  work  like  this.  Yet,  as  there  is 
no  disease  which  it  does  not  sometimes  simulate,  and  as  the  diagnosis 
between  real  or,  to  speak  more  correctly,  organic  disease  and  hysterical 
or  nervous  affection  is  of  daily  importance  and  of  the  greatest  difficulty 
in  some  of  the  most  common  surgical  complaints,  notably  those  of  the 
spine  and  joints,  it  is  a  condition  which  cannot  be  passed  over  unnoticed 
in  any  systematic  treatise  on  surgery.  Besides  the  general  remarks  in 
tliis  chapter  the  reader  will  find  observations  on  the  various  special  affec- 
tions in  other  parts  of  the  book — especially  in  the  chapters  on  diseases 
of  the  Joints,  the  Spine,  and  the  Breast. 

I  have  just  said  that  it  is  more  accurate  to  speak  of  hysterical  disease 
of  a  part  as  contrasted  with  "  organic  "  than  with  "  real  "  disease  ;  and 
this  is  very  important.  Hysteria  is  sometimes  spoken  of  as  if  it  were 
unreal — a  mere  fancy — perhaps  a  mere  simulation.  Such  a  view  is  most 
erroneous,  and  practice  founded  on  it  cannot  be  successful.  The  struc- 
ture of  the  part  is  not  as  a  rule  in  any  visible  or  tangible  way  affected 
(though  to  this  rule  some  exceptions  will  be  pointed  out),  and  there  is  no 
danger  to  life  or  limb  ;  yet  it  is  impossible  to  doubt  that  in  many,  and  I 
would  say  most  cases  the  sensations  are  as  real  as  those  of  any  other 
disease,  and  the  patient  as  anxious  to  be  rid  of  it  as  of  any  other  disease. 
Tlie  cause  of  the  disease  may  be  imperceptible  to  our  senses ;  but  it  is 
none  the  less  really  present,  and  its  effect  is  as  real  as  any  tumor  or  other 
visible  product. 

Perhaps  the  best  definition  of  hysteria  would  be  tiiat  it  is  a  morbid 
state  in  which  various  symptoms  are  produced  depending,  not  on  disease 
of  the  part  affected,  but  on  some  condition  of  thti  central  nervous  organs. 
That  condition  was  supposed  to  be  excited  in  the  cerebro-spinal  centre 
by  uterine  disturbances  when  the  disease  was  named,  and  doubtless  such 
disturbances  are  a  frequent  exciting  cause  ;  but  the  disease  may  exist  in 
women  whose  uterine  functions  are  perfectly  normal,  and  even  (though 
not  so  often)  in  men.  In  these  latter  cases  the  origin  of  the  hysterical 
disturbance  is  obscure  ;  and  in  tlie  case  of  disordered  uterine  functions, 
tliough  the  cause  may  be  plain  enough,  its  mode  of  action  is  utterly 
unknown. 

Hysteria  differs  from  mere  delusion,  hypochondriasis,  or  fictitious  dis- 
ease in  the  fact  that  the  morbid  sensations  or  other  symptoms  are  due  to 
a  really  existing  physical  cause — though  it  is  remote  from  the  part  affected, 
and  though  its  detection  may  be  difficult;  but  it  must  be  allowed  that 
much  of  delusion  and  hypochondriacal  exaggeration  is  mixed  up  with 
almost  all  cases  of  hysteria,  and  that  in  many  of  them  the  patient  wilfully 
exaggerates  many  of  tlie  symptoms,  and  very  likely  feigns  others.  So 
that  there  is  a  mixture  of  mental  and  jjhysical  causes  in  the  disease,  and 
its  cure  must  be  attempted  by  treatment  addressed  to  the  mind  as  well 
as  to  the  body. 


SYMPTOMS    AND    DIAGNOSIS.  383 

^''Nervous  Mimicry.'" — Sir  James  Paget,  in  a  strikinor  series  of  lec- 
tures on  this  subject,  recently  publisherl,'  wishes  to  abolish  the  old 
term  "hysteria"  altogether,  at  least  to  restrict  it  to  the  mere  hysterical 
convulsive  affection.  The  great  class  of  diseases  usually  spoken  of  as 
hysterical  he  would  call  "neuro-inimetic,"  or  "nervous  mimicries"  of  the 
diseases  of  the  various  organs.  As  a  general  rule  he  denies  tliat  such 
diseases  have  any  more  connection  with  the  sexual  than  with  any  otlier 
system  of  organs  in  the  body.  "In  the  defective  ovarian  or  uterine  func- 
tions of  certain  patients,"  he  says,  "some  see  the  centre  and  chief  sub- 
stance of  the  whole  disease:  a  very  mischievous  fallacy.  Of  course,  the 
sexual  organs  appear  generally  in  fault  to  those  who  are  rarelly  consulted 
for  the  diseases  of  any  other  part;  but  in  general  practice  they  are,  in  a 
large  majority  of  cases,  as  healthy  as  any  other  parts  are,  or  not  more 
disturbed.  The  close  and  multiform  relations  of  the  sexual  organs  with 
the  mind,  and  with  all  parts  of  the  nervous  sj'stem,  are  enough  to  make 
the  disorders  of  these  organs  dominant  in  a  disorderly  nervous  consti- 
tution ;  but  their  relation  to  'hysteria'  or  to  'neuromimesis,'  though 
more  intense,  is  only  the  same  in  kind  as  that  of  an  injured  joint  or  an 
irritable  stomach.  All,  in  their  degrees,  may  be  disturbers  of  a  too  per- 
turbable  nervous  system,  and  equally  on  every  one  of  them  the  turbu- 
lence of  a  nervous  centre  may  be  directed  with  undivided  force."  (Op. 
ciL,  p.  191.) 

In  fact,  nervous  or  hysterical  disease  may  be  excited  by  anything 
which  makes  a  strong  impression  on  the  nervous  system  :  whether  it  be 
sexual  disturbance,  imagination,  bodily  injury,  mental  affection,  intense 
emotion,  or  any  form  of  disease. 

Symptoms  and  Diagnosis. — The  usual  manifestations  of  hysteria  are 
the  hysterical  fit,  the  globus  hystericus,  the  clavus  hystericus,  and  the 
diseases  resembling  those  of  various  organs. 

The  hysterical  fit  may  be  taken  as  a  simulation  of  epilepsy,  though  it 
is  usually  distinguished  from  it  by  characters  too  obvious  to  allow  of  any 
mistake.  It  begins  generally  with  rising  in  the  throat,  a  sense  of  chok- 
ing, followed  b}'  wild,  convulsive  movements,  or  rather  semivoluntary 
movements  resembling  convulsions,  with  partial  or  sometimes  complete 
loss  of  consciousness,  flushed  face,  eye  usually  sensitive  to  light,  the  fit 
ending  generally  in  crying,  screaming,  and  laughing.  This  is  followed 
by  a  copious  flow  of  pale  urine,  very  often  by  tympanitis,  and  generally 
by  profound  sleep.  Sometimes  one  fit,  or  a  succession  of  fits,  may  last 
for  several  hours. 

The  diagnosis  and  treatment  of  hysterical  fits  is  more  within  the  prov- 
ince of  the  physician  than  the  surgeon.  The  imperfect  insensibility,  the 
absence  of  any  obstruction  to  respiration,  the  age  and  sex  of  the  patient 
(for  true  fits  hardly  ever  occur  in  male  hysteria),  are  the  main  distinctive 
marks.  No  treatment  should,  as  a  general  rule,  be  adopted  beyond  see- 
ing that  the  patient  does  lierself  no  harm  by  her  movements,  and  limiting 
the  officiousness  of  bystanders.  The  rough  awakening  of  a  cold  douche 
or  some  other  similar  shock  is  often  effective  enough  in  dispelling  tlie  fit, 
and  it  may  occasionally  be  advisable  to  use  such  measures,  but  ordinarily 
they  do  more  harm  than  good. 

The  globus  hystericus  is  tlie  sensation  of  some  weiglit  or  substance 
which  rises  from  the  abdomen  into  the  throat,  and  this  sensation  is  often 
followed  by  the  choking  and  otlier  phenomena  of  a  fit  o*f  hysterics.  The 
"clavus,"  or  hysterical  headache,  is  a  feeling  as  if  a  nail  were  driven  into 


1  Clinical  Lectures,  p.  172  et  seq. 


384  HYSTERIA. 

the  head.  It  is  a  common  and  troublesome  but  subordinate  feature  in 
the  general  disease. 

The  main  point,  however,  in  practical  surger}^  is  to  distinguish  those 
surgical  diseases  which  are  hysterical  or  nervous  from  the  organic  affec- 
tions of  the  same  organs.  Tlie  joints,  the  spine,  and  the  breast  are 
the  most  frequent  seat  of  h^'sterical  pain  and  loss  of  function  ;^  but 
hysteria  may  simulate  almost  any  surgical  as  well  as  medical  disease, 
and  the  diagnosis  is  often  rendered  the  more  perplexing  by  the  fact  tliat 
hysteria  very  frequently  aggravates,  and  sometimes  masks,  diseases 
which  really  exist ;  so  that  in  the  former  case  the  surgeon,  seeing  that 
there  is  distinct  proof  of  organic  disease,  is  apt  to  attribute  grave  im- 
portance to  what  is  really  only  a  trifling  complaint  aggravated  by  hys- 
terical symptoms;  while  in  the  latter  case  the  symptoms  of  hysteria  are 
so  prominent  that  he  overlooks  some  disease  which  is  really  present. 

The  diagnosis  between  hysterical  and  organic  affections  rests  mainly 
on  the  following  considerations  :  1.  The  podn  in  hysteria  is  usually  inter- 
mitting, irregular,  and  often  much  in  excess  of  anything  that  the  visible 
condition  of  the  parts  can  account  for;  it  bears  no  relation  to  the  dura- 
tion of  the  disease,  and  is  often  obviously  affected  by  emotional  causes, 
and  often  b}-  the  state  of  the  uterine  or  digestive  functions.  It  differs 
from  true  neuralgia  in  not  being  general  periodic  and  in  not  following 
the  distribution  of  any  nerve,  though  in  many  cases  hysterical  pain  is 
called  neuralgia.  2.  The  tenderness  which  is  almost  always  complained 
of  is  diffused,  and  is,  as  it  were,  inconsistent.  Thus,  for  instance,  in 
hysterical  disease  of  the  spine  the  patient  will  often  complain  of  quite  as 
much  pain  from  a  light  touch  to  the  skin  as  from  pressure  made  on  the 
vertebral  spines  themselves,  and  it  is  greatly  aggravated  by  tlie  patient's 
own  attention  being  directed  to  it :  a  patient  who,  while  her  attention 
was  fixed  on  the  surgeon's  examination,  could  not  bear  the  lightest 
touch  on  the  back  without  complaining  of  acute  pain,  will  often  be  hardly 
sensible  of  firm  pressure,  if  made  at  a  moment  when  she  is  eagerly  talk- 
ing of  something  else.  3.  The  course  of  the  disease  is,  however,  one  of 
the  main  elements  in  the  diagnosis,  and  perhaps  of  all  others  the  most 
satisfactory  in  cases  wliich  are  otherwise  somewhat  obscure.  We  have 
only  too  often  opportunities  of  seeing  poor  women  who  from  unfortunate 
errors  in  the  diagnosis  have  been  condemned  to  years  of  total  inactivity 
for  supposed  spinal  or  articular  disease ;  yet  no  abscess,  no  deformity, 
no  material  alteration  in  the  shape  of  the  parts  has  resulted,'^  still  less 
any  of  the  formidable  consequences  which  inflammation  would  have  pro- 
duced on  the  parts  in  the  neighborhood.  It  is,  however,  noticed,  and 
not  in<^leed  very  rarely,  that  there  is  some  tumefaction  round  the  seat  of 
the  disease,  often  the  result,  as  Sir  B.  Brodie  tells  us,  of  local  applica- 
tions,' but  also  present,  I  think,  in  some  cases  where  no  friction  or 
blistering  has  been  employed,  and  then  probably  the  result  of  conges- 
tion. The  cause  which  produces  such  congestion  is  no  doubt  the  pain, 
for  the  pain  in  h^'sterical  disease  is  often  (as  I  have  said  above)  as  real 
as  any  other  pain,  and  pain  easily  affects  the  suppl}'^  of  blood  to  the  part, 
just  as  in  periodical   neuralgia  the   pulsation  of  small  and   previously 


*  Sir  B.  Brodie  says  that  "  among  tho  hiijher  classes  of  society  at  least  four-flfths 
of  th(!  fomale  patients  who  are  comniDnly  supposod  to  labor  under  disease  of  the 
joints  liihor  under  hysteria  and  nothing  else."  Sir  B.  Brodie's  collected  works,  vol. 
iii,  p.  157. 

^  Sir  J.  Paget  gives  some  striking  instances  of  tho  perfectly  heulthy  condition  of 
joints  aft/'r  prolonged  disuse  (op.  cit..  p.  20G). 

3  Op.  cit.,  p.  159. 


TREATMENT.  385 

invisible  arteries  becomes  plainly  perceptible  before  and  during  the 
paroxysm.  Sir  B.  Brodie  has  noticed  that  in  some  hysterical  affections 
of  the  joints  there  is  a  periodical  change  of  temperature,  not  only  of  tlie 
part  but  of  the  whole  limb,  and  he  dwells  on  the  value  of  quinine  in 
such  cases  (Works,  vol.  ii,  pp.  308,  309).  These  cases  mark  still  more 
})lainly  the  affinity  between  hysteria  and  neuralgia. 

Temperatui'e  in  Hi/sleria. — Sir  J.  Paget  has  also  pointed  out  the 'extra- 
ordinary' variations  in  temperature  which  sometimes  occur  in  "nervous" 
maladies.  As  a  general  rule  the  temperature  is  an  important  fact  in  the 
diagnosis  of  hysterical  affections,  since  it  is  far  nearer  the  normal  than 
it  would  be  if  the  disease  were  organic;  or,  if  it  varies,  the  variations 
are  limited  and  probably  periodic.  But  these  excitable  and  nervous 
patients  are  liable  to  great  disturbances  of  temperature  from  slight  causes, 
so  that  Sir  J.  Paget  says  of  the  temperature,  that  though  "prudently 
estimated,  it  is  of  the  highest  value,  even  in  nervous  patients ;  overesti- 
mated, it  is  more  fallacious  in  them  than  in  any  others." 

General  Character  of  Hi/sterical  Fatienta. — These  are  the  chief  features 
in  the  diagnosis  of  hysterical  affections  from  their  local  symptoms.  Next 
the  surgeon  has  to  weigh  carefully  the  general  symptoms  which  the  patient 
presents.  The  complexion  of  the  patient's  mind  must  be  studied.  The 
extensive  experience  of  Sir  J.  Paget  has  taught  him  that  "  nothing  can 
be  more  mischievous  than  a  belief  that  mimicry  of  organic  disease  is  to 
be  found  only  or  chiefly  in  the  sill}',  selfish  girls  among  whom  it  is  com- 
monly supposed  that  hysteria  is  rife,  or  almost  a  natural  state."  He 
believes  it  to  be  more  true  to  say  that  these  nervous  diseases  are  seldom 
found  in  "patients  who  have  ordinary'  minds — such  minds  as  we  may 
think  average,  level,  and  evenly  balanced"— but  that  in  the  majority  of 
patients  of  this  class  "  there  is  something  notable,  bad  or  good,  higher 
or  lower,  than  the  average."  Any  observations,  however,  which  may  thus 
be  made  on  the  patient's  mental  constitution  can  amount  to  nothing  more 
than  a  probability,  and  that  not  of  a  very  high  class.  More  tangible 
evidence  may  be  obtained  from  the  patient's  family  history;  many  of  the 
worst  instances  of  hysteria  occur  in  girls  brought  up  by  mothers  them- 
selves hysterical;  from  the  circumstances  of  the  case,  many  nervous  dis- 
eases springing  from  the  contemplation  of  cases  occurring  in  the  family 
or  in  public ;  and  from  the  strange  possession  which  such  diseases  take 
of  the  patient's  mind  and  will.  "Few  patients,"  as  Sir  J.  Paget  says, 
"  with  real  hip  disease  or  real  spinal  disease  think  half  so  much  about 
their  ailments  as  the}'  do  whose  nervous  systems  imitate  those  diseases;" 
and  he  also  gives  some  striking  illustrations  of  the  possession  which  such 
affections  obtain  over  the  will  even  of  those  who  in  other  matters  possess 
some  firmness  of  mind  ;  so  that  "  a  man  who  has  intellect  and  will  to 
manage  a  great  business  ....  cannot  will  to  endure  sitting  u})rlght  for 
ten  minutes,  or  cannot  distract  his  attention  enongli  to  be  indifferent  to 
an  unmeaning  ache  in  his  back." 

With  the  best  attention  the  surgeon  can  give  to  the  case  it  must  be 
allowed  that  the  diagnosis  is  often  a  ver}'  doubtful  one;  and  in  order  to 
justify  a  confident  opinion  in  any  but  the  plainest  cases  repeated  exami- 
nation and  observation  are  essential. 

Treatment. — Nothing  can  be  more  difficult  than  the  treatment  or  man- 
agement of  some  of  these  hysterical  affections.  Too  much  attention  on 
the  part  of  the  surgeon  fixes  the  patient's  mind  on  her  ailment,  increases 
its  apparent  importance  in  her  eyes,  and  in  many  cases  certainly  tends 
to  protract  it ;  on  the  other  hand,  roughness  or  neglect  loses  her  confi- 
dence, without  which  all  treatment  is  nugatory.     The  moral  treatment 

25 


38G  HYSTERIA. 

of  hysterical  affections  is  of  as  much  impoitance  as  the  medical,  or  more. 
The  lifst  point  is  to  convince  the  patient  that  the  disease  is  understood, 
and  its  real  importance  admitted,  though  not  exaggerated.  For  we  must 
allow  that  liysteria,  though  not  dangerous  to  life,  and  seldom  threatening 
the  reason,  is  a  very  grave  disease,  and  often  entails  lifelong  misery  on 
its  victim.  When,  however,  tlie  patient  is  relieved  from  the  worst  anxie- 
ties, such  as  the  fear  of  permanent  paralysis,  lameness,  or  other  organic 
disease,  the  medical  or  surgical  treatment  of  the  case  becomes  easier.  I 
can  hardly  do  better  than  transcribe  Sir  B.  Brodie's  excellent  remarks 
on  the  treatment  of  hysterical  joint  affections: 

''  The  recovery  of  patients  laboring  under  these  hysterical  affections  is 
often  tedious.  But  much  depends  on  the  treatment,  moral  as  well  as 
physical.  The  sulphate  of  quinine,  preparations  of  iron,  the  citrate  of 
quinine  and  iron,  may  generally  be  exhibited  with  advantage;  and  these 
may,  according  to  circumstances,  be  combined  with  ammonia  or  the 
ammoniated  tincture  of  valerian.  In  most  instances  the  bowels  are  in  a 
very  torpid  state,  and  active  purgatives  are  from  time  to  time  required. 
The  air  of  the  country,  and  especially  that  of  the  seacoast,  is  more  favor- 
able to  the  patient  than  that  of  a  large  town  ;  and  while  at  the  seaside 
she  may  use  cold  sea-bathing  with  advantage  during  the  summer  and 
earl}-  part  of  the  autumn.  However,  as  to  constitutional  treatment,  the 
best  rule  that  can  be  laid  down  is,  that  the  medical  attendant  should 
inquire  into  the  state  of  the  general  health,  and  prescribe  for  tlie  patient 
according  to  the  circumstances  of  each  individual  case.  If  the  menstrua- 
tion be  irregular,  deficient,  or  excessive,  he  should  make  it  an  especial 
ol>ject  to  restore  this  function  to  a  healthy  condition To  a  consid- 
erable extent  these  cases  admit  of  being  benefited  by  medical  and  surgical 
treatment ;  but  what  I  have  termed  the  moral  treatment  of  them  is  of 
still  greater  importance.  If  a  young  lady  who  is  thus  afflicted  be  con- 
fined to  her  sofa,  her  attention  being  constantly  directed  to  her  complaint 
by  the  anxious  inquiries  of  her  friends,  the  daily  visits  of  her  medicial 
attendant,  and  the  exhibition  of  a  variety  of  drugs,  the  symptoms  may 
continue  unaltered  for  many  months,  and  even  (and  that  is  by  no  means 
an  unusual  occurrence)  for  several  years.  The  very  opposite  course  to  this 
should  be  pursued.  Her  attention  should  be  as  much  as  possil)le  directed 
to  other  objects.  She  should  enter  into  the  society  and  join  the  pursuits 
of  persons  of  her  own  age.  She  should  be  encouraged  to  use  the  limb, 
even  though  the  attempt  to  do  so  gives  her  pain  in  the  first  instance,  and 
she  should  pass  a  portion  of  each  day  in  the  open  air.  Under  this  mode 
of  treatment  I  have  known  many  cures  to  i)e  obtained  without  any  medical 
or  surgical  treatment  whatever."*  Sir  Benjamin  also  gives  some  direc- 
tions for  the  local  treatment,  as  applicable  to  hysterical  affections  of  joints. 
Such  treatment  must,  of  course,  vary  for  different  organs.  Its  general 
[)rinciple  is  to  do  as  little  as  possible  to  fix  the  patient's  attention  on  the 
part.  Any  plaster,  bandage,  or  other  application  which  keei)s  the  i)art' 
comlbrtably  warm,  and  [jrevents  the  patient  from  handling  or  looking  at 
it,  may  do  good.  Sometimes  pain  suddenly  inflicted,  as  by  the  tnoxa  or 
a  galvanic  shock,  effects  a  wonderful  cure,  similar  to  Sir  I>.  Brodie's  case, 
in  which  a  young  lady  was  cured  of  an  hysterical  i)ain  in  the  hip  by  a  fall 
from  a  donkey.  An(l  there  are  cases  (as  he  also  mentions)  in  which  a 
sudden  mental  impression,  such  as  a  sudden  call  to  "  rise  up  and  walk," 
has  produced  the  desired  result.  But,  as  a  general  rule,  little  is  required 
in  the  way  of  local  applications  beyond  what  is  necessary  to  maintain  the 


'  Sir  IJ.  Brodie's  Work^,  vol.  ii,  p.  309. 


COMPLICATIONS    OF    GONORRHCEA.  387 

natural  warmth  of  the  part.  Warm  bathing  is  often  of  much  service; 
and  so  is  galvanism,  if  properly  applied.  Cold,  Sir  J.  Paget  says,  almost 
always  does  harm. 

Narcotics  and  opiates  are  to  be  avoided  by  all  means  if  possible.  They 
are  generally  unnecessary  and  often  most  injurious,  and  should  only  be 
used  when  it  is  impossible  to  avoid  it;  and  this  impossibility  should  not 
be  hastily  admitted.  I  have  often  known  patients  habituated  to  the  use 
of  o[)ium  for  nervous  pain  who  could  l)y  no  means  sleep  without  pills,  but 
who  slept  quite  as  well  when  they  were  made  of  bread  as  of  opium.  At 
the  same  time  the  patient  must  have  quiet  sleep;  and  althougli  exercise 
is  to  be  enforced,  yet  long  periods  of  rest  afterwards  arc  needed. 


CHAPTER    XX. 

GONORRHCEA  AND  SYPHILIS. 

The  diseases  which  owe  their  origin  to  sexual  intercourse  are  gonor- 
rhcEa  and  syphilis,  the  former  almost  exclusively  a  local  disease,  yet  which 
has,  as  we  shall  see,  its  constitutional  manifestations  also  ;  the  latter 
usually  also  entirely  local,  yet  in  its  constitutional  form  one  of  the  most 
insidious  and  abiding  infections  to  which  the  human  body  is  liable. 

Gonorrhoea  differs  widely  in  the  two  sexes.  It  is  so  much  slighter  a 
disease  in  women  that  the  descriptions  of  it  are  always  taken  from  the 
male  sex.  Four  stages  of  the  complaint  are  described, — the  premonitory, 
the  inflammatorj',  the  stage  of  decline,  and  that  of  gleet. 

The  Fremonitory  Stage. — The  tirst  lasts  often  only  a  few  hours,  some- 
times as  much  as  two  da3's,  and  commences  generally  from  two  to  five 
days  after  intercourse — rarely  later.  It  is  marked  by  a  slight  itching  and 
a  little  tumefaction  of  the  lips  of  the  meatus,  and  possibly  some  slight 
discharge,  just  enough  to  make  the  lips  stick  together. 

The  Inflammatory  Stage. — This  is  succeeded  by  the  second  stage,  in 
which  there  is  high  inflammation  of  the  lips  of  the  urethra,  and  sometimes 
also  of  the  prepuce,  causing  phimosis,  with  cream\^,  greenish,  purulent  dis- 
charge, tenderness  to  pressure  along  the  urethra,  scalding  in  making 
water,  which  is  sometimes  so  painful  as  to  occasion  much  spasm  and  diffi- 
culty in  doing  so,  even  temporary  retention  ;  a  sensation  of  vveight  in  the 
perineum,  and  painful  erections,  especially  at  night.  Sometimes  char-dee 
is  present,  i.  e.,  an  ett'usion  of  lymph  into  the  corpus  spongiosum,  which 
prevents  distension  of  its  cells  in  erection,  causing  the  distended  corpora 
cavernosa  to  bend  over  it,  and  thus  giving  the  organ  a  curved  shape,  as 
if  bound  down  by  a  cord.  This,  however,  is  rare  by  comparison  with  the 
occurrence  of  mere  painful  erections,  and  still  rarer  are  the  cases  in  which 
the  ett'usion  takes  place  into  the  corpus  cavernosum,  causing  the  penis  to 
curve  to  one  side  in  erection. 

The  inflammatory  stage  lasts  from  one  to  three  weeks.  Its  symptoms 
are  due  to  acute  inflammation  and  sometimes  ulceration  of  the  mucous 


388  GOXORRIICEA. 

membvaiie  lining  the  urethra,  usually  situated  around  the  fossa  navicu- 
laris  and  in  or  almut  the  bulb,'  though  it  seems  that  any  part  or  the  whole 
of  the  canal  may  be  aflected. 

The  Sloge  of  Decline. — The  third  stage  (which  is,  in  fact,  a  part  of  the 
second)  is  marked  by  the  recession  of  all  the  s3^mptoras,  the  scalding  sub- 
siding, the  discharge  becoming  more  and  more  mucous,  and  the  disease 
tlien  either  disappearing  altogether  or  passing  into  the  fourth  stage, 
that  of  gleet,  which  is  a  mere  thin  water}''  discharge,  unaccompanied  by 
any  symptoms  except,  perhaps,  a  little  tenderness  to  pressure  over  the 
affected  part  of  the  urethra,  the  discliarge  proceeding  from  localized  in- 
flammation, or,  as  some  think,  probably  ulceration  of  the  mucous  lining 
of  the  fossa  navicularis  or  bulb. 

The  common  complications  of  gonorrhoea  are  as  follows: 

Abs^cess  may  form  in  the  areolar  tissue  of  the  penis  or  scrotum  ;  or,  as 
is  mucli  more  common,  in  one  of  the  lacunfe  of  the  urethra.  Such  ''lacu- 
nar abscess"  also  occurs  from  other  causes,  as  from  riding  on  a  wet  sad- 
dle or  inflammation  behind  a  stricture.  It  forms  a  small,  hard,  painful 
swelling  in  the  course  of  the  urethra,  which  often  occasions  considerable 
difficulty  in  micturition,  amounting  even  to  complete  retention.  For  its 
treatment  it  is  usually  sufficient  to  apply  a  poultice  and  pass  a  catheter 
when  necessary  to  relieve  retention,  in  <loing  which  the  abscess  is  often 
ruptured  and  the  complication  disappears.  If  there  is  much  pain  there 
can  be  no  objection  to  making  a  puncture.  The  abscess  bursts  generally 
into  the  urethra;  if  through  the  skin  fistula  hardly  ever  results,  for  the 
opening  into  the  urethra  either  does  not  exist  or  closes  spontaneously. 

Balanitis  is  less  a  complication  than  a  form  of  gonorrhoea.  We  have 
noticed  tliat  in  ordinary  gonorrhoea  the  prepuce  may  be  so  much  swollen 
as  to  cause  phimosis.  Sometimes  this  inflammation  and  swelling  of  the 
prepuce  and  the  surface  of  the  glans  is  the  whole  of  the  disease,  the  in- 
terior of  the  urethra  being  unaffected,  though  sometimes  the  lips  of  the 
urethra  are  also  inflamed.  The  absence  of  scalding  in  making  water 
will  lead  the  surgeon  to  the  belief  that  he  has  a  case  of  pure  balanitis 
to  deal  with,  but  he  can  hardly  be  certain  until  the  inflammation  of 
the  prepuce  has  subsided  sufficiently  to  allow  of  the  examination  of  the 
meatus. 

Phiw()i<iH. — Again,  inflammation  of  the  prepuce  leading  to  phimosis  is 
so  common  with  sypliilitic  sores,  that  often  cases  which  have  l^een  diag- 
nosed as  balanitis  turn  out  really  to  be  syphilitic.  Hence  a  good  deal 
of  reserve  in  forming  and  expressing  an  opinion  is  desirable.  Cases  of 
verital)le  balanitis  are  to  be  treated  by  keeping  the  penis  raised  and  wash- 
ing out  the  i)repuce  frequently  with  injections  of  cold  water  or  some  as- 
tringent, as  lime-water  or  weak  solution  of  nitrate  of  silver.  The  parts 
may  be  dusted  at  night  with  calomel  in  fine  powder  mixed  with  magnei^ia, 
to  be  washed  away  with  the  injection  in  the  morning.  The  mere  phi- 
mosis produced  in  ordinary  cases  by  gonorrhoea  seldom  requires  any 
operation,  as  it  will  sul)side  on  the  recession  of  the  disease;  but  in  cases 
of  gonorrluea  affecting  persons  who  have  congenital  phimosis  it  is  often 
necessary  to  operate. 

Paraphimoain  \fi  a  much  more  painfid  affection  than  phimosis,  of  which 
it  is  a  sequel.  The  phimosed  and  inliamed  pre[)uce  lias  been  forcibly 
drawn  behind  the  corona  glandis,an(l  has  there  swelled  and  inflamed  still 
more,  producing  great  constriction  and  consequent  swelling  of  the  glans, 
with  grievous  pain  ;  and,  if  unrelieved,  leading  to  ulceration  where  the 

^  See  a  preparation  in  St.  George's  Hospitiil  Museum,  Ser.  xii,  No.  Gl. 


COMPLICATIONS    OF    GONORRIICEA.  389 

penis  is  constricted  by  the  prepuce,  and  to  more  or  less  extensive  gan- 
grene of  the  constricted  glans  penis.  A  paraphimosis  can  always  be  re- 
duced, if  seen  before  adhesion  has  taken  place  between  the  constricting 
prepuce  and  the  tissues  beneath.  The  fore  and  middle  fingers  of  the 
two  hands  should  be  crossed  on  each  other  around  the  penis,  which  is 
thus  firmly  grasped,  and  the  prepuce  pulled  forwards,  while  witli  the  two 
thumbs  the  blood  is  kneaded  out  of  the  glans  and  the  latter  pushed  back. 
As  this  is  acutely  painful  it  is  usual  to  administer  chloroform  or  ether. 
If  the  paraphimosis  be  irreducible,  the  strangulation  must  be  liberated 
by  cutting  freely  through  the  constricted  prepuce  on  either  side  of  the 
penis,  so  as  neither  to  endanger  the  vessels  on  the  dorsum  nor  the  urethra 
on  the  lower  surface  of  the  organ.  After  all  swelling  has  subsided  the 
prepuce,  if  too  long,  must  be  circumcised. 

Spasms  and  Hsematuria. — Another  complication  of  gonorrhoea  is  severe 
spasm  in  making  water,  sometimes  complicated  with  htemorrhage  from 
the  urethra,  and  then  ver}^  probably  depending  on  ulceration  of  the  lining 
membrane.  Tliis  is  more  anno^-ing  and  alarming  to  the  patient  than 
really  dangerous.  The  spasms  will  subside  by  very  free  use  of  the  warm 
hipbath  (in  which  the  patient  can  generally  pass  water  easily)  and  by 
rest,  abstinence  from  any  irritating  medicines  or  applications,  bland 
drinks,  and  opium.  The  haemorrhage  is  never  really  formidable,  but  if  it 
is  at  all  copious  the  acetate  of  lead  or  Ruspini's  styptic  may  be  given 
internally,  and  the  patient  kept  in  bed,  with  ice  applied  to  the  perineum. 
The  hannorrhage  occurs  most  frequently  in  connection  with  chordee,  and 
the  treatment  which  obviates  the  latter  condition  will  stop  it.  The  most 
effectual  treatment  for  chordee  is  to  procure  very  sound  sleep,  by  means 
of  bromide  of  potassium  and  opium  taken  immediately  before  going  to 
bed.  The  patient  should  also  be  kept  slightly  below  par  by  low  diet  and 
small  doses  of  tartar  emetic.  When  the  chordee  comes  on  some  patients 
derive  relief  by  the  application  of  sudden  cold  to  the  penis,  as  by  putting 
it  against  the  cold  stone  or  metal  of  the  chimney-piece,  but  to  sit  in  warm 
or  hot  water  is  generally  much,  more  eff'ectual  and  grateful. 

Bubo  is  a  common  complication,  and  sometimes  the  lymphatics  of  the 
penis  are  themselves  inflamed  and  stiffened,  whereby  a  difficulty  in  erec- 
tion is  produced,  something  like  chordee.  In  these  cases  mercurial  oint- 
ment in  small  quantities  should  be  rubbed  in.  The  inflamed  inguinal 
glands  should  be  treated  at  first  by  complete  rest,  and  then,  if  hard  and 
indolent,  by  tinct.  of  iodine,  or  by  blistering.  The  latter  is  an  excellent 
remedy  in  chronic  bubo,  frequently  procuring  the  absorption  of  the  swell- 
ing, and,  when  it  does  not  do  so,  usually  causing  it  to  suppurate.  When 
suppuration  is  decided  the  abscess  should  be  laid  open  pretty  freely. 
Some  surgeons  lay  great  stress  on  making  the  opening  perpendicular  in- 
stead of  parallel  to  Poupart's  ligament,  thinking  that  the  movements  of 
the  thigh  and  body  will  have  less  tendency  to  keep  the  wound  open.  I 
cannot  say,  however,  that  I  attach  much  importance  to  the  direction  of 
the  incision,  provided  it  passes  pretty  completely  through  the  cavity. 

Gonorrhoeal  and  Capivi-i'ash. — Gonorrhoea  is  sometimes  followed  by 
an  eruption  of  red  papules.  This  is  usually  the  consequence  of  the  ad- 
ministration of  capivi  to  a  patient  whose  stomach  will  not  bear  it,  and 
is  hence  called  "the  capivi-rash  ; "  but  a  similar  rash  may  also,  though 
rarely,  be  found  when  gonorrhoea  is  complicated  with  other  forms  of 
gastric  irritation  not  caused  by  capivi.  The  eruption  being  papular  re- 
sembles lichen  more  than  any  other  form  of  skin  disease,  but  sometimes 
is  merely  a  rash  like  roseola.  In  other  cases  it  is  mixed  with  wheals  of 
urticaria.     The  treatment  consists  in  leaving  off"  capivi  or  anything  else 


390  GONORRHOEA. 

which  inny  be  disagreeinp:  with  the  stomach,  free  purging,*and  the  cor- 
rection of  tlie  secretions  by  alkalies  with  mercury. 

Goyiorrhccal  rheumatism^  or  synovitis,  is  a  painful  and  often  a  very  in- 
tractable disease.  Its  pathology  is  still  a  matter  of  dispute;  but  there 
seems  now  a  A'ery  general  agreement  that  it  depends  in  some  way  or  other 
on  the  irritation  and  discharge  in  the  urethra,  and  that  its  cure  must  be 
sought  for  in  the  cure  of  the  urethral  discharge;  and  this  lends  at  any 
rate  considerable  probability  to  Mr.  Barwell's'  speculation  that  the  disease 
may  really  be  a  form  of  pyjieniia,  or  blood-poisoning,  the  starting-point  of 
which  is  inflammation  of  the  veins  around  the  urethra  or  prostate  gland. 
It  is  often  noticed  that  the  inflammation  will  persist  so  long  as  the  dis- 
charge persists,  and  even  so  long  as  there  is  any  tenderness  in  the  affected 
portion  of  the  urethra,  but  subsides  at  once  when  the  urethra  has  become 
perfectly  healthy.  Such  rheumatism  is  not  confined  entirely  to  gonor- 
rhoea! inflammation  of  the  urethra,  but  is  sometimes,  though  rarely,  found 
after  urethritis  from  other  causes."  It  is  far  rarer  in  women  than  men, 
and  this  corresponds  witii  the  general  immunity  of  the  female  urethra  in 
gonorrhoea,  though  cases  of  gonorrhoeal  rheumatism  have  been  recorded 
in  females.  It  almost  always  affects  the  knee  ;  other  joints  may  also  be 
implicated,  but  I  can  hardly  recollect  a  case  in  which  the  knee  was  not 
the  principal  seat  of  the  disease.  The  pain  is  not  usually  acute,  but  it  is 
constant,  worse  at  night,  and  accompanied  by  considerable  synovial  effu- 
sion. 

"  There  is  also,"  says  Mr.  Bond,  "  a  most  common  and  characteristic 
complication  affecting  the  eyes,  and  this  is  a  congestion  of  the  sclerotic. 
The  conjunctiva  is  sometimes  slightly  congested,  and  the  caruncuhie  red 
and  injected  ;  but  the  great  peculiarity  is  the  congestion  of  the  sclerotic 
vessels,  which  are  seen  radiating  around  the  cornea." 

The  patients  are  usually  pale,  anjiemic  men,  in  whom  discharges  are 
very  lial)le  to  occur  and  very  difficult  to  cure ;  and  the  connection  of  the 
rheumatism  with  the  gleet  is  sometimes  conclusively  proved  by  the  re- 
currence of  the  former  when  any  accidental  cause  (of  which  the  most 
frecpient  is  sexual  intercourse)  has  produced  a  renewal  of  the  latter. 

Accordingly  the  first  indication  of  treatment  is  to  cure  the  discharge. 
If  a  bougie  or  catheter  be  passed  it  will  almost  always  be  found  that 
there  is  considerable  spasm,  and  that  the  urethra  bleeds  very  readily. 
Under  the  influence  of  instruments  gradually  increasing  in  size  the  irri- 
tability of  the  urethra  will  often  sul)side  and  the  gleet  disappear.  If 
not,  astringent  and  sedative  injections  must  be  resorted  to,  Mr.  Bond 
speaks  highly  of  an  injection  made  with  half  a  drachm  of  tannin  in  six 
ounces  of  cold  water,  with  two  drachms  of  opium  added.  A  fine  pre- 
cipitate is  formed.  The  injection  is  to  be  well  shaken  just  before  use, 
and  this  precipitate  will  adhere  to  the  walls  of  the  uretiira,  making  the 
astringent  and  sedative  action  of  the  application  more  permanent  H.han 
that  of  a  merely  fluid  injection  can  be.  The  general  health  must  be 
carefully  attended  to;  steel,  quinine,  str3^chnia,  bark,  or  any  other  tonic 
which  may  he  preferred,  must  be  administered,  with  good  diet  and  a  suf- 
ficient supply  of  stimulants.  At  the  same  time  the  digestion  and  the 
state  of  the  urine  must  be  carefully  attended  to. 

Iodide  of  i)otassium  is  often  administered  in  this  disease,  and  when 
the  patient  is  in  robust  health  and  the  drug  agrees  with  him  I  have  seen 

'  On  Diseases  of  the  Joints,  18^1,  p.  101. 

*  Hence  it  is  somolimns  culled  "  iiretlinil  rheumatism."  See  a  very  interesting 
paper  by  Mr.  Bund,  Lancet,  Marcli  23,  1872. 


TREATMENT.  391 

very  good  results  from  it ;  but  I  agree  with  Mr.  Bond  in  dissuading  its 
employment  in  cachectic  persons. 

Locally,  some  mild  counter-irritant  generally  answers  best,  combined 
with  gentle  pressure  when  the  pain  has  subsided.  Scott's  bandage  is  a 
very  good  application  in  the  last  stages  of  the  complaint. 

Other  Complications. — Tlie  other  complications  of  gonorrhoea  are  in- 
flamjnation  and  abscess  of  the  prostate,  orchitis  or  epididymitis,  and 
gouorrhoeal  ophthalmia. 

These  will  be  found  treated  of  in  the  chapters  on  diseases  of  the  uri- 
nary organs,  of  the  testicle,  and  of  the  eye  respectively. 

Treatment. — The  treatment  of  gonorrhnea  is  often  very  difficult,  and 
the  more  so  the  more  virulent  is  the  affection  and  the  more  cachectic  the 
patient.  With  regard  to  the  former  particular,  there  can  be  no  doubt 
that  inflammation  of  the  male  urethra  follows  sexual  intercourse  with 
women  who  have  no  specific  disease,  but  who  are  suffering  from  leucor- 
rhcea,  or  who  have  some  ulceration  of  the  os  uteri,  or  who  are  menstru- 
ating ;'  but  such  affections,  if  they  deserve  the  name  of  gonorrha?a,  are 
far  less  acute  under  ordinary  circumstances  than  the  disease  which  is 
excited  b}' true  gonorrhoeal  pus,  and  they  come  on  with  less  premonitory 
symptoms. 

In  the  early  stage  gonorrhoea  may  doubtless  be  often  cut  short  by  re- 
peated injections,  for  which  purpose  either  mere  water  may  be  used,  cold 
or  tepid,  or  a  weak  solution  of  acetate  of  lead  or  sulphate  of  zinc,  the 
object  being  merely  to  wash  out  the  discharge.  The  patient  must  be 
carefully  instructed  in  tiie  method  of  injecting,  and  the  process  be  re- 
peated ever}'  hour  while  he  is  awake. 

At  the  same  time  demulcent  drinks,  low  diet,  slight  purging,  and  com- 
plete rest,  in  bed  if  possible,  are  to  be  ordered. 

Some  practitioners  use  stronger  injections,  such  as  arg.  nit.  in  solution, 
but  they  are  more  dangerous  and  not  more  efficient.  The  first  effect  of 
these  strong  injections  is  to  increase  the  inflammation,  so  that  after 
about  two  days  there  will  be  a  good  deal  of  discharge,  and  perhaps  a 
little  blood..  Then  the  injection  is  to  be  stopped,  in  the  hope  that  the 
discharge  will  subside  and  the  patient  recover  under  the  same  precau- 
tions about  rest  and  diet  as  before. 

In  the  inflammatory  stage  the  treatment  should  not  certainly  at  first 
be  too  active.  The  patient  seems  to  me  to  recover  more  speedily  if 
treated  at  first  by  demulcents,  rest,  frequent  warm  bathing,  warmth  or 
poultice  to  the  perineum,  with  leeches  there  if  the  symptoms  be  very 
urgent,  and  low  diet  with  much  bland  fluid,  than  where  any  specific  med- 
icines are  ordered.  Injections  other  than  those  of  tepid  water  should 
not  be  used  while  there  is  much  scalding  and  inflammation.  The  meatus 
must  be  kept  clean  by  frequent  ablution,  and  the  penis  should  not  be  too 
closel}'  covered.  When  the  acute  symptoms  are  subsiding  copaiba  often 
is  most  useful,  and  in  some  cases  indispensable  to  the  cure  of  the  disease. 
I  have  known  cases  in  which  the  discharge  would  at  once  recur  when  the 
drug  was  omitted,  though  in  other  respects  tlie  treatment  and  all  other 
circumstances  were  the  same.  But  there  are  cases  in  which  it  does  no 
good,  and  some  in  which  it  does  much  harm,  upsetting  the  digestion, 
causing  rash,  and  probably  irritating  the  urethra,  and  so  i)redisposing  to 
gleet  and  other  complications.  It  is  best  prescribed  either  in  the  form 
of  an  emulsion  or  in  doses  of  Jss.  or  Jj,  mixed  with  njjxv  of  dilute  sul- 

^  It  is  on  this  account  that  it  is  coinmunly  said  thiit  gonorrhoea  is  more  frequent 
in  men  than  women. 


392  GONORRHCEA. 

pburic  acid  in  infusion  of  roses.  Tlie  common  capsules  disguise  the 
taste  of  the  drug,  and  ai'e  in  that  respect  most  convenient;  but  they  are 
not  so  much  to  be  relied  upon.  Cubebs  appears  to  me  much  less  effica- 
cious, and,  indeed,  by  itself  nearly  inert  as  far  as  the  ciwe  of  the  disease 
goes ;  but  some  practitioners  think  that  an  addition  of  about  ten  drops 
of  the  tincture  of  cubebs  increases  the  efficacy  of  the  copaiba.^ 

Treatment  of  Gleet. — The  treatment  of  gleet  is  often  even  more  tedious 
and  difficult  than  that  of  gonorrhoea..  The  patient  is  usually  M^eak,  sallow, 
and  cachectic,  and  depletion  does  not  agree  with  him.  But  neither  does 
any  copious  indulgence  in  stimulants.  Moderate  allowances  of  meat,  wine, 
and  exercise  are  usually  to  be  recommended.  Any  defect  of  the  general 
health  must  be  discovered,  and,  as  far  as  may  be,  corrected,  and  some 
tonic,  such  as  steel,  strychnia,  or  bark,  will  generally  i)rove  beneficial. 
Local  treatment  must  be  directed  in  the  fii'st  instance  to  discover- Avhether 
there  is  any  contraction  (spasmodic  or  other)  of  tlie  urethra ;  and  often 
the  constant  passage  of  bougies,  increasing  in  size  until  the  urethua  is 
distended  to  its  extreme  limit,  will  cure  the  complaint;  or  else  the  use 
of  injections,  or  touching  any  tender  spot  of  the  urethra  with  the  porte 
caustique,  or  with  a  solution  of  perchloride  of  iron,  will  cure  the  discharge. 
But  often  it  will  not  subside  till  the  patie^it  has  undergone  a  thorough 
change  of  climate  and  wa}'  of  life. 

Gonorrhcea  in  Women.— \\\  females  gonorrhoea  is  a  much  less  severe 
complaint  than  in  males.  It  affects  chiefly  the  vulva  and  vagina,  rarely 
the  urethra  or  bladder.  It  is  difficult  or  impossible  to  distinguish  aggra- 
vated leucorrhoea  from  mild  forms  of  gonorrhoea  ;  nor  is  it  of  much  im- 
portance, since,  doubtless,  such  leucorrhoea  will  excite  gonorrhoea  in  the 

1  *rhe  treatmont  of  f:;()norrhoea  in  private  or  hospital  out-patient  practice  is  neces- 
saril}'  somewhat  unsatisfactory,  since  it  is  hardly  possible  to  insist  on  the  complete 
rest  and  abstinence  from  all  forms  of  excitement  which  is  so  necessary  to  ra)iid  re- 
cover}'.  In  civil  hospitals  jiersons  affected  with  gonorrhcea  are  seldom  admitted  as 
in-]iatients.  But  in  military  hospitals  the  disease  is  constantly  under  treatment,  and 
cure  is,  as  a  rule,  speedily  and  easily  obtained.  I  have  accordingly  requested  my 
friend,  Mr.  E.  Venning,  Assist. -Surgeon  to  the  1st  Life  Guards,  to  sketch  out  for  me 
the  f)lan  which  he  usually  adopts,  and  which  may  be  taken  as  agreeing  in  the  main 
with  that  adopted  in  other  regimental  hospitals.  Mr.  Venning  speaks  as  follows  : 
"  In  slight  cases,  in  which  the  urethral  discharge  is  not  verj^  profuse  and  there  is  not 
great  inflammatory  action  present,  I  simply  give  the  patient  a  warm  bath,  and  have 
him  placed  in  bod  and  keep  him  in  the  horizontal  position.  I  generally  order  a  mild 
purgative  to  be  administered,  and  direct  him  to  use  an  injection  consisting  of  zinci 
sulph.,  gr.  iv  ;  glycerin,  .^ss.  ;  morph.  acetat.,  gr.  \]  aqute  destil.,  ad  5VJ.  To  be 
injected  every  hour  or  two,  provided  no  pain  is  caused.  The  diet  to  be  light  and 
non-stimulating.  In  severe  cases,  where  there  is  much  inflammatorj'  action,  shown 
by  a  profuse,  thick,  yellow  discbarge,  and  accompanied  with  great  urethral  irritation 
during  micturition,  which  latter  is  generally  very  frequent,  and  when  chordee  causes 
great  distress,  I  also  commence  treatment  with  a  warm  bath  and  a  brisk  purge,  and 
order  a  saline  demulcent  mixture  (occasionally  combining  antimony  with  it)  to  be 
given  every  four  hours,  and  I  give  directions  for  the  urethra  to  be  constantly  washed 
out  with  tepid  water.  In  addition  to  this  I  order  a  suppository  containing  morphia 
and  henbane  to  be  administered  at  night  to  relieve  the  chordee.  The  diet  to  be  light 
and  non-.ttimulating.  Perfect  rest  in  bed  to  be  maintained.  Wiien  the;  most  acute 
symptoms  have  subsided  I  then  prescribe  a  mixture  containing  oil  of  sandalwood, 
mucilage  of  acacia,  and  tinct.  of  orange-peel  twice  a  day,  and  an  injection  consisting 
of  zinci  sulpho-carbolat.,  ^ss. ;  morph.  acet.,  gr.  \;  aqua  destil.,  ad  5viij.  To  be 
used  every  two  hours.  If  any  pain  is  caused  by  this,  to  dilute  it  with  distilled  water. 
If  tlie  discharge  does  not  rapidly  decrease  under  this  treatment  I  increase  the  diet 
at  once,  as  I  have  often  found  that  discharge  is  kept  up  by  the  patitmt  becoming 
lowered  in  strength  by  the  constant  drain  on  the  .system  ;  and  that  the  administra- 
tion of  wine  in  the  form  of  claret,  with  a  generous  diet,  has  been  attended  with  ex- 
cellent results." 


GONORRHOEA    IN     FEMALES.  393 

male.  Prostitutes  are  especially  liable  to  leucorrhoea  in  consequence  of 
the  constant  excitement  of  the  o^enerative  organs  ;  but  the  certifying 
surgeons  under  the  Contagious  Diseases  Acts  only  think  it  necessary  to 
secfiide  those  in  whom  the  discharge  is  purulent.  There  is  a  form  of 
purulent  discharge  from  the  vulva  pretty  often  seen  in  young  children— 
the  leucorrhoea  infantum — which  was  at  one  time  confounded  with  gon- 
orrhcjea,  and  was  believed  to  be  due  to  impure  connection  ;  but  this,  in 
the  great  majority  of  cases,  is  an  unfounded  suspicion.  In  some  cases 
no  doubt  young  children  are  affected  with  ordinary  gonorrhoea,  but  in 
such  instances  marks  of  violence  about  the  vulva  will  exist,  and  will  show 
that  forcible  entrance  has  been  attempted  ;  or  possibly,  if  the  case  be  seen 
soon  after  the  rape,  spermatozoa  may  be  discovered  in  the  vulva.  Usually, 
however,  this  discharge  originates  either  from  dirt  or  from  some  cause 
difficult  to  discover.  Many  of  the  children  certainly  suffer  from  worms. 
Attention  to  the  general  health,  strict  cleanliness,  frequent  washing  out 
of  the  vagina,  and  the  use  of  a  tent  steeped  in  some  astringent  lotion, 
will  effect  a  cure. 

Gonorrhoea  in  the  female  causes  acute  inflammation  of  the  vagina  and 
vulva,  frequently  accompanied  by  swelling  of  the  nymph?e,  which  protrude 
beyond  the  labia.  The  discharge  is  sometimes  very  profuse,  and  there 
are  often  excoriations  in  various  parts  of  the  vagina;  the  labia  are  fre- 
quently much  swollen,  and  abscess  often  forms  there.  Hence  there  is 
much  pain  in  walking  and  in  sexual  intercourse.  Sometimes  the  inflam- 
mation attacks  the  urethra,  and  then  usually  causes  more  or  less  cystitis; 
occasionally  it  spreads  backwards  as  far  as  the  os  or  cervix  uteri,  and  it 
seems  certain  that  peritonitis  may  be  caused  by  its  passage  inwards,  and 
that  a  form  of  inflammation  sometimes  attacks  the  ovary  analogous  to 
the  orchitiG  of  the  otlier  sex.  The  acuter  attacks  of  gonorrhoea  are  pain- 
ful, but  tliere  is  rarely  any  scalding  in  micturition,  as  in  men.  The  com- 
plications also  are  much  rarer  than  in  the  male.  Ovaritis  would  cause 
pain,  swelling,  and  tenderness  in  the  iliac  fossa,  with  nausea  and  fever, 
and  the  pain  would  be  aggravated  by  coughing  or  other  exertion  of  the 
abdominal  muscles.  Rest,  free  leeching  of  the  abdomen,  salines,  and 
opium  constitute  the  appropriate  treatment. 

Bubo  is  not  so  common  as  in  males.  Its  treatment  is  the  same. 
Abscess  of  the  labium  is  the  most  common  complication,  and  it  some- 
times extends  to  a  great  distance.  I  once  had  a  patient  who  was  sent 
into  the  hospital  for  supposed  fistula  in  ano.  The  opening  was  a  good 
way  behind  the  anus,  and  on  probing  it  I  found  that  it  passed  forwards, 
and  then  on  examination  of  the  vulva  the  case  resolved  itself  into  one  of 
gonorrhoea  with  labial  abscess. 

Vegetations  and  mucous  patches  around  the  labia  and  anus  are  very 
common,  particularly  in  prostitutes.  Any  discharge  which  may  be  present 
being  cured,  these  vegetations  will  either  subside  of  themselves  or  may 
be  treated  with  the  strong  liquor  plumbi,  or  snipped  off,  or  tied  with  an 
elastic  ligature.  When  they  are  very  numerous  and  large  it  is  better  to 
remove  them  freely  on  a  level  with  the  skin  and  apply  the  actual  cautery 
to  any  bleeding  point. 

Treatment. — The  treatment  of  gonorrhoea  in  the  female  is  very  much 
easier  than  in  the  male,  provided  that  the  patient  is  properly  under  con- 
trol. In  hospital  out-patients  the  disease  is  often  very  intractable,  because 
the  patient  will  not  take  care  of  herself  nor  abstain  from  sexual  intercourse ; 
but  with  perfect  rest,  perfect  cleanliness,  and  frequent  copious  injections, 
the  disease  will,  in  almost  all  cases,  soon  subside.  The  injection,  or  rather 
the  washing  out  of  the  vagina,  should  be  managed  by  means  of  large 


394  SYPHILIS. 

quantities  of  some  weak  lotion,  such  as  Goulard,  or  a  solution  of  sulphate 
of  zinc,  two  grains  to  the  ounce,  pumped  in,  while  the  patient  is  I'ecum- 
bent,  bv  an  endless  syrinoe  (Evory  Kennedy's)  and  allowed  to  run  out. 
If  any  ulceration  can  be  seen  it  can  be  touched  with  caustic  throutjh  the 
speculum.  Lint  steeped  in  the  lotion  should  be  placed  between  the  labia 
to  avoid  their  mutual  contact,  or  the  vajjina  plugged  with  a  pessary  of 
tannin.  While  the  inflammation  is  acute  salines  and  low  diet  must  be 
ordered,  but  "the  exhit)ition  of  specifics  (copaiba  or  cubebs)  in  the  gon- 
orrluea  of  women  is  perfectly  futile,  unless  the  urethra  be  affected,  and 
even  then  the}'  seem  to  be  productive  of  little  if  any  benefit."    (Marson.) 


SYPHILIS. 

Syptiilts  is  defined  a«  being  a  specific  disease  produced  by  the  conta- 
gion of  the  same  disease  in  another  person,  and  characterized  (a)  in  its 
primary  form  by  the  appearance  on  the  part  inoculated  of  one  of  two 
ditferent  kinds  of  sore  (or  chancre)  ;  and  (i),  in  its  secondary'  or  consti- 
tutional form,  by  various  eruptions  on  the  skin,  by  sore  throat,  aff'ections 
of  the  eye,  the  glands,  the  bones,  and  almost  every  other  tissue  of  the 
body. 

Tlie  contagion  is  always  conveyed  by  direct  inoculation,  generally,  of 
course,  in  sexual  intercourse,  but  accidentally  in  other  forms  of  personal 
contact,  as  when  a  surgeon  inoculates  a  wound  in  his  finger  by  touching 
a  syi)hilitic  sore,  or  a  wet-nurse  inoculates  a  crack  on  her  breast  by  suck- 
ling a  syphilitic  infant,  or  when  the  syphilitic  virus  is  purposely  inocu- 
lated for  medicinal  or  experimental  purposes. 

In  tliis  definition  all  diseases  excited  by  sexual  intercourse  which  are 
not  gonorrhoeal  but  are  marked  liy  the  appearance  of  a  chancre  are  classed 
as  sy[)hilitic  ;  but  there  is  a  striking  and  radical  difference  between  the 
two  kinds  of  chancre,  viz.,  that  in  one  kind  the  disease  is  local  merely, 
never  affecting  the  constitution,  and  followed,  therefore,  by  complete  re- 
covery as  soon  as  the  local  mischief  is  healed,  while  the  other  kind  con- 
stitutes the  most  obstinate  infection  to  which  the  human  subject  is  liable, 
remaining  during  the  whole  of  the  person's  lifetime  (in  the  more  obstinate 
and  inveterate  cases,  which,  however,  are  happily  rare)  as  a  constant 
source  of  trouble  and  danger,  breaking  out  after  long  intervals  of  health 
in  one  part  of  the  body  after  another,  and  Iteing  transmitted  through  the 
blood  of  the  mother  or  the  semen  of  the  father  from  one  generation  to 
another.  ' 

Varietiesf  of  Nomenclature. — Hence  some  pathologists  separate  these 
two  forms  from  each  other  in  nomenclature  as  they  are  separated  in  prac- 
tice— calling  the  non-constitutional  form  of  chancre  "  the  venereal  dis- 
ease," or ''  the  non-infecting  sore,"  while  they  restrict  the  name  of  "  syph- 
ilis "  to  the  constitutional  disease  or  "  the  infecting  sore."  But  witliout 
entering  on  the  controversy  whether  there  is  one  kind  of  S3'philitic  ])oison 
or  two,  I  think  it  sufficient  to  sa}'  that  the  definition  adopted  in  the  fol- 
lowing pages  is  the  most  common,  and  has  the  advantage  of  involving  no 
theory,  but  being  a])lain  statement  of  everyday  facts. 

Local  Hi/philiii. — To  commence  with  the  local  form  of  syphilis.  This 
exhiliits  itself  in  three  principal  varieties:  1.  The  common  soft  chancre 
unaccompanied  by  bubo;  "suppurative  syphilitic  inflammation,"  as  Mr. 
H.  Lee  calls  it.  The  sore  a[)pears  four  or  five  days  after  connection,  and 
begins  to  sup|)urato  at  once  ;  it  looks  as  if  a  piece  had  been  chipped  or 
punched  out  of  the  part ;  its  borders  are  defined  and  often  slightly  un- 


SLOUGHING    SORES,  395 

dermined,  its  base  sometimes  thickened  by  the  inflammation  of  tlie  tissues 
under  it ;  bnt  this  hardness  is  different  in  character  from  thatof  tlie  hard 
or  Hunterian  chancre,  as  will  be  presently  pointed  out.  The  sore  heals 
with  no  remaining  induration  in  three  or  four  weeks.  The  absorbents 
and  glands  are  unaffected.  In  many  cases  there  are  two  or  more  sores  at 
the  same  time.  Sometimes  the  orifice  of  the  prepuce  is  surrounded  by  a 
ring  of  radiating  cracks  or  sores. 

The  term  "  phlegmonoid  "  is  applied  to  a  variety  of  soft  sore  in  which 
there  is  greater  induration  and  a  more  raised  margin,  from  the  more  ac- 
tive nature  of  the  inflammation,  and  in  wliich  the  sore  is  slower  to  heal. 

2.  The  Sore  xvith  Suppurating  Bubo. — When  the  soft  sore  is  accom- 
panied by  a  suppurating  bubo,  or  in  those  rare  cases  in  whicli  the  inguinal 
glands  are  enlarged  and  suppurate  without  any  breacli  of  surface  on  the 
genitals,  the  case  is  classed  l\y  Mr.  Lee  under  tlie  name  of  "  ulcerative 
syphilitic  inflammation."  The  sore  is  ragged  and  worm-eaten  ;  the  ab- 
sorbents are  often  affected  as  well  as  the  glands,  and  specific  al)scesses 
are  sometimes  though  rarely  formed  in  the  (course  of  the  absorbent  vessel. 
It  is  found  by  experiment  that  matter  taken  from  any  part  of  this  course 
as  far  as  the  gland  is  contagious.  Yet  the  contagion  is  destroyed  at  the 
glands,  so  that  no  part  of  the  body  beyond  the  gland  is  affected,  nor  is 
the  blood  contaminated.' 

The  treatment  of  these  forms  of  syphilis  is  expectant  only.  If  the  pa- 
tient be  haunted  by  nervous  feelings  produced  by  the  sore,  or  if  from  any 
circumstance  it  is  of  especial  moment  to  him  to  hasten  its  cure,  this  may 
perhaps  be  effected  b}'  destroying  its  surface  with  some  strong  caustic, 
such  as  potassa  fusa,  or  the  acid  nitrate  of  mercury  ;  but  such  treatment 
being  entirely  superfluous  should  only  be  adopted  at  the  express  instance 
of  the  patient.  AH  that  is  necessary  is  to  keep  the  jiart  clean,  to  apply 
some  slight  stimulant,  such  as  the  black  or  red  wash,  to  poultice  the  bubo 
and  open  it  as  soon  as  it  suppurates,  and  to  enforce  abstinence  from  sexual 
intercourse. 

Syphilitic  PhimosU. — When  such  sores  are  inflamed  from  any  cause, 
the  inflammation  may  propagate  itself  to  the  prepuce,  causing  phimosis  ; 
and  if  the  surgeon  has  not  seen  the  case  liefore  this  has  taken  place  he 
may  be  uncertain  whether  the  case  is  one  of  balanitis,  soft  sore,  or  hard 
sore,  for  hard  sores  when  inflamed  may  suppurate  freely.  'I'he  safest  plan 
on  the  whole  is  to  wait  until,  under  the  measures  recommended  in  gonor- 
rhoeal  phimosis  (see  p.  388),  the  swelling  has  been  subdued  and  the  glans 
can  be  uncovered  and  thoroughly  examined.  If  necessary,  however,  it 
is  justifiable  to  divide  the  prepuce,  and  so  uncover  the  sore  and  expose  it 
to  treatment,  since  sometimes  it  can  hardly  be  got  to  heal  otherwise.  I 
have  often  done  this  with  impunity,  and  Dr.  Humphry  speaks  of  having 
done  it  a  great  number  of  times  with  no  bad  results.  Still  it  must  be  al- 
lowed that  there  is  some  risk  (particularly  if  the  sore  below  is  of  the  in- 
fecting variety)  that  the  whole  wound  will  become  one  large  V-shaped 
chancre,  as  I  saw  happen  in  one  instance  not  under  my  own  care.  Some 
idea  can  occasionally  be  formed  of  the  existence  and  of  the  character  of 
a  sore  b^'  feeling  the  glans  through  the  prepuce,  but  very  often  the  latter 
is  too  much  swollen  to  permit  this. 

8.  Sloughing  Soren. — The  third  form  of  local  chancre  is  the  gangrenous 
— a  far  more  serious  affection  than  either  of  the  others,  but  resembling 


1  From  this  fact  Mr.  Lee  is  led  to  question  the  office  of  the  absorbents  and  glards 
in  the  infecting  form  of  syphilis  in  conveying  the  virus  into  the  system,  a  function 
which  he  is  inclined  to  attribute  to  the  veins. 


396  SYPHILIS. 

tlieni  in  not  being  followed  by  secondary  symptoms.  It  is  subdivided 
into  tlie  sloughing  and  the  phagedenic  form  of  sore.  In  the  former  the 
gangrene  is  of  tlie  moist  variety,  spreading  sometimes  with  alarming 
rapidity.  It  is  more  commonly  seen  in  this  country  in  women,  who  are 
almost  always  prostitutes,  broken  down  by  want  and  debauchery  ;  but  in 
military  practice  it  shows  itself  in  soldiers  whose  circumstances  have 
been  somewhat  similar,  as  a  kind  of  epidemic  affection,  which  sometimes 
assumes  formidable  proportions.  It  occurs  either  primarily — the  sore 
sloughing  as  soon  as  formed — or  a  previously  formed  sore  takes  on  a 
slougliing  action.  It  seems  often  implanted,  as  from  one  labium  to  the 
other,  or  from  tlie  glans  to  the  prepuce.  It  does  not  affect  the  absorbents 
(though  it  may  attack  a  bubo),  nor  is  it  followed  by  secondary  symptoms  ; 
but  it  often  spreads  to  a  dreadful  extent,  and  may  even  prove  fatal  by  ex- 
haustion or  by  haemorrhage  in  the  separation  of  the  sloughs. 

The  other  form  is  the  phagedenic,  and  tliis  also  may  occur  either  pri- 
marily or  secondaril}'.^  It  is  inoculable.  Sometimes,  when  a  bubo  has 
existed,  this  also  becomes  phagedenic  ;  otherwise  this  form  does  not  affect 
the  absorbents. 

Both  these  forms  are  local  only.  The  first  is  best  treated  by  poultic- 
ing (with  charcoal  or  yeast,  if  the  sore  be  very  foul),  free  doses  of  opium, 
diffusible  and  alcoholic  stimulants,  and  very  nutritious  diet.  In  the 
phagedenic  form  the  surface  of  the  sore  maybe  destroyed  by  nitric  acid, 
if  tlie  sloughing  action  does  not  extend  deeply' ;  otherwise  lotions  of  nitric 
acid  or  of  potassio-tartrate  of  iron,  or  of  bark  and  myrrh,  or  of  carbolic 
acid,  should  be  applied,  and  a  regimen  similar  to  the  above  ordered. 

The  con st.it idional  form  of  syphilis,  syphilis  proper,  or  infecting  sore, 
is  distinguished  by  the  occurrence  on  the  genital  organs,  or  other  part 
primarily  affected,  of  a  peculiar  form  of  chancre,  the  "hard"  or  "Hun- 
terian  "  chancre,  which  is  characterized  by  the  occurrence  of  adhesive 
inflammation  in  the  neighborhood  of  the  ulcer,  producing  a  peculiar  indu- 
ration, and  by  a  chronic  engorgement  of  the  l^'mphatic  glands,  which  are 
\Qvy  slow  to  suppurate  even  on  irritation,  and  which  under  ordinary  cir- 
cumstances remain  in  an  indolent  condition  for  an  indefinite  time,  form- 
ing a  bunch  of  hard  knobs  under  the  skin  ("  amygdaloid  glands  ").  The 
chancre  begins  at  a  variable  time  after  exposure  to  contagion.  It  may 
be  as  eai'ly  as  three  or  five  days,  but  well-authenticated  instances  are  on 
record  in  which  several  weeks  have  elapsed.'^  Slight  itching  is  first  noticed 
at  the  part,  then  redness,  and  a  small  vesicle  forms,  which  soon  cracks, 
and  induration  shows  itself  at  the  base  of  the  crack  ;  the  sore  spreads  and 
becomes  excavated  and  glazed,  with  little  or  no  granulation  on  its  surface. 
Its  natural  secretion,  if  examined  microscopically,  is  found  not  to  be 
pundent,  but  to  contain  only  a  little  granular  matter,  though  the  sore 
can  be  made  to  sujjpurate  by  the  friction  of  the  clothes  or  by  irritating 
ap|)lications.  The  liardness  at  the  base  of  the  ulcer  from  which  the  sore 
takes  its  usual  appellation  is  of  a  peculiar  kind,  different  from  that  which 
is  fouufl  at  the  base  of  a  pldegmonoid  soft  sore,  in  this,  that  in  the  Ilun- 
terian  chancre  the  hardening  feels  as  if  due  to  a  la^er  of  parchment  or 
other  hard  material  let  into  the  tissues,  that  is  to  say,  it  is  of  limited 


1  The  primary  phagedenic  sore  must  of  course  be  carefully  distinguishi'd  from 
phagedena  affecting  a  secondary  syphilitic  ulcer,  such  as  are  sometimes  found  on  the 
genital  organs. 

2  Laneereaux  gives  a  table  often  cases  of  inoculation  with  matter  from  secondary 
sores.  The  mean  period  of  incubation  was  twenty-eight  days.  When  the  disease  is 
derived  from  a  primary  sore  the  period  of  incubation  is  probably  much  shorter,  but  in 
two  cases  related  by  him  it  was  eighteen  days. 


LOCAL    AND    CONSTITUTIONAL.  397 

thickness,  and  abruptly  ceases  where  the  health}-  tissues  commence; 
while  the  hardness  at  the  base  of  a  i)hlegmonoid  sore  being  due  to  the 
infiltration  of  lymph  from  common  inflammation  of  the  cellular  tissue,  is 
of  a  much  less  defined  character,  extends  farther,  and  fades  away  much 
more  gradually  into  the  healthy  tissues.  It  must  be  remembered  that  the 
nature  of  the  tissues  in  which  the  sore  is  seated  will  much  affect  the 
amount  of  hardness  around  it.  Thus  a  sore  will  be  much  less  indurated 
on  the  glans  penis  tliau  on  the  prepuce,  in  consequence  of  the  absence  of 
any  cellular  membrane  in  the  former. 

The  nature  of  the  secretions  is  also  much  relied  on  as  a  test  between 
the  infecting  (adhesive)  and  the  non-infecting  (su})pnrative)  form  of  sore. 
Mr.  Lee  says:  "If  the  secretion  from  an  uncomplicated  infecting  sore  be 
placed  on  a  piece  of  glass,  and  a  drop  of  dilute  nitric  acid  be  added, 
the  microscopic  appearances  will  be  found  to  be  very  different  from  those 
characteristic  of  the  secretion  from  a  naturally  suppurating  sore.  The 
secretion  from  an  infecting  chancre  is  not  pus,  it  consists  of  epithelial 
debris,  of  globules  of  lymph  more  or  less  perfectly  formed,  or  of  these 
same  products  undergoing  disintegration  and  of  serum  more  or  less  turbid. 
These  different  products  may  often  be  found  matted  together,  mixed  occa- 

FlG.  175. 


A.  Secretion  from  local  suppurating  sore,  treated  with  dilute  acetic  acid  and  magnified  700  diams.  b. 
Secretion  from  indurated  sore,  examined  in  the  same  way  as  a. — From  Mr.  H.  Lee's  Essay  on  Syphilis. 
Syst.  of  Surg.,  vol.  i,  2d  ed. 

sionally  with  a  few  pus-cells;"  while  of  the  secretion  from  the  soft  sore 
he  says  that  "it  consists  of  well-formed  pus;  and  each  globule  is  of 
nearly  the  same  size  and  distinct  from  the  rest.  If,  in  any  doubtful 
case,  some  of  the  secretion  from  a  sore  be  mixed  with  a  little  dilute  acetic 
acid  and  placed  under  the  microscope,  the  distinctive  character  of  the 
pus-nuclei  will  be  seen."^  The  annexed  figures,  borrowed  from  Mr.  Lee's 
work,  will  render  the  distinction  obvious.  But  Mr.  Lee  takes  care  to  ex- 
plain tliat  this  distinction  depends  for  its  clearness  on  the  absence  of  irri- 
tation of  the  sore.  And  I  think  I  may  add  that  both  of  these  tests  are 
more  applicable  in  the  male  than  the  female  sex,  for  in  women  chancres 
presenting  the  characteristic  induration  are  indisputably  rare,  and  sup- 
puration is  far  more  easily  excited  in  a  chancre  within  the  vulva  than 
in  one  on  the  penis.  Another  very  reliable  test  is  the  nature  of  the  ac- 
companying bubo,  the  indolent  hard  bubo  wliich  is  caused  by  the  infect- 
ing sore  being  easily  distinguished  from  the  irritable,  inflammatory,  and 
rapidly  suppurating  bubo  of  local  syphilis.  Again,  the  bubo  of  soft 
chancre  usually  affects  a  single  gland,  while  the  indolent  bubo  consists 
more  commonly  of  several.  The  character  of  the  bubo  seems  to  me  taken 
by  itself  much  more  reliable  than  either  of  the  other  diagnostic  marks 
between  the  two  forms  of  chancre.     But  it  is  of  course  safer  to  take  all 


1  Sy.st.  of  Surg.,  2d  ed.,  vol.  i,  pp.  406  and  403. 


398  SYPHILIS. 

the  tests  at  tlie  same  time.  I  have  not  enumerated  among  these  diag- 
nostic symptoms  the  inociilability  of  the  secretion  on  tlie  patient's  own 
body,  since  eminent  pathologists  differ  as  to  the  value  of  that  test.  The 
reader  is  referred,  on  this  head,  to  the  section  which  treats  of  "Syphil- 
ization."  By  one  or  other  or  all  of  these  tests  an  infecting  can  usually  he 
distinguished  from  a  non-infecting  sore ;  but  it  is  undeniable  that  mis- 
takes are  tolerably  often  made.  The  experience  of  civil  practitioners  is 
hardly  available  for  showing  what  the  proportion  of  such  mistakes  is, 
since  a  surgeon,  as  a  general  rule,  has  not  enough  of  his  patients  under 
observation  for  a  number  of  3ears  to  tell  how  many  mistakes  he  may  really 
have  made ;  but  in  military  i)ractice  it  is  otherwise.  An  army  surgeon 
has  the  means  of  ascertaining  the  medical  history  of  most  of  his  men  for 
many  years  together ;  and  this  was  the  case  under  the  system  of  long 
service  still  more  than  it  is  at  present,  and  it  appears  to  result  from  the 
records  of  military  hospitals  that  in  about  nine-tenths  of  the  cases  the 
diagnosis  has  been  accurate.  Military  surgeons  are  so  much  occupied 
with  the  diagnosis  and  treatment  of  s^'philis  that  we  can  hardly  expect 
better  results  from  the  practice  of  civil  surgeons. 

The  causes  of  mistaken  diagnosis  between  the  infecting  and  non-in- 
fecting Ibrms  of  syphilis  seem  chiefly  two:  1.  That  both  forms  may  coexist, 
t'.e.,  a  previously  existing  soft  sore  may,  in  a  second  connection,  be  inocu- 
lated with  the  virus  of  an  infecting  chancre,  and  the  surgeon,  deceived 
by  the  evidences  of  local  syphilis,  may  overlook  those  of  the  constitu- 
tional disease,  or  the  latter  may  be  still  dormant  and  undiscoverable;  or 
(2)  the  hard  sore,  and  even  in  some  cases  the  hard  bubo,  may  by  irrita- 
tion be  made  to  suppurate,  and  thus  be  taken  foi*  a  soft  sore  or  an  inflam- 
matory bubo.  The  above  observations  apply  to  the  mistake  of  taking  an 
infecting  for  a  non-infecting  chancre,  and  to  the  refutation  of  that  mistake 
by  the  appearance  of  secondary  syi)hilis.  How  often  a  soft  sore  is  pro- 
nounced to  be  a  Hunterian  or  infecting  chancre,  and  the  patient  is  conse- 
quently exposed  to  a  course  of  mercury  which  is  really  unnecessary,  cannot 
be  determined,  since  there  is  nothing  to  detect  the  mistake.  No  secondary 
symptoms  follow,  and  both  patient  and  surgeon  congratulate  themselves 
on  the  success  of  the  treatment.' 

Besides  the  Huntei'ian  chancre  Mr.  Lee  describes  two  forms  of  infect- 
ing syphilis  which  are  unassociated  with  ulceration,  viz.:  (1)  a  jjimple,  the 
cuticle  appearing  as  if  peeled  of!'  the  upper  part  of  the  glans  penis,  or  a 
circumscribed  patch  remaining  for  days  together,  with  a  separation  of 
epithelial  scales  mixed  with  lymi)h-globules  from  the  surface,  but  with  no 
speciUc  induration  ;  and  (2j  an  indurated  tubercle,  formed  below  the  skin 
or  mucous  membrane,  without  any  visiljle  loss  of  sid)stance.  The  latter 
is  regarded  by  many  surgeons  as  a  chancre  which  has  skinned  over. 
Infecting  sores  seem  to  be  always  single. 

treatment. — When  a  sore  has  been  diagnosed  as  infecting — i.e.,  as  likely 
in  the  ordinary  course  to  be  followed  by  constitutional  symptoms — the 
next  question  is  as  to  the  treatment.  An  immense  i)reponderance  of 
opinion  at  the  present  day  supports  the  doctrine  usually  taught — and 
wliich  I  must  say  that  I  hold  unreservedly — that  the  only  ellicicmt  treat- 
ment iov  constitutional  S3"i)hilis  is  mercury,  and  that  that  treatment  is 
usually  ellicient.     In  thus  teaching,  the  rational  and  juilicious  advocates 

'  An  interchling  summary  of  the  (i]iini()n8  of  the  most  exporieiiced  surgeons  of  the 
diiy  on  th<'  cliai^nosis  of  iiifi'cting  and  ndri-inrectinj;  oliimcrcs  will  be  found  in  a  paper 
by  Mr.  Vcnninji,  in  the  5th  vol.  of  the  St.  G('org(;'.<  Hospital  Itcjiorts,  ontitlod  A 
Slimtnary  of  the  Jividt^nce  adduced  bol'ore  the  Conunittee  appointc^d  t<>  inquire  into 
the  I'atliiiiogy  and  Treatment  of  the  Venereal  Disease,  published  in  1807. 


INFECTING    SYPHILIS.  399 

of  mercnry  do  not  intend  to  assert  that  syphilis  is  any  exception  to  the 
common  rnles  which  are  observed  in  all  otiier  diseases,  viz.:  (1)  that  dis- 
eases when  left  to  themselves  do  not  always  run  through  all  their  phases, 
but  that  they  may' be  spontaneously  cured  and  disappear  at  any  period 
of  their  course;  so  that  constitutional  syphilis,  though  it  naturally  tends 
to  produce  secondary  symptoms,  does  not  always  do  so,  but  may  disap- 
pear spontaneously  and  no  secondary  or  tertiary  symptcMiis  ever  Ibllow  ; 
and  (2)  that  remedies,  however  eliicient,  are  not  always  and  uniformly 
successful;  and  therefore  that  mercury,  though  when  thoroughly  given 
it  usually  eradicates  the  disease,  and  especially  if  given  as  soon  us  the 
disease  shows  itself,  yet  does  not  always  do  so,  and,  therefore,  that 
secondary  symptoms  are  sometimes  seen  even  after  a  perfectly  satisfactory 
course  of  mercury.  But  many  of  the  cases  which  are  cited  by  the  indis- 
criminate opponents  of  the  nse  of  mercury  (who,  I  may  perhaps  be  ex- 
cused for  saying,  are  not  always  very  correct  diagnosticians)  in  order  to 
prove  that  constitutional  syphilis  can  be  treated  with  success  by  other 
means  than  mercury,  so  that  no  secondary  symptoms  will  follow,  were  no 
doubt  instances  of  mere  local  syi)hilis  ;  and  in  man}^  of  the  cases  in  which 
mercury  is  said  to  have  lailed  to  eradicate  the  disease,  so  that  secondary 
symptoms  followed  on  its  use,  the  course  of  mercury  has  been  insuMicient, 
or  it  has  been  begun  after  the  secondary  sj'mptoms  had  really  been 
developed. 

The  best  form  in  which  to  administer  mercury  has  long  been  a  subject 
of  dispute.  The  common  plan  of  giving  it  by  the  mouth  has  the  advan- 
tage of  requiring  no  confinement  to  the  house,  and  being  easily  carried 
on  without  attracting  observation — an  important  and  in  some  cases  almost 
indispensable  condition  in  the  treatment  of  these  maladies ;  but  it  has 
the  disadvantage  of  seriously  disturbing  the  digestion  and  general  health 
of  many  ijatients.  The  mildest  form,  and  the  one  least  likely  to  disturb 
the  bowels  and  derange  the  digestion,  is  the  blue  pill,  which  may  be  given 
in  doses  of  3  or  5  grains  twice  a  day,  with  a  small  quantity  (gr.  ^-h)  of 
powdered  opium,  this  quantit}^  of  opium  being  the  smallest  which  is 
found  necessary  to  obviate  irritation  of  the  bowels.  This  is  to  be  continued 
for  about  six  weeks,  until  all  traces  of  the  sore  and  all  subcutaneous 
hardening  around  it  and  around  the  bubo  has  disappeared.  During  the 
course  of  mercury  the  state  of  the  breath  and  of  the  gums  should  be  cau- 
tiously watched.  There  is  a  peculiar  fetor  in  the  mouth,  easily  recognized 
by  the  initiated,  and  usually  accompanied  by  a  coppery  taste,  perceived 
by  the  patient,  which  generally  precedes  the  spongy  and  congested  state 
of  the  gums.  When  the  latter  sets  in,  and  tlie  blue  line  is  seen  round 
the  roots  of  the  teeth,  it  becomes  a  little  unpleasant  to  the  patient  to  chew 
a  crust.  If  the  mercury  be  pushed,  in  nndiminished  quantity,  salivation 
commences,  and  then  the  gums  recede  from  the  teetii ;  the  latter  may 
drop  out,  and  even  the  jawbones  may  become  necrosed.  At  the  same 
time  a  peculiar  state  of  constitutional  cachexia  sets  in,  well  knovvn  in  old 
days  under  the  name  of  "mercurial  erethism,"  of  which,  happily-,  we  see 
but  little  now,  since  the  indiscriminate  use  (or  rather  abuse)  of  mercury 
has  been  given  up.  It  is  described  by  Pearson  as  being  characterized  by 
"great  depression  of  strength,  a  sense  of  anxiety  alxnit  the  praecordia, 
irregular  action  of  the  heart,  frecpient  sighing,  trembling,  partial  or  uni- 
versal, a  small,  quick,  and  sometimes  an  intermitting  pulse,  occasional 
vomiting,  a  pale,  contracted  countenance,  a  sense  of  coldness."  He  adds 
that  in  this  condition  any  sudden  exertion  will  sometimes  prove  fatal, 
and  tiiat  in  his  day  almost  every  year  one  or  two  deaths  took  place 
in  the  Lock  Hospital  of  men  who  had  nearly,  and  sometimes  entirely, 


400  SYPHILIS. 

completed  their  mercurial  course,  for  which  he  could  find  no  other 
explanation.' 

Another  mild  and  unirritating  preparation  of  mercury,  much  in  use 
when  the  drug  is  to  be  given  for  long  periods,  is  the*  "  gray  powder'' — 
Hydr.  cum  creta — in  5-grain  doses,  either  in  the  form  of  powder  or  pill. 
The  late  Mr.  H.  C.  Johnson  used  to  use  the  Ung.  hydrarg.  made  into  the 
form  of  a  pill,  as  bringing  the  patient  rapidly  under  the  influence  of  mer- 
cur}-,  and  generally  agreeing  well  with  the  bowels.^  Calomel  is  more  irri- 
tating, but  also  more  powerful.  It  generally  purges  if  given  alone,  but 
may  be  administered  in  2  or  3  grain  doses,  with  half  a  grain  of  opium, 
twice  a  day. 

The  endermic  method  of  giving  mercury  is  much  more  easily  tolerated, 
produces  far  less  depression,  and  is  quite  as  efficient;  but  it  is  not  so 
easily  carried  out,  especially  in  private  practice.  In  hospitals  it  is  exten- 
sively used,  either  by  inunction  or  fumigation.  The  former  consists  in 
making  the  patient  rub  3^^.-5]  of  the  Ung.  hydrarg.  into  the  inner  sur- 
face of  the  thigh  (where  the  skin  is  thin)  until  the  ointment  has  entirely 
disappeared.  In  the  latter  the  patient  sits  naked  on  a  cane-bottomed 
chair,  witli  a  mackintosh  sheet  or  a  cloak  or  a  common  blanket  wrapped 
round  his  neck  and  reaching  to  the  ground  all  round  the  chair.  Under 
the  chair  is  placed  a  spirit-lamp,  over  which  is  a  saucer  containing  a  little 
boiling  water,  and  projecting  out  of  the  saucer  a  shelf^  on  which  is  laid 
powdered  calomel,  gr.  x-xx.  As  the  water  evaporates  its  vapor  mixes 
witli  the  sublimed  calomel,  and  the  fine  powder  is  deposited  on  the 
moistened  and  relaxed  skin,  Avhich  is  thus  prepared  to  absorb  it.  The 
quantity  of  calomel,  of  water,  and  spirit  is  so  adjusted  in  the  regular 
lamp  that  when  the  flame  goes  out  the  saucer  is  dry  and  all  the  calomel 
sublimed.  The  patient  should  sit  quiet  for  a  few  minutes,  then  put  on 
his  nightgown,  and  without  wiping  the  skin  at  all  get  into  bed.  In  hos- 
pitals, when  the  patient  is  confined  to  bed,  the  bath  may  be  given  at  any 
time ;  in  private  practice  it  should  always  be  at  bedtime,  since  any  check 
to  the  perspiration  spoils  the  action  of  the  remedy.  It  will  usually  be 
found  that  after  about  twelve  baths,  given  every  other  da}',  the  patient 
begins  to  get  slightly  affected.  Then  the  action  should  be  kept  up  by 
decreasing  the  quantity  of  calomel,  so  tliat  the  patient  should  just  be 
conscious  of  the  mercurial  taste. 

The  action  of  mercury  is  made  much  more  safe,  speedy,  and  certain 
b}'  confining  the  patient  to  bed,  though,  of  course,  this  is  seldom  possible 
in  ordinary  cases  of  syphilis;  and,  as  my  late  friend  and  teacher  Mr. 
Cutler  used  to  point  out,  it  is  a  very  useful  jjrecaution  to  weigh  the 
patient  every  thice  or  four  da3s.  A  rapid  loss  of  weight  will  often  show 
that  the  remedy  is  disagreeing,  and  will  s[)arc  the  patient  some  more 
disagreeable  proof  of  the  fact. 

When  the  patient  cannot  tolerate  mercury  the  iodide  of  potassium  may 
be  administered,  but  it  does  not  appear  to  exercise  any  radically  curative 
effect  on  the  syphilitic  cachexia,  though  it  rapidly  removes  some  of  its 
remote  effects.  The  other  alleged  remedies  for  syphilis  are  now  generally 
thought  to  be  quite  inert. 

1  Sec  South's  Chelius,  vol.  i,  p.  677. 

*  Thf  ff>rnuila  for  "Sedillot's  pill"  is  strong  nifrcurial  ointment,  soap,  powdered 
mnr.slimaliow,  Ih  gr.  of  oafii. 

3  Tills  little  apparjitus  cjiri  now  bo  hiid  at  any  instrument  maker's.  If  a  proper 
apparatus  is  not  at  hand  an  extemporf!  contrivance  may  Ix;  made  out  of  a  common 
saucer  with  u  piece  of  hot  brick  laid  in  the  water,  on  which  the  calomel  is  to  bo 
strewn. 


SECONDARY    SYMPTOMS.  401 

There  are  surgeons  who,  while  they  admit  the  power  which  mercury 
exerts  over  the  constitutional  manifestations  of  syphilis  in  its  secondary 
form  deny  its  power  of  preventing  secondary  symptoms,  and  therefore 
repudiate  its  use  in  primary  syphilis.  These  are  reduced  either  to  an 
expectant  treatment  or  to  the  extirpation  of  the  sore  by  means  of  caustic. 
But  there  seems  little  proof  of  the  advantage  of  such  extirpation  even 
when  practiced  during  the  period  of  incubation,'  and  no  proof  at  all  that 
when  the  sore  has  become  developed  any  advantage  could  be  derivecv  from 
its  removal. 

Secondary  Syphilis. — The  secondary  symptoms  of  constitutional  syph- 
ilis appear  at  a  variable  period  after  the  original  inoculation,  usually  not 
till  after  the  primary  sore  has  healed,  which  it  will  commonly  do,  if  left 
to  itself,  in  about  six  weeks,  though  harden^ing  ma}'  persist  and  the  cica- 
trization may  not  be  quite  sound.  The  period,  however,  is  quite  uncer- 
tain at  which  secondary  syphilis  shows  itself.  In  the  great  majority  of 
cases  it  is  under  half  a  year,  but  there  seems  no  time  of  life  at  which  a 
person  can  be  pronounced  absolutely  safe,  though  doubtless  most  of  the 
liistories  which  we  have  of  persons  who  have  suffered  from  secondary 
symptoms  a  very  long  period  after  the  primary  sore  are  mistakes  or  wilful 
inaccuracies,  the  patient  having  really  contracted  the  disease  afresh  in  the 
interval. 

Sometimes,  it  is  said,  the  advent  of  secondary  syphilis  is  ushered  in 
by  what  is  termed  "  the  syphilitic  fever ;"  "  the  patient  feels  feverish  and 
uncomfortable,  the  skin  becomes  dry,  and  the  tongue  perhaps  coated," 
and  rheumatic  pains  are  complained  of,  especially  in  the  head  and  at 
night.-  It  is  certain,  however,  that  secondary  syphilis  is  very  often 
developed  with  no  such  premonitory  symptoms.  The  first  symptoms  are 
generally  either  in  the  throat  or  the  skin,  the  early  skin  eruptions  being 
usually  either  roseola  (very  common  in  young  girls)  or  lichen,  and  the 
sore  throat  being  referred  with  great  probability  to  the  formation  of 
similar  spots  on  the  mucous  nien)brane  of  the  mouth  or  fauces.  The 
syphilitic  eruptions  which  are  peculiar  to  the  secondary  or  earlier  stage 
of  the  constitutional  disease  are  all  considered  to  resemble  each  other, 
and  to  resemble  the  primary  sore  in  the  fact  that  they  depend  on,  or  tend 

^  In  Lancereaux's  Treatise  on  Syphilis,  translated  for  the  Now  Syd.  Soc,  vol.  ii, 
p.  304,  will  be  found  an  account  of  some  experiments  by  Sigmund  in  fifty-seven  cases 
of  probable  syphilitic  contagion,  in  the  persons  of  physicians,  accoucheurs,  nurses, 
etc.,  who  had  been  induced  to  place  excoriated  surfaces  on  their  own  bodies  in  con- 
tact with  syjihilitic  matter.  Of  twenty-two  left  to  themselves  eleven,  exactly  one- 
balf,  became  syphilitic.  Of  the  other  thirty-five,  in  whom  the  excoriated  part  was 
removed  by  caustic  at  various  times  from  the  first  to  the  tenth  day,  ten  became 
syphilitic.  But  twenty-four  out  of  these  thirty-five  were  Ciuiterized  before  the  end 
of  the  third  day,  and  of  these  only  three  became  syphilitic.  These  facts,  allowing 
their  reality,  would  seem  to  sht)W,  as  far  as  such  very  small  numbers  can,  that  there 
would  be  some  chance  of  removing  the  virus  before  it  had  entered  the  system,  if  we 
could  know  the  spot  on  which  it  has  acted,  and  destroy  that  part  thoroughly  by  an 
active  caustic  ;  but  the  opportunity  for  doing  this  in  practice  must  be  infinitely  rare. 
It  would  tinly  occur  where  a  person  knowing  him  or  herself  to  have  a  crack  oi'  sore 
on  the  genital  organs  has  been  exposed  to  a  suspicious  connection,  and  then  consults 
the  surgeon  at  once;  and  in  such  a  case  it  would  certainly  be  justifiable  to  cauterize 
the  sore  freely  with  one  of  the  active  caustics.  Lanceneaux  himself,  though  he  rejects 
the  mercurial  treatment  in  ordinary  cases  of  primary's.ypi)ilis,  even  when  the  hard- 
ness of  the  Hunterian  chancre  is  well  marked,  because  he  says  it  does  not  prevent  the 
occurrence  of  secondary  symptoms,  yet  admits  its  necessity  when  the  hardening  is 
long  in  disappearing. 

^  In  Lancereaux's  work,  vol.  i,  p.  125  et  seq.,  will  be  found  a  very  complete  account 
of  these  premonitory  symptoms  of  secondary  syphilis. 

2(5 


402  SYPHILIS. 

to,  the  effusion  of  adhesive  or  fibrinous  material  in  the  neighborhood  of 
the  inflamed  part,  and  tlie  same  is  tlie  case  with  the  lesions  of  other  parts 
of  the  body,  as  the  eye,  the  bones,  etc.  As  the  disease  progresses  into 
its  later  secondary  and  into  the  tertiary  stages  the  tendency  to  ulceration 
and  suppuration  becomes  more  marked.^ 

The  earlier  eruptions  are  either  exanthematous  (roseola),  papular 
(lichen),  tubercular  (syphilitic  acne  on  the  skin,'^  mucous  tubercle  on  the 
mucous  surfaces  or  on  their  orifices),  or  squamous  (pityriasis,  psoriasis, 
and  lepra).  They  are  distinguished  from  the  similar  eruptions  which  are 
not  specific  partly  by  conforming  less  completely  to  the  regular  form, 
parti}'  by  their  color,  which  in  English  works  is  generally  described  as 
copper}',  and  in  the  French  more  accurately  as  the  color  of  lean  ham,  and 
partly  by  their  circular  or  horseshoe  form,  and  the  tendency  they  have 
to  disappear  in  the  centre  while  creeping  or  spreading  at  their  edge,  from 
which  the  old  term  "serpigo"  was  derived.  As  the  disease  progresses 
vesicular  and  pustular  eruptions  are  seen,  the  latter  especially  on  the 
hairy  scalp.'* 

JMany  other  tissues  of  the  body  are,  however,  affected  in  secondary 
s^'philis,  though  tiie  deeper  the  parts  affected  are  the  later  probabl}^  is 
the  stage  of  the  disease,  and  the  more  it  approaches  to  the  tertiary  pe- 
riod. Thus  the  eye  and  tlie  larynx  are  affected  in  the  later  secondary 
stage — both  parts  of  the  general  surface  of  the  body,  but  lying  deeper 
than  the  common  integument,  and  liable  also  to  be  involved  in  tlie  ter- 
tiary symptoms.  The  superficial  affections  also  of  the  bones  (periostitis 
or  nodes)  are  seen  at  the  later  periods  of  secondary  as  well  as  in  the  ter- 
tiary stage,  but  the  deeper  alTections  of  the  bones  (caries  and  necrosis) 
are  as  a  rule  tertiary  symptoms.  The  ulcerations  of  the  skin  which  are 
due  to  syphilis  may  he  the  result  of  the  giving  way  of  skin  affected  by 
secondary  eruptions,  but  are  far  more  common  after  the  suppurating 
eruptions  (pempliigus,  ecthyma,  and  rupia)  which  are  characteristic  of 
the  tertiary  stage.  The  affections  of  the  viscera,  such  as  the  tubercles 
in  the  liver  and  the  ''cirrhosis"  of  the  lung  which  are  due  to  syphilis 
seem  to  be  amongst  its  later  manifestations,  though  in  some  cases  they 
have  lieen  noted  as  secondar3^ 

MucouH  Tubercle. — Other  secondary  symptoms  must  be  briefly,  but 
very  briefly,  mentioned.  One  of  the  most  important  is  the  development 
of  "mucous  tubercles,"  flat,  raised,  oval  patches,  generally  situated  at  or 
near  the  junction  of  the  skin  and  mucous  membrane,  covered  with  a 
whitish  velvet}'  epidermal  tissue,  and  yielding  a  secretion  which  is  easily 
inoculable,  and  which  is  probably  a  fertile  source  of  syphilitic  inocula- 
tion. Their  usual  seat  is  near  the  anus  or  vulva,  and  the  mouth  is  a 
common  situation,  liut  any  part  of  the  body  may  be  affected,  especially 
where  the  skin  is  in  fohls,  and  where  it  is  irritated  by  heat,  dirt,  and 
retained  discharges.  The  local  action  of  mercury  is  very  beneficial  in 
these  cases.  The  tubercle  generally  disapi)ears  rapidly  under  the  use  of 
powdered  calomel,  kept  upon  it  by  means  of  some  simple  ointment,  strict 
cleaidiiiess  being,  of  course,  enforced.  Syphilitic  vegetations  and  con- 
dylomata are  very  nearly  allied  to  mucous  tubei'cle,  and  like  it  seem 

'  Lancereaux  divides  a  complete  attack  of  constitutional  syphilis  into  four  periods  : 
1.  That  of  incubation.  2.  Tliat  of  local  eruption  or  primary  lesion.  8.  Tliat  of 
general  erupli'iti  or  .secondary  atfeclion.  And  4.  That  of  gum m}'  [gummatous]  prod- 
ucts or  terliary  and  quatcrnar}'  alVections. 

2  Acne  is  g(;herally,  lit>w(!ver,  a  late  secondarj-  symptom,  and  is  often  regarded  as 
one  of  ihe  tertiary  forms. 

3  See,  on  Skin  Diseases,  the  chapter  on  that  subject  in  the  sequel. 


SECONDARY     SYMPTOMS.  403 

decidedly  contagious.  Tliey  will  be  best  described  in  the  chai)ter  on 
Skin  Diseases.  One  of  the  commonest  of  all  secondary  affections  is 
sypliilitic  baldness,  or  "alopecia."  The  hair  of  the  head  becomes  thin, 
comes  away  plentifully  in  combing,  and  at  length  the  patient  may  become 
almost  or  entirely  bald.  There  are  cases  much  less  common  in  whicli  the 
baldness  attacks  other  parts,  usually  the  chin  and  eyebrows.  The  remedy 
lies  in  shaving  the  head,  applying  some  gently  stimulating  lotion,'  or  in 
more  serious  cases  painting  the  part  occasionally  with  blistering  fluid. 
But  far  more  important  than  the  local  treatment  is  the  correction  of  the 
syphilitic  diathesis  by  a  proper  mercurial  course.  Alopecia,  like  many 
other  of  the  symptoms  which  usually  are  secondary,  appears  also  in  the 
tertiary  stage  of  the  disease.  Alopecia  is  often  accompanied  by  des- 
quamation of  the  epidermis — pityriasis,  an  affection  which  is  essentially 
almost  identical  with  the  shedding  of  tlie  hair.  Onychia,  again,  is  an 
affection,  very  nearly  allied  to  the  affections  of  the  skin  and  liair,  and  is 
often  described  as  a  psoriasis  of  the  nails.  I  must  refer  the  reader  on 
this  point  also  to  the  chapter  on  affections  of  the  skin. 

Syphilitw  sore  throat  is  an  almost  universal  symptom  in  the  secondary 
stage,  and  generall}'  the  earliest  of  its  phenomena.  But  affections  of  the 
throat  are  also  to  be  met  with  in  the  later  secondar}^  and  in  the  tertiary 
stages.  The  main  forms  of  syphilitic  sore  throat  are  three  :'"  1.  The  ulcer 
of  the  tonsils,  a  deep  ulceration  commencing  on  the  surface  of  the  central 
part  of  one  or  both  tonsils,  and  accompanied  by  swelling  and  induration 
of  the  gland  around  it.  This  is  said  by  Mr.  Babington  to  be  often  ac- 
companied by  a  tubercular  eruption.  2.  The  phagedenic  or  sloughing 
sore  throat,  commencing  with  ulceration  on  either  the  tonsils,  the  velum 
palati,  or  the  pharynx,  and  often  leading  to  extensive  destruction  of 
those  parts.  This  is  usually  accompanied  by  rupia,  and  is  therefore  a 
later  phenomenon.  3.  The  sore  throat  which  is  due  apparently  to  tlie 
development  of  psoriasis  on  the  mucous  membrane  of  the  fauces  or 
mouth.  This  is  distinguished  by  the  opaque  white  color  of  the  surface. 
"•This  appearance  sometimes  supervenes  at  the  edge  of  an  ulcer  on  the 
tonsil.  More  frequently  there  is  no  ulceration,  but  simply  this  change 
of  the  surface,  accompanied  by  more  or  less  of  redness,  and  as  it  were  of 
excoriation  of  the  neigliborhood,  more  or  less  swelling  of  the  membrane, 
much  soreness,  but  ver}' little  pain.  This  superficial  affection  may  attack 
any  part  of  the  tonsils,  arches  of  the  palate,  velum  pendulum  and  uvula, 
and  even  the  tongue  or  the  inside  of  the  cheeks.  It  is  very  frequently 
to  be  seen  at  the  angles  of  the  mouth.  It  often  occupies  the  soft  palate, 
spreading  upwards  in  a  semicircular  form  towards  the  roof  of  the  mouth. 
The  white  appearance  may  be  removed  by  slightly  touching  it  with 
caustic,  and  tlien  the  surface  beneath  looks  as  if  excoriated."  There  are 
other  forms  also  of  syphilitic  sore  throat,  but  the  above  are  those  which 
are  commonly  met  with. 

Affeclions  of  Glands — Next  in  importance  to  the  affections  of  the  skin 
and  its  appendages  are  those  of  the  glands.  It  is  an  old  and  a  very  ob- 
vious observation  in  syphilis  that  the  absorbent  glands  become  less  prone 
to  sliare  in  the  affections  of  the  surface  tlie  later  the  stage  of  the  disease 
IS.  Thus  in  primary  syphilis  bubo  is  constant  in  the  glands  which  derive 
their  absorbents  from  tlie  seat  of  the  chancre  ;  in  secondary  affections  of 
the  skin  the  absorbent  glands  are  not  nearly  so  often  affected,  and  in 
tertiary  disease  they  are  hardly  ever  enlarged.     But  the  glands  thcm- 

'  Mr.  Nayler  prescribes  the  following:  Liq.  Ammon.  Acet.  ^ss.  ;  Sp.  Ammon. 
Co.,  ^ss. ;  Glycerinas,  §ss.  ;    Aq.  Kosa;  ad  ^viij. 

2  See  Hunter's  works,  vol.  ii,  p.  415,  note  by  Mr.  Babington. 


404  SYPHILIS. 

selves  are  very  liable  to  secondary  and  tertiary'  syphilitic  enlargement 
apart  from  all  atlection  of  the  parts  from  which  they  derive  their  lym- 
pliatics.  In  those  allections  which  are  excited  by  the  presence  of  eruption 
the  gland  is  more  disposed  to  inflammation  than  in  tliose  which  are  due 
to  the  eHect  of  tlie  general  syphilitic  poison.  The  posterior  cervical 
glands,  those  lying  in  the  posterior  triangle  of  the  neck,  are  the  most 
commonly  atlected  independently'  of  other  organs  in  constitutional 
syphilis,  forming  a  chain  of  hard,  knotty  tumors  under  the  edge  of  the 
trapezius  muscle,  or  the  inguinal  glands  below  Poupart's  ligament. 
These  glandular  affections  are  more  marked  either  at  a  late  stage  of  the 
secondary  or  in  the  tertiary  stage.  The  other  common  secondar}-  affec- 
tions are  those  of  tlie  periosteum,  of  the  testicle,  of  the  larynx,  and  of 
the  eye,  for  which  I  must  refer  the  reader  to  the  chapters  on  diseases  of 
those  organs. 

Inoculability. — That  secondary  syphilis  is  inoculable  on  a  healthy  per- 
son has  been  abundantly  proved,'  and  practitioners  of  experience  seem 
now  to  be  of  the  opinion  that  syphilis  is  very  often  propagated  in  this 
manner.  Mr.  H.  Lee  has  lately'  called  particular  attention  to  the  contro- 
A'crsy  which  has  been  going  on  ever  since  the  days  of  Hunter  on  this 
subject.  Hunter  taught  that  the  contagion  of  all  venereal  diseases — 
gonorrhoea,  local  syphilis,  and  constitutional  syphilis — was  the  same, 
though  he  appears  to  have  been  perfectlj'  acquainted  with  the  fact  that 
some  kinds  of  syphilis  are  local  only  ;  and  he  taught  also  that  secondary 
syphilis  was  not  inoculable  on  the  patient's  own  body,  while  he  doubted 
(though,  as  Mr.  Lee  shows,  he  did  not  deny,  as  he  is  usuall}'  represented 
as  doing)  that  it  can  be  inoculated  on  a  healthy  person.  The  experi- 
ment on  which  Hunter  mainly  relied  for  showing  the  identity  of  the 
gonorrhoeal  and  syphilitic  poisons  was  one  vvhicli  he  made  on  himself,  by 
inoculating  on  his  own  person  matter  taken  from  a  patient  suffering,  as 
he  thought,  only  from  gonorrhoea,  and  this  inoculation  produced  pri- 
mary and  secondary  syphilis.  But  Mr.  Lee  has  called  attention  to  the 
Cfjmparative  frequency  of  discharges  fi-om  the  male  uretiira  in  secondary' 
syphilis  which  proceed  from  some  inflammation  of  the  urethra,  the  pre- 
cise nature  and  seat  of  which  has  not  yet  been  ascertained,  but  which 
seems  to  affect  any  part  of  the  tube  from  the  prostate  forwards.*  This 
affection  is  analogous  to  those  somewhat  rare  cases  in  whicli  the  l)ron- 
ciiial  or  the  gastro-intestinal  mucous  membrane  is  aflfected  in  secondary 
syphilis,  probably  with  some  of  the  forms  of  eruption  which  are  seen  on 
tile  skin.  The  matter  with  which  Hunter  inoculated  himself  was,  there- 
fore, probably  syphilitic. 

Treatment. — That  secondary  syphilis  requires  the  mercurial  treatment 
for  its  cure  is  admitted  by  many  even  of  those  who  do  not  use  mercury 
in  tlie  treatment  of  the  primary  disease.  But  the  course  of  mercury  must 
be  more  prolonged,  and  therefore  milder,  since  the  patient's  general 
health  is  to  be  maintained  during  tlie  whole  period.  The  symptoms  will, 
indeed,  rapidly  subside  in  many  cases  under  the  use  of  iodide  of  potas- 
sium, especially  such  as  are  accompanied  by  pcrcejjtible  fll)rinous  exuda- 
tion ;  but  it  is,  however,  I  think,  more  and  more  admitted  that  such  cures 
are  usually  only  temporary,  and  that  for  the  complete  eradication  of  the 
diathesis  a  full  and  prolonged  mercurial  course  is  necessary.  No  hesita- 
tion need  be  experienced  in  prescribing  raercur3'  in  cases  where  there 

'  Sec  Lancereaux,  vol.  i,  p.  69. 

2  Sec  Mr.  Lee's  Lettsomian  Lectures,  publi.slicd  in  the  Glh  vol.  of  the  St.  George's 
Hospital  Reports  ;  also  bis  Lectures  at  the  Royal  College  of  Surgeons  in  1876. 


TERTIARY    SYPHILIS.  405 

is  no  ulceration  or  suppuration  ;  but  when  this  is  the  case  mercur}^  is 
generally  held  to  be  contraindicated.  I  think,  however,  that  any  one 
who  will  make  trial  of  the  fumigation  of  syphilitic  ulcers  or  syphilitic 
eruptions  of  the  pustular  form,  with  very  small  doses  of  calomel  (say  5 
grains  every  night),  will  be  convinced  of  the  great  benefit  of  this  form 
of  treatment.  In  many  cases  also  of  ulcerated  sore  throat  fumigation  or 
a  mercurial  gargle  (as  Liq.  hyd.  perchlor.,  with  equal  parts  of  water), 
acts  most  favorably.  In  conditions  of  extreme  cachexia,  indeed,  every 
form  of  mercur}'  may  be  inadmissible  ;  but  in  sucli  conditions  iodine  is 
generally  inadmissible  also,  and  the  patient's  health  must  be  renewed  by 
careful  feeding,  stimulants  in  moderation,  rest,  and,  if  possible,  in  bed, 
tonics,  and  opium,  before  any  definite  treatment  is  commenced.  I  know 
of  no  tonic  which  seems  so  generally  beneficial  as  the  compound  decoc- 
tion of  sarsaparilla,  a  pint  daily,  with  steel  wine  and  laudanum  if  neces- 
sary. The  administration  of  iodine  and  mercury  together  is  a  very 
successful  plan  of  treating  secondary  syphilis.  Thus  the  iodide  of  po- 
tassium may  be  given  in  doses  of  5  to  10  grains,  while  the  patient  is 
undergoing  a  course  of  mild  mercurial  fumigation  ;  or  the  red  or  green 
iodide  of  mercury  may  be  prescril)ed  either  in  pill  or  draught.  The  red 
or  biniodide  is  the  salt  generally  used,  and  may  be  given  in  doses  of  Jg 
to  1^  of  a  grain  in  pill  three  times  a  day,  or  in  a  draught  by  combining  the 
iodide  of  potassium,  gr.  v-x,  with  the  liq.  hyd.  perchlor.,  5ss.-j  in  some 
bitter  infusion. 

Tertiary  SijphiHs. — The  tertiary  stage  of  syphilis  is  distinguished  from 
the  secouflary  in  the  same  way  as  the  latter  is  from  the  primary,  namely, 
by  the  occurrence  of  an  interval  of  health.  The  secondary  symptoms  have 
disappeared,  with  or  without  treatment,  for  I  repeat  that  secondary  syph- 
ilis does  sometimes  disappear  spontaneously,  and  then,  after  a  very  varia- 
ble interval,  commences  tlie  stage  usually  called  tertiary,  or,  as  Lance- 
reaux  puts  it,  the  stage  of  the  gummatous  products.  The  period  which 
separates  the  latest  from  the  secondary  stage  of  syphilis  is  very  uncer- 
tain, and  often  it  is  not  separated  at  all,  the  secondary  or  exudative  stage 
passing  on  into  the  tertiary  or  gummatous  condition  with  no  definite 
limit ;  whilst  at  other  times  there  is  an  interval  of  months  or  even  years. 

The  main  distinction  between  the  secondary  and  tertiary  stages  of 
syphilis  is  that  the  new  growths  in  the  former  resemble  more  the  products 
of  inflammation  regarded  as  a  reproductive  process,  they  resemble  more 
the  filirous  tissue,  while  in  the  latter  the}'  resemble  more  the  products  of 
inflammation  regarded  as  an  ulcerative  process.  In  fact,  a  gumma  bears 
a  very  great  resemblance  to  a  granulation,  and  it  is  prone  to  soften,  break 
down,  and  leave  an  ulcerating  surface.^ 

It  is  not,  however,  in  every  part  tliat  such  gummatous  tumors  can  be 
observed  preceding  the  ulceration  of  tertiary  syphilis ;  nor,  again,  do 
these  gummata  always  ulcerate.  In  many  cases  the  ulceration  occurs 
without  an}'  recognizable  deposit,  being,  however,  probably  preceded  by 
a  similar  aplastic  deposit  diflfused  in  the  cellular  tissue  of  the  part.    And 


1  Dr.  Green  thus  describes  the  structure  of  gummata  :  "  The  gummata  consist  of 
atrophied  and  degenerated  elements  imbedded  in  a  scanty  and  obscurely  fibrillated 
stroma.  The  central  portions  of  the  growth  are  composed  almost  entirely  of  closely 
packed  granular  debris,  fat-granules,  and  cholesterin,  amongst  which  there  may  be 
an  exceedingly  scanty  fibrillated  tissue.  Surrounding  this,  and  directly  continuous  with 
it,  is  a  more  "completely  fibrillated  structure;  while  the  peripheral  jtortions  of  the 
growth,  which  are  continuous  with  the  surrounding  tissue,  consist  entirely  of  small 
round  cells,  resembling  granulation-cells  and  lymph-corpuscles.  The  bloodvessels, 
which  only  exist  in  the  external  portions  of  the  growth,  are  very  few  in  number." — 
Pathology,  p.  120. 


406  •  SYPHILIS. 

in  the  interior  of  the  body,  as  well  as  near  the  surface,  tertiary  syphilitic 
deposits  may  long  remain  inert,  and  then  wither  away  into  a  kind  of 
cicatrix  or  he  reabsorbed. 

The  affections  characteristic  of  tertiary  syphilis  appear  in  every  part 
of  the  body,  and  I  cannot  affect  to  give  a  complete  account  of  the  matter 
here.  I  will  endeavor  to  direct  the  reader's  attention  to  the  points  most 
commonly  met  with  in  practice.  For  the  rarer  and  more  dubious  lesions 
which  are  connected  with  syphilis,  such  as  the  affections  of  the  viscera 
and  nervous  system,  special  works  on  the  subject  must  be  consulted. 

The  affections  of  the  skin  which  are  seen  in  tertiary  syphilis  are  of  the 
suppurative  and  ulcerative  type — rupia  and  ecthyma  are  the  commonest 
eruptions  ;  and  the  softening  of  the  subcutaneous  gummata  frequentl}^ 
leads  to  ulceration.  The  various  forms  of  syphilitic  ulcer  are  described 
in  the  following  chapter.  Even  more  important  than  the  external  affec- 
tions are  the  diseases  of  the  bones  which  so  constantly  occur  in  tertiary 
sypliilis,  and  which  now  no  longer  affect  only  the  periosteum  and  exter- 
nal table  of  the  bone  in  the  form  of  nodes  which  show  little  tendency  to 
suppuration  ;  but,  on  the  contrary,  the  tissue  over  the  bone  rapidly  softens 
and  exposes  a  carious  or  necrosed  condition  of  the  bone  itself,  which  is 
regarded  as  being  the  result  of  a  similar  aplastic  deposit  in  the  substance 
of  the  bone  to  that  which  we  have  just  spoken  of  as  met  with  in  the  cel- 
lular tissue  of  soft  parts.  These  syphilitic  affections  of  bone  will  be 
afterwards  more  fully  treated  of  in  speaking  of  the  Diseases  of  the  Bones. 
The  glands  are  deep!}'  affedted  in  tertiary  syphilis,  not  exclusively  or  even 
mainly  the  absorbent  glands  (though  the  induration  of  the  posterior  cer- 
vical and  inguinal  glands  is  constant  in  tertiary  syphilis),  but  also  the 
great  secreting  and  blood  glands,  the  liver,  spleen,  thyroid,  testicle,  etc., 
and  it  seems  probable  that  though  generally  the  syphilitic  deposit  occurs 
in  the  form  of  definite  masses  (gummata  or  syphilitic  tubercles),  yet 
that  the  diffused  waxy  or  lardaceous  disease  of  these  organs  may  also  be 
sometimes  of  syphilitic  origin.  The  nervous  system  is  also  profoundly 
affected,  not  merely  by  inflammation  propagated  to  the  brain,  spinal  mar- 
row, and  nerves  from  their  bony  cavities,  but  b}^  tertiary  deposit  in  the 
structure  of  the  nervous  masses  or  their  membranes,  leading  to  irritation 
or  paralysis. 

Thus  it  seems  that  there  is  no  part  of  the  body  which  may  not  be  and 
is  not  constantly  affected  in  constitutional  syphilis. 

The  treatment  of  the  tertiary  must  be  the  same  in  principle  as  that  of 
the  secondary  stage  of  syphilis.  But  here  again,  as  the  cachexia  is  more 
profound,  so  must  the  treatment  be  milder,  more  supporting  and  stimu- 
lating, and  longer  continued.  The  iodine  or  mercury  which  may  be  nec- 
essary for  tiie  treatment  must  be  introduced  gradually  in  very  small 
doses  combined  with  tonics  and  opium.  Wine  and  good  food  are  essential. 
Change  of  air,  a  warm  climate,  and  the  use  of  appropriate  mineral  waters 
are  most  useful  adjuncts  to  a  treatment  which  must  be  carried  on  through 
so  long  a  period  of  time. 

The  length  of  time  during  which  a  course  of  mercury  should  be  con- 
tinued is  stated  by  Ricord'  at  about  twelve  months,  and  Lancereaux  es- 
timates it  at  about  half  a  year.  In  such  prolonged  courses  the  mildest 
prei)arations  of  mercury  must  be  selected,  the  dose  must  be  a  very  mod- 
erate one,  intermissions  must  be  allowed  from  time  to  time,  and  the  prep- 
aration and  vehicle  must  be  varied. 

'  See  Carter  On  the  Principles  of  Oplitlmlmic  Tlicrapoulics,  St.  George's  Hospital 
Reports,  vol.  vii,  p.  111. 


INFANTILE    SYPHILIS.  407 

Infavtile  or  Congenital  Syphilis. — Two  special  forms  of  sypliilis  remain 
to  be  described — infantile  or  congenital  sy|)hilis  and  vaccino-syphilis. 
Congenital  syphilis  is  a  form  of  secondary  or  constitutional  disease, 
transmitted  to  the  foetus  in  utero  eitlier  through  the  blood  of  the  mother 
or  the  semen  of  the  father,  or  both.  The  old  idea,  that  infants  are  inocu- 
lated with  syphilis  at  the  time  of  birth  from  syphilitic  sores  in  the  mother's 
vulva  is  given  up.  Without  denying  the  possibility  of  such  an  occurrence, 
the  disease  which  we  usually  see  is  strictly  analogous  to  secondary  syph- 
ilis, and  is,  in  fact,  a  form  of  it,  differing  only  in  this,  that  the  ])rimary 
sore  has  occurred  on  the  body  of  the  parent  instead  of  the  infant  itself. 
The  popular  name  of  infantile  syphilis  is  "the  snuffles,"  and  this  ex- 
presses one  of  its  chief  features — a  persistent  coryza,  or  snuffling  in  the 
nose,  along  with  which  is  a  reddish  or  coppery  eruption,  usually  either 
roseola  or  lichen,  on  various  parts  of  the  body,  and  especially  on  the 
genitals  and  on  the  palms  and  soles.  In  these  latter  situations,  however, 
it  is  sometimes  more  of  a  scaly  nature  ;  there  are  also  very  commonly 
crescentic  patches  of  mucous  tubercle  on  the  interior  of  the  mouth,  on 
the  lips,  anus,  etc.  Combined  with  these  symptoms  there  is  a  peculiar 
cachexia,  a  wasted  look  like  that  of  age,  and  a  good  deal  of  emaciation, 
with  a  yellow  complexion. 

These  symptoms  begin  at  a  variable  period.  If  they  commence  in 
utero  they  usually  lead  to  the  death  of  the  foetus,  and  often  to  abortion. 
But  very  commonly  they  do  not  commence  till  some  weeks  after  birth  ; 
and  it  is  believed  that  the  affection  in  the  parent  becomes  milder  as  the 
stage  of  the  disease  is  later,  so  that  the  later  children  are  less  profoundly 
poisoned  than  the  earlier.  Thus  there  are  families  in  which,  after  several 
abortions,  a  child  has  been  born  alive,  but  with  advanced  congenital  syph- 
ilis, and  soon  died  ;  the  next  has  perhaps  survived,  and  the  later  children 
have  shown  no  marks  of  the  disease  for  the  first  few  months  of  life,  or 
even  perhaps  at  all. 

The  diagnosis  of  this  complaint  is  a  matter  of  much  importance.  My 
late  friend  Dr.  Ballard  published  a  paper  which  he  read  at  the  Medical 
Society  of  London,  the  effect  of  which  would  have  been  almost  to  shake 
our  belief  in  the  reality  of  congenital  syphilis  altogether.  This  conclu- 
sion I  cannot  accept,  but  I  think  Dr.  Ballard  succeeded  in  showing  (what, 
indeed,  I  have  always  believed)  that  many  of  the  cases  which  are  diag- 
nosed as  syphilis  infantum  are  really  only  eruptions  due  to  dirt  and  neg- 
lect. Children's  skins  are  tender  and  irritable,  and  if  they  are  allowed 
to  remain  wrapped  up  in  hot  dirty  flannel  in  which  urine  and  faeces  are 
putref^'ing  they  will  be  affected  with  some  of  those  eruptions  which  ai'e 
included  by  nurses  under  the  vague  name  of  "  red-gum  " — however 
healthy  and  sound  may  be  their  constitution — and  such  neglected  chil- 
dren are  also  very  likely  to  suffer  from  chronic  cold  ;  but  in  the  genuine 
instances  of  infantile  syphilis  the  eruption  is  quite  different  from  the 
effects  of  common  irritation,  and  it  is  present  on  the  soles  of  the  feet,  the 
palms  of  the  hands,  and  in  the  mouth  and  cheeks,  where  no  such  cause 
is  possible.  Besides,  the  family  history  is  a  very  powerful  aid  to  the 
diagnosis,  and  in  doubtful  cases  there  is  no  objection  to  defer  the  spe- 
cific treatment  until  the  effects  of  cleanliness  and  attention  have  been 
ascertained. 

When,  however,  the  diagnosis  is  clear  the  mercurial  treatment  is  ur- 
gentl}^  indicated.  Infantile  syphilis  has  its  tertiary  stage,  though  the 
phenomena  are  not  very  well  understood.  I  have  seen  two  or  three  cases 
in  which  the  bones,  especially  of  the  palate,  have  been  destroyed,  and 
there  seems  no  doubt  that  some  of  the  gummatous  tumors  found  in  the 


408 


SYPHILIS. 


Sypliilitic  teeth. — From  a  paper  by  Mr.  Jona- 
than Hutchinson,  Path.  Soc. Trans.,  vol.x,  p.  296. 


lungs,  liver,  spleen,  and  other  viscera  in  childhood  have  been  syphilitic. 
The  affection  of  tlie  cornea  described  b}^  Mr.  J.  Hutchinson  as  interstitial 
keratitis  is  admitted  to  be  syphilitic,  and  so  is  the  condition  of  the  per- 
manent teeth  which  he  has  also  described.  The  syphilitic  keratitis  will 
be  found  treated  of  in  the  cliapter  on  Diseases  of  the  Eye,  but  a  few 
words  must  be  added  here  about  the  condition  of  the  teeth.  It  is  only 
seen  in  the  permanent  teeth,  at  least  it  is  only  in  them  that  it  can  be 
recognized,  since  the  milk-teeth  are  subject  to  so  many  irregularities  that 

if  any  of  these  are  due  to  syphilitic 
Fi«.  i"G.  causes  it  has  not  been  found  possi- 

ble to  identify  them.  The  affections 
of  the  teeth  are  believed  by  Mr. 
Hutchinson  to  be  the  effects  of 
stomatitis  merely;^  so  that  if  a 
syphilitic  infant  escape  stomatitis 
his  teeth  will  not  be  irregular,  and, 
therefore,  the  non-occurrence  of 
this  dental  irregularity  is  no  proof 
of  the  absence  of  s^'philis,  though 
its  presence  is  a  strong  confirmation 
of  the  diagnosis.  The  syphilitic 
characters  are  onl}'  marked  in  the  incisors  and  canines,  which  will  be 
found  to  be  small,  of  a  bad  color  (dirty  gray  instead  of  pearl}'  white), 
and  notched,  so  as  to  display  a  deep  groove  on  their  edge,  or  sometimes 
several  (serrated  teeth),  or  two  with  a  central  projection  (pegtop  teeth). 
They  are  also  soft,  from  deficienc}'  of  enamel,  and  therefore  wear  down 
easii.v,  so  that  these  characters  can  hardly  be  recognized  after  many  years 
of  wear.  It  is,  therefore,  only  from  the  age  of  eight  to  twenty-five  or 
thirty  that  any  confident  opinion  can  be  formed  on  the  subject. 

The  occurrence,  then,  of  tertiary  symptoms  after  infantile  syphilis 
forms  a  powerful  argument  for  eradicating  tlie  disease  by  mercury,  and 
the  effect  of  the  disease  on  the  general  health  is  a  still  stronger  one. 
When  mercur}'^  is  administered  in  an  appropriate  case  the  general  health, 
the  complexion,  and  the  digestion  immediately  improve,  while  under  ordi- 
nary remedies  (cldorate  of  potasli,  etc.)  the  child  may  have  been  pre- 
viously deteriorating  from  day  to  day.  I  have  frequently  tested  this 
experimentally. 

There  is  no  necessity  for  giving  large  doses  of  mercury — in  fact,  they 
are  not  well  borne  b}'  the  bowels — nor,  indeed,  is  there  any  need  to  ad- 
minister mercury  by  the  mouth  at  all.  If  the  mother  or  nurse  be  also 
syphilitic  the  calomel  vapor-bath  can  ])e  administered  to  both  at  o)ice  with 
advantage  ;  otherwise  the  old  plan  recommended  b}'  Brodie  answers  admi- 
rably, viz.,  to  make  tiie  child  wear  around  its  arm  a  piece  of  flannel  about 
two  inches  wide,  smeared  with  ung.  hydr.  The  objection  to  this  plan  is 
that  ignorant  people  tliink  "nothing  is  l)eing  done''  for  the  chiUl,  and 
consequently  are  very  liable  to  neglect  the  use  of  the  ointment.  In  such 
cases  1.",-  or  2  grs.  of  gray  powder,  witli  3  grs.  of  compound  chalk-powder, 
ma}'  be  given  twice  a  day.  The  treatment  should  last  about  six  weeks, 
or  al>out  a  fortnight  after  all  traces  of  eruption,  snuflles,  and  cachexia 
have  vanished.  No  other  treatment  is  needed,  except  cleanliness,  and, 
if  the  obstruction  of  the  nose  is  so  extreme  as  to  constitute  an  impedi- 
ment to  sucking,  constant  cleansing  of  the  nostrils  by  gentle  syringing 
with  an  alkaline  lotion. 


>  Path.  Trans.,  vol.  ix,  p.  449. 


INFANTILE    SYPHILIS.  409 

Under  this  treatment  the  disease  is  seldom  dangerous,  nor,  indeed,  is 
congenital  syphilis,  as  far  as  I  have  seen,  often  fatal  directl}' ;  but  many 
S3'philitie  infants  die,  in  consequence  of  the  cachexia,  being  too  weak  to 
resist  any  intercurrent  disorder. 

We  ought  not  to  quit  the  subject  of  congenital  syphilis  without  noting 
the  important  observation  of  Mr.  Hutchinson,  which  seems  to  be  sup- 
ported by  other  experience,  that  healthy  women  may  be  infected  with 
secondary  syphilis  by  carrying  syphilitic  children.  In  such  cases  there 
is,  no  doubt,  some  difficulty  in  determining.whether  the  woman  has  been 
infected  directlv  from  her  husband  or  indirectly  from  her  child.  The  test 
is,  of  course,  the  occurrence  or  non-occurrence  of  primary  syphilis;  but 
this  may  easily  have  been  overlooked. 

A"on-co)}genifal  Syphilift  iu  InfontK. — There  is  no  doubt  that  syphilis  is 
inoculable  in  the  secondary  as  well  as  in  the  primary  stage — in  fact,  one 
of  the  forms  of  secondary  syphilis  (the  mucous  tubercle)  yields  a  secre- 
tion which  is  often  very  contagious — but  other  secondary  sores  may  be 
communicated,  though  their  contagion  is  less  active  than  that  of  the  pri- 
mary sore,  so  that  it  requires  a  longer  contact  in  order  to  act,  and  takes 
a  longer  time  to  develop  its  effects.  But  it  must  be  recollected  that  the 
effect  of  the  inoculation  of  syphilis  anywhere,  whether  primar}'  or  secon- 
dary, is  to  produce  a  chancre  on  the  part  inoculated. 

This  appears  to  be  the  usual  cause  of  the  non-congenital  form  of  syph- 
ilis in  infants.  In  countries  where  wet-nursing  is  common  it  appears  to 
be  not  very  unusual  for  an  infant  when  nursed  by  a  syphilitic  woman  to 
contract  the  disease,  either  from  secondary  ulcers  on  the  nurse's  nipples, 
or  from  contact  between  some  accidental  abrasion  on  any  part  of  its  body 
and  some  sore  on  the  person  of  the  nurse.  In  the  former  case  tlie  chan- 
cre will  be  on  the  lip,  and  the  bubo  which  almost  always  accompanies  it 
will  l)e  in  the  glands  under  the  jaw  ;  in  the  latter  case  the  glands  next  in 
sequence  to  the  inoculated  crack  will  be  affected. 

Vaccino-si/philis. — Tliis  accidental  syphilis  of  infants  is  exactly  the 
same  disease  essentially  as  vaccino-syphilis,  in  which  the  S3'philitic  poison 
is  inoculated  by  mistake  in  conjunction  with  the  vaccine  matter.  Such 
cases  are  rare,  but  it  is  impossible  to  den}'  that  they  do  occur,  although 
it  would  appear  that  a  very  moderate  amount  of  caution  would  prevent 
them.^ 

In  vaccino-syphilis  the  vesicle  soon  suppurates,  and  the  edges  of  the 
resulting  sore  become  hard  and  chancrous,-  the  axillary  glands- soon  en- 
large and  run  the  ordinary  course  of  the  indolent  non  suppurating  bubo; 
the  hair  then  begins  to  drop  off,  and  eruptions  show  themselves  on  vari- 
ous parts  ;  in  fact,  the  usual  train  of  secondary-  and  tertiary  symptoms 
ensue. 

Other  ir?'egular  foinns  of  Syphilis. — The  treatment  of  these  unusual 
instances  of  syphilis  is  exactly  the  same  as  that  of  the  common  disease; 
but  their  exceptional  character  renders  the  diagnosis  somewhat  difficult, 

'  The  cautions  requisite  are  well  known.  They  are  four  in  number,  viz. :  1.  Use 
a  perfectly  eleiin  lancet.  2  Take  the  lymph  not  later  than  the  eighth  day  after 
vaccination,  so  as  to  avoid  any  mixture  of  pus.  3.  Take  only  lymph — no  blood  or 
any  other  secretion.  4  Examine  carefully  the  child  from  whom  the  lymph  is  taken, 
so'astobe  sure  that  it  is  not  syphilitic  It  seems  probable  that  the  blood  or  any 
other  secretion  of  a  syphilitic  person  may  convey  the  disease,  and  Mr.  Leo  believes 
that  the  mixture  of  blood  with  the  syphilitic  virus  under  any  circumstances  much 
increases  the  virulence  of  its  contagion.  Hence  the  desirability  of  taking  lymph  only; 
but  there  can  be  no  doubt  that  most  of  the  instances  of  vaccino-syphilis  were  produced 
by  a  neglect  of  the  ordinary  precautions — 1  and  4  above, 

"^  See  pi.  vii,  Fig.  15,  in  Mr.  Lee's  essay. 


410  SYPHILIS. 

as  it  is  also  in  the  irregular  chancres  that  occur  in  adults.  Such  chancres 
are  most  common  either  on  the  lip  or  on  the  finger.  A  chancre  on  the 
lip  does  not  present  exactly  tlie  same  appearance  as  it  does  on  the  geni- 
tals. It  is  generally  much  larger  and  flatter,  and  there  is  less  induration 
around  it  ;  but  its  indolent  appearance,  flat  surface,  and  accompanying 
bubo  in  the  glands  beneath  the  jaw  will  generally  indicate  its  nature  to 
a  practiced  eye;  and  if  there  be  much  doubt  a  few  weeks'  delay  will 
usually  prove  the  existence  of  syphilis  by  the  appearance  of  a  secondary 
eruption.  Chancres  on  the  fijigers  are  still  harder  to  diagnose.  In  fact, 
the  natural  action  is  interfered  with  in  these  exposed  parts  by  the  con- 
stant irritation  to  which  the  sores  are  subjected.  But  in  doiilitful  cases 
the  effect  of  mercury  generally  settles  the  question,  by  producing  the 
rapid  subsidence  of  the  sore  and  disappearance  of  the  bubo,  I  have  seen 
man}'  instances  of  this  in  supposed  epithelioma  of  the  lip. 

Syphilitic  Inoculation  and  Syphilization. — It  remains  to  say  a  very  few 
words  about  syphilitic  inoculation.  The  purposed  inoculation  of  syphi- 
litic matter  into  the  body  of  a  healthy  person  is  an  experiment  which  I 
cannot  speak  of  as  otherwise  than  unjustifiable,  even  if  the  subject  be  the 
experimenter  himself,  though  we  liaA^e  the  example  of  Hunter;  and  if 
done  on  another  person,  however  well-instructed  that  person  ma}^  be  on 
the  sul)ject,  it  seems  to  me  little  less  than  criminal.  But  to  inoculate 
innocent  and  ignorant  patients  in  a  hospital,  as  has  been  done  before 
now,  is  an  action  which  should  at  once  be  made  the  subject  of  judicial 
punishment.'  So  far,  I  presume  (at  any  rate  in  the  last  particular)  most 
people  would  agree.  Yet  syphilitic  inoculations  have  been  most  exten- 
sively practiced  of  late  years  in  hospitals,  on  patients  who  could  only  very 
imperfectly  apprehend  the  enormous  risk  which  they  were  running  for  the 
purpose  of  testing  a  theory  which  teaches  that,  as  the  constitution  may 
be  made  proof  against  a  renewed  attack  of  small-pox  or  scarlatina  or  any 
similar  constitutional  malady  by  saturating  the  body  with  the  virus,  so  a 
person  might  procure  an  immunit^^  from  constitutional  syphilis  if  his  or 
her  system  were  once  properly  "syphilized,"  or  saturated  with  the  dis- 
ease.^ The  analogy  no  doubt  is  good,  if  constitutional  syphilis  be  inocu- 
lable  on  the  patient  alread}'  affected  (for  not  even  the  most  ardent  advo- 
cate of  the  method  has  proposed  to  give  a  healthy  person  syphilis  in  order 
to  protect  him  from  it)  ;  and  that  this  was  so  was  taught  unhesitatingly 
by  Kicord,  who  laid  it  down  as  a  test  of  the  infecting  or  constitutional 
disease  that  tlie  matter  from  the  chancre  would  reprocluce  a  similar  chan- 
cre, if  inoculated  on  a  different  part  of  the  patient's  own  body;  from 
the  second  chancre  a  third  coulcl  be  produced,  and  so  on,  until  after 
a  variable  number  of  successive  crops  of  chancres  had  been  produced 
(sometimes  as  many  as  fifty  or  more)  the  system  would  get  charged  with 
the  virus  and  no  further  action  could  be  elicited.  And  tliis  was  the  treat- 
ment whicli  was  absolutely  followed  out  for  a  long  time  in  some  Conti- 
nental hospitals,  and  wliich  received  a  full  trial  at  our  own  female  Lock 
llosjjital  in  Ijondon.  Mr.  IT.  Lee,  however,  teaches  the  very  reverse  of 
Ilicord's  doctrine.  He  says  that  the  chancres  which  are  autoinoculable 
are  the  soft  chancres,  that  the  matter  from  a  Hunterian  chancre  is  only 

'  Can  any  ono  road  without  indiijnation  and  di.«£jiipt  the  record  of  experiments  such 
as  tho.«e  of  Waller  of  Prat^ue,  (quoted  by  ^Fr.  Lee  in  St.  George's  Ho.^pital  Reports, 
vol.  vi,  p.  0,  where  heiiUhv  eliiidren  wlio  were  elio.^en  tor  tlieir  proved  iniinunily  from 
svfibilitic  cachexia  were  inoculiitcd  with  tlie  secretions  of  diseased  prostitutes?  No 
scientific  end  can  for  a  moment  justify  the  use  of  meun.s  so  barbarous  and  so  criminal. 

''  Med.-Chir.  Trans.,  vol.  i,  p.  281. 


ULCERS.  411 

inoculable  in  its  initial  stage,  before  the  characteristic  induration  has 
manifested  itself,  or  at  a  later  stage,  whenever  the  sore  has  been  artifici- 
ally irritated  and  made  to  sni^pnrate;  and  that  even  then  the  inocnlation 
will  not  last  any  long  time,  but  that  on  the  second  or  third  trial  it  will 
fail ;  while,  on  the  other  hand,  the  soft  sore  can  be  inoculated  for  an  unlim- 
ited number  of  times ;  and  this  doctrine  seems  to  be  a  jyriori  the  more 
probable,  and  is  now  extensively  accepted.  If  this  be  so,  syphilization' 
would  be  doubl}^  unjustifiable,  since  at  the  end  of  the  process  the  patient 
would  only  have  procured  immunity  from  a  local  action  which  was  never 
formidable,  and  would  have  ceased  much  earlier  if  left  alone,  and  an  im- 
munity which  is  only  temporary,  as  Mr.  Lee  demonstrated  clearly  by 
reinoculating  a  patient  who  had  previously  been  tlioroughly  syphilized 
not  very  long  before,  and  was  thought  to  have  obtained  complete  protec- 
tion from  all  future  infection. 

As  a  method  of  treatment,  therefore,  syphilization  is  now  given  up,  at 
least  in  this  country  ;  but  it  is  still  practiced  as  a  means  of  diagnosis. 
If  a  sore  be  repeatedly  inoculable  it  may  safely  be  pronounced  syphilitic. 
Secondary  sores  can  be  inoculated  a  few  times,  but  not  nearly  so  often 
as  suppurating  primary  chancres.  Those  who  hold  unreservedly  to  Mr. 
Lee's  doctrine  w^ould  believe  that  the  repeated  inoculability  of  a  sore  was 
a  contraindication  to  the  use  of  mercury. 

A  very  interesting  question  is,  what  degree  of  immunity  does  a  patient 
obtain  by  a  previous  attack  of  constitutional  syphilis  against  a  renewed 
infection  ?  To  this  question  we  are  not  in  a  position  at  present  to  give 
an  altogether  confident  answer.  That  there  is  considerable  immunity 
from  the  risk  of  another  constitutional  infection  cannot  be  doubted,  but 
several  cases,  recorded  b}'  careful  observers,  seem  to  show  that  this  im- 
munity is  by  no  means  so  complete  as  in  the  case  of  the  eruptive  fevers, 
though  in  them  it  is  not  perfect.^ 


CHAPTER   XXL 

ULCERS— CICATRICES,  AND  THEIR  DISEASES. 

The  process  of  ulceration  has  been  described  in  a  previous  chapter 
(see  p.  43).  When  this  process  has  gone  on  for  some  time  around  a 
wound,  so  that  it  has  spread  to  a  large  size,  or  when,  as  is  more  com- 
monly the  case,  a  slough  has  formed  and  come  away,  the  granulating 
surface  which  is  left  is  called  an  ulcer,  and  it  maintains  this  name  till 

'  By  syphilization  is  meant  the  process  of  inoculating  the  patient  from  the  original 
sore  (say  on  the  genitals)  in  three  or  four  places  in  a  different  {)art  of  the  body,  usu- 
ally the  thigh,  from  these  on  another  part,  and  so  on,  until  sometimes  the  whole 
body  is  covered  with  the  marks  of  more  than  100  chancres.  (See  the  cases  recorded 
in  the  50th  volume  of  the  Med.-Chir.  Trans.) 

2  See  a  series  of  cases  of  reinfection  reported  by  Mr.  G.  Gascoyen,  in  the  forth- 
coming (58th)  volume  of  the  Med.-Chir.  Trans. 


412  ULCERS. 

the  healing  process  has  been  completed  and  the  whole  is  filled  up  and 
converted  into  a  .s-ca?-. 

The  matter  which  is  furnished  during-  the  ulcerating  process  varies  in 
character  according  to  the  nature  of  the  ulcer,  being  sanious  or  foul, 
ichorous,  contagious,'  etc.,  approaching  more  and  more  nearly  to  health_y 
pus  as  the  healing  process  advances.  The  distinctive  characters  of 
ulcers  depend  on  differences  observed  in  the  base,  the  granulations  and 
the  pus  which  they  secrete,  the  edge,  and  the  parts  surrounding  the 
ulcer. 

Ulcers  are  divided  into  classes  (I),  according  to  the  constitutional 
causes  on  which  they  depend,  and  (11),  according  to  the  local  characters 
which  tiiey  present. 

1.  With  reference  to  the  constitutional  causes  which  modify  the  char- 
acter of  the  ulcer,  the  following  varieties  are  described  : 

1.  Tlie  simple  or  healthy  ulcer,  such  as  that  which  follows  accidental 
injur}-  in  a  healthy  person.  Its  base  is  level  and  slightly  depressed. 
The  granulations  are  florid,  uniform,  small,  soft,  elastic  to  the  touch, 
vascular,  hut  not  usually  bleeding  spontaneously,  and  not  highl}'  sensi- 
tive ;  the  edges  shelve  gentl}-,  are  not  peculiarly  hard,  and  are  of  an 
opaque  white  at  the  circumference,  where  the  epithelium  is  condensed 
and  heaped  up,  getting  redder  towards  the  ulcer ;  the  pus  is  healthy  or 
"  laudable." 

This  form  of  ulcer  will  heal  under  the  simplest  treatment,  or,  in  fact, 
under  no  treatment  at  all,  if  defended  from  all  irritation  or  congestion. 
If  the  patient  is  obliged  to  go  about  the  ulcer  should  be  protected  from 
congestion  by  strap[)ing  and  bandage.  This  is  most  thoroughly  done  by 
the  plan  called  Ba^nton's.  The  limb  is  encircled  with  strips  of  strap- 
I^ing,  each  lying  half  over  the  one  below  it,  and  all  crossing  in  front, 
from  an  inch  below  to  as  much  above  the  ulcer,  and  is  evenly  bandaged 
from  the  foot  to  some  distance  above  the  sore. 

2.  Injlammator-y  Ulcer. — The  nearest  to  healthy  ulcers  are  the  inflam- 
matory. Tlie}'  are  usually  single  and  small;  the  skin  around  is  hot  and 
red,  often  edematous,  with  burning  pain  in  the  part.  The  base  is  level 
and  little  depressed,  but  ragged  and  flocculent ;  the  granulations  are 
generally  absent,  so  that  the  base  looks  raw ;  it  is  rudd_y  in  color,  or  ash- 
gray,  or  yellowish,  with  thin  adherent  sloughs.  The  edges  are  abrupt, 
irregular,  or  shreddy.  The  pus  is  ichorous,  thin,  water}',  excoriating  the 
edges,  and  frequently  blood-stained. 

In  the  treatment  of  such  ulcers  the  main  point  is  to  subdue  the  inflam- 
mation by  rest  in  the  raised  position  of  the  limb,  with  warm  soothing 
applications,  such  as  warm  Goulard-water,  Oss. ;  tinct.  opii,  .^j  ;  on  a 
tiiick,  soft  rag  or  compress  of  lint  covered  with  oiled  silk.  In  some 
cases  benefit  seems  to  accrue  from  applying  leeches  at  a  distance. 

The  patient  is  often  weak,  and  requires  tonics  and  support. 

3.  Eczemalous   Ulcer.  —  The   eczematoun    resemble   tlie   inflammator}' 


'  Tlu!  f-pecific  characters  of  pus  have  not  boun  much  studied,  but  we  sometimes  see 
the  inr)oulability  of  matter  tested  in  tlie  case  of  ulcers  or  sores  prcsiitned  to  be  syphilitic, 
and  in  ca-cs  of  jjjonorrhojiil  ophthalmia.  Sy|)hilitic  pus  will  excite  a  specific  action, 
reprodiicini;  a  similar  action  for  a  grctat  minihcr  of  times  in  cases  of  soft  sore,  and 
Pomcthin<^  similar  takes  place  in  hard  sores  which  have  been  inflamed.  The  inocu- 
lation of  ordinary  pus,  on  the  contrary,  only  causes  a  little  pimple,  which  soon  dis- 
appears. So  with  gonorrhfi'al  nuilter.  I'us  taken  from  a  case  of  acute  gonorrhoea 
and  placed  in  the  conjunctival  sinus  will  excite  the  most  acute  infliimmation,  often 
rapidly  destroying  the  eye,  while  pus  from  an  ordinary  abscess  will  only  cause  a 
slight  and  transient  inflainrnalion,  and  often  none  at  all. 


STRUMOUS    ULCERS.  413 

ulcers,  but  are  complicated  with  eczema  of  the  surrounding  skin.  The 
constitutional  condition  which  is  the  remote  cause  of  the  eczema  must 
be  discovered  and  treated — whether  it  be  gout,  struma,  or  other  cachexia 
— and  the  eczematous  skin  must  be  treated  as  well  as  the  ulcer.  AVet 
strapping  to  the  limb  is  often  useful,  i.e.^  the  application  of  strips  of  wet 
linen  exactly  in  the  same  way  as  the  strips  of  diachylon  or  other  plaster 
would  be  used  for  strapping  it,  the  application  being  kept  moist  by  wet- 
ting it  as  often  as  necessary;  or  blotting-paper  may  be  applied,  or  the 
skin  dusted  with  starch  or  washed  over  with  nitrate  of  silver  lotion. 
Na3der  recommends  an  ointment  of  red  precipitate  of  mercury,  5  to  10 
grains  to  the  ounce,  covered  with  a  compress  of  linen  wrung  out  of  hot 
water.^ 

Occasional  Harvi  froyn  Healing  an  Ulcer. — Paget^  sa3's  :  "  It  is  prob- 
ably these  more  than  any  otlier  ulcers  that  have  given  rise  to  the  question 
whether  ulcers  should  always  be  cured  if  possible.  There  is  sufficient 
reason  to  believe  that  the  cessation  or  cure  of  an  established  eczema  has 
been  attended  with  serious  disease  of  the  brain  or  other  internal  organ  ; 
the  same  may  happen  with  an  ulcer  of  this  or  probabl}'  some  other  kinds. 
The  event  is  certainly  very  rare,  but  it  may  often  be  right  to  guard  against 
it  by  making  an  issue  in  some  place  more  convenient  than  the  ulcer,  or 
by  renewing  the  cutaneous  disease  by  counter-irritants." 

Ulcers  similar  to  the  eczematous  form  in  other  constitutional  eruptions. 

4.  Cold  ulcera  resemble  small  inflammatory  ulcers,  occurring  spontane- 
ously, especially  at  the  ends  of  the  fingers  and  toes,  preceded  by  severe 
pain  and  small  inflammatory  spots.  Thej^  occur  in  persons  of  feeble  cir- 
culation, whose  feet  and  hands  are  always  cold,  and  the  parts  around 
them  are  livid  and  cold  to  the  thermometer. 

The  treatment  is  by  dry  applications  or  stimulating  lotions,  tonics, 
especially  iron,  with  purgatives,  warm  clothing,  warm  bathing,  and  ex- 
ercise. 

5.  Senile  ulcers  somewhat  resemble  the  inflammatory,  but  with  more 
tendency  to  sloughing.  The  base  of  the  ulcer  is  generally  dr}',  the  gran- 
ulations rusty  in  color,  and  surrounded  with  a  dusky  pinkish  area.  The 
skin  is  sometimes  sloughing  in  one  part  while  the  ulcer  is  healing  in  an- 
other. Such  ulcers  are  found  in  the  dry,  withered  limbs  of  those  "who 
are  growing  old  witli  either  a  timely  or  premature  degeneracy." 

For  their  treatment,  besides  generous  diet,  wine,  tonics,  opium,  warmth, 
and  all  the  comforts  which  old  age  sliould  have,  stimulating  and  balsamic 
applications  are  required.  Paget  recommends  strapping  them  with  equal 
parts  of  Xing.  Resinaj  and  Balsam  of  Peru  spread  on  lint. 

6.  Strumous  ulcers  are  such  as  occur  in  strumous  subjects,  usually  in 
combination  with  other  local  symptoms.  Thej'  often  follow  on  suppurat- 
ing glands  or  softening  of  subcutaneous  masses  of  tubercle,  as  evidenced 
by  the  presence  of  small  nodular  masses,  which  soften,  with  a  low  inflam- 
mation of  the  skin  over  them.  They  are  often  multiple,  the  individual 
ulcers  being  originally  small  and  oval,  but  afterwards  coalescing  into 
irregular  shapes.  The}'  are  found  more  frequently  in  the  situation  of  the 
lymphatic  glands,  i.  e.,  in  the  neck  and  groin,  and  are  frequent  on  the 
face  and  head  ;  but  they  do  also  occur  on  the  limbs.  The  base  is  soft, 
unequal  in  level,  the  granulations  are  large,  pale,  soft,  cedematous,  often 
exuberant,  and  bleed  easily  ;  the  pus  is  thin,  greenish-\-ellow,  and  pos- 
sibl}'^  curdy ;  the  edges  are  undermined,  pale  pink  or  purplish,  with  over- 

'  See  the  chapter  on  Eczema  in  Navler's  Diseases  of  the  Skin,  2d  ed. 
*  Syst.  of  Surg.,  vol.  1,  p.  184,  2d  ed. 


414  ULCERS. 

hanging,  thin,  or  irregularly  hardened  skin,  and  there  is  often  a  warty 
growth  of  the  papilhu  around  (particularly  in  tlie  hands  and  feet),  which, 
coml)ine(l  with  tlie  otlier  character  of  the  edges,  gives  some  resemblance 
to  epithelioma,  but  strumous  ulcers  want  the  hard  base,  sinuous  raised 
border,  and  rapid  progress  of  cancerous  ulcers.  There  is  seldom  much 
pain,  tliough  wliere  they  have  existed  long  the  parts  around  become 
(Edematous. 

Tlie  edges  often  require  to  be  destroyed  with  caustic  potash  before  the 
sore  will  heal. 

The  general  treatment  of  struma  must  be  pursued,  and  the  ulcers 
locally  stimulated  with  iodine  in  the  form  of  ointment,  or  of  lotion  applied 
on  linen  strapping,  or  with  nitrate  of  silver  lotion.  Their  scars  are  often 
causes  of  deformity,  either  by  contraction  or  by  overgrowth,  which  is 
more  frequent,  and  which  must  be  combated  by  repeated  slight  blistering. 

Very  deep,  obstinate,  and'extensive  ulcers  may  justify  amputation,  par- 
ticularly when  situated  near  the  ankle,  and  when  au}^  neighboring  joint 
or  bone  is  simultaneousl}^  affected. 

7.  Sco7-butic  ulcers  are  those  which  accompau}'  scurvy,  and  derive 
their  peculiarities  from  the  effusion  on  their  surface  of  the  same  semi- 
organized  plastic  material  which  occasions  the  swelling  of  the  gums,  the 
intermuscular  swellings,  and  the  vibices  and  petechia  of  scurvy. 

The  ulcers  are  livid,  with  irregular,  swollen  borders,  their  surface 
covered  with  a  dark,  spongy,  fetid  crust,  which  adheres  so  strongly  that 
its  removal  causes  free  bleeding,  and  which  is  rapidly  reproduced.  The 
treatment  must  be  directed  to  the  constitutional  disorder.  When  this  is 
removed  the  ulcer  becomes  of  a  simple  nature. 

8.  Gouiy  Ulcers. — Gouty  persons  often  suffer  from  inflammatory  or 
eczematous  ulcers,  but  the  proper  gouti/  nicer  is  that  which  is  found  "over 
gouty  deposits  or  in  parts  distinctly  gouty,  and  it  usually  involves  only 
part  of  the  thickness  of  the  skin.  The  base  is  florid,  the  granulations 
absent,  or  grayish  or  yellow,  the  edges  low  and  shelving,  the  pus  thin 
and  ichorous,  frequently  leaving  a  white,  chalky  deposit.  The  ulcers^are 
very  indolent,  "  exceedingly-  slow  in  getting  either  better  or  worse." 

The  treatment  here  again  is  directed  to  the  disorder  of  the  constitution. 
The  local  treatment  is  limited  to  water-dressing,  simple  cerate,  or  weak 
solutions  of  nitrate  of  silver. 

9.  Syphilitic  ulcers  are  those  which  form  on  the  skin  in  secondary  or 
tertiary  syphilis.  They  are  situated  usually  on  remote  parts,  but  the 
genital  organs  may  also  be  affected  with  secondary  sores,  and  it  seems 
certain  that  the  matter  from  such  sores  is  contagious. 

r  Secondary  ulcers  are  much  more  rare  than  tertiary.  They  generally 
proceed  from  the  sloughing  of  parts  affected  with  pustular  eruptions  in 
cachectic  persons. 

Tertiary  syphilitic  ulcers  "  usually  appear  among  the  latest  signs  of 
syphilis,  and  are  most  severe  in  those  who  are  most  reduced,  whether  b^'' 
the  syphilitic  i)oison  abiding  in  them  or  b}-  mercury,  or  both,  or  by 
poverty,  intemperance,  or  naturally  unsound  constitution.  Tliere  is 
probaldy  no  form  of  ulcer  in  which  the  influence  of  all  these  evils  is  more 
intensely  felt." 

Tertiary  ulcers  are  divided  into  two  forms,  not,  however,  generally  dis- 
tinguishable at  a  late  stage :  (a)  the  superficial.,  which  follows  on  rupia 
or  some  oilier  ulcerative  eruption,  sometimes,  though  not  usually,  com- 
mingled with  such  eruption.  These  are  best  known  by  their  annular  or 
horseshoe  form,  spreading  from  the  exterior  while  healing  from  the  inside 
(serpigo),  and  are  often  multiple,  arranged  in  some  circular  or  curved 


LUPOUS    ULCERS.  415 

figure.  Their  local  characters  are  not  otherwise  very  decisive,  and  the 
diagnosis  is  made  from  the  history  or  concomitant  symptoms.  Some- 
times the  discharge  is  heaped  up  into  scabs  resembling  tliose  of  rupia. 
These  ulcers  have  usually  no  induration,  and  often  do  not  penetrate  the 
whole  cutis, 

(6)  The  deep  tertiary  ulcer  usually  commences  in  the  softening  of  a 
subcutaneous  gummatous  swelling,  over  which  the  skin  gives  way,  leaving 
a  circular  sore,  which  looks  as  if  the  skin  had  been  punched  out.  The 
base  of  the  sore  is  often  found  sloughing.  The  sore  is  at  first  surrounded 
by  a  ring  of  induration,  which  is  gradually  destroyed  and  falls  into  the 
ulcer.  There  is  often  an  area  of  dusky  redness  round  the  ulcer,  which 
forms  a  contrast  to  the  pink  halo  already  described  as  surrounding  the 
strumous  ulcer.  Tertiary  ulcers  may  extend  to  any  depth,  tlirough  the 
fascia  to  the  muscles,  periosteum,  or  bone.  They  occur  in  late  stages  of 
syphilis,  often  with  no  other  syphilitic  svmptoms,  though  in  other  cases 
ostitis  or  periostitis  may  be  present  elsewhere.  Frequently  the  diagnosis 
can  only  be  made  by  the  eftccts  of  specific  treatment.  In  ulcers  situated 
on  the  leg  it  is  useful  to  remember  that  the  simple  and  the  varicose  ulcers 
generally  occur  on  the  inner  aspect  of  the  limb,  a  little  above  the  malleo- 
lus, and  are  usually  single;  while  the  syphilitic  ulcers  occur  more  often 
on  the  outer  side,  and  are  commonly  multiple,  ver}'  often  appearing 
simuUaneousl}'  on  both  legs,  and  sometimes  nearly  or  quite  symmetrical 
on  botli. 

Specific  treatment  is  usually  of  no  use  so  long  as  the  ulcer  is  inflamed ; 
but  when  by  rest  and  soothing  applications  all  inflammatory  complica- 
tions have  been  subdued  it  generally  succeeds  rapidly.  The  iodide  of 
potassium,  in  full  doses  of  gr.  v-viij  or  x  three  times  a  da}^  usually  pro- 
cures the  speedy  healing  of  the  ulcer,  which,  however,  in  many  cases  soon 
breaks  out  again.  For  permanent  cure  a  course  of  mercury  is  generally 
necessary,  and  it  is  best  administered  in  the  form  of  the  calomel  vapor- 
bath,  either  applied  to  the  whole  bod_y,  with  some  mercurial  ointment  or 
lotion  to  the  part,  or  in  the  form  of  local  fumigation  ;  and  in  that  case 
smaller  doses  of  the  salt  suffice:  about  5  grains,  in  a  small  lamp  sur- 
mounted by  a  tube,  with  a  mouthpiece  fitting  the  sore,  will  usually  be 
enough,  if  applied  every  night  so  long  as  the  sore  is  open,  and  followed 
by  a  somewhat  larger  dose  up  to  the  end  of  six- weeks,  the  quantity  being 
regulated  by  the  state  of  the  gums. 

10.  LujwuH  ulcers  are  characterized  by  the  precedence  of  the  tubercles 
of  lupus,  which,  however,  perish  in  the  ulceration.  Tliey  are  more  com- 
mon on  the  face  than  on  any  other  part,  and  particularly  the  ahie  of  the 
nose,  where  the  skin  joins  the  mucous  membrane,  and  are  frequently 
accompanied  l)y  perforating  ulcers  of  the  septum  nasi  or  in  the  plu\r3'nx. 
They  generally  occur  in  persons  of  strumous  constitution.  The  base  is 
pale  and  in  sou)e  cases  level,  but  in  others  covered  with  coarse,  dusky, 
prominent  granulations,  raised  highest  at  the  centre  of  the  sore.  The 
borders  are  abrupt,  irregular,  eroded,  and  sometimes  slightl}'  raised  and 
thickened  ;  the  pus  often  scabs  on  the  surface.  The  ulceration  slowly 
extends  at  the  margins  and  beneath  the  scabs  till  it  perforates  tlie  parts 
below,  as  the  cartilages  and  bones  of  the  nose,  the  mucous  membrane, 
etc.,  thx)ugli  still  vvitliout  pain. 

Tiiese  ulcers  are  allied  to  struma,  of  which  other  symptoms  may  be 
present,  and  the  general  treatment  is  the  same,  but  thej'  are  seldom  got 
to  heal  without  destroying  the  surface  of  the  ulcer.  This  is  best  done  b}^ 
one  of  the  powerful  caustics,  as  potassa  fusa  or  acid  nitrate  of  mercury. 
Other  forms  of  lupus  are,  however,  frequently  met  with — the  chronic,  or 


416  ULCERS. 

lupus  non-excdens,  the  syi^hilitic,  the  erythematous,  etc.,  for  the  full  de- 
scription of  which  I  must  refer  to  works  on  diseases. of  the  skin/ 

The  contraction  of  lupous  ulcers,  especially  around  the  mouth  or  the 
orihce  of  the  nose  or  near  the  eyelid,  gives  rise  to  deformity,  which  is  best 
treated  when  it  assumes  the  form  of  an  annular  constriction  by  gradual 
dilatation  with  sea-tangle  tents  or  ivory  wedges,  and  in  case  of  ectropion 
by  a  plastic  operation,  which  will  be  found  described  in  the  chapter  on 
Affections  of  the  Eye. 

1 1.  Rodent  ulcer  is  very  like  lupous  ulcer,  but  it  occurs  later  in  life  ;  the 
latter,  like  other  strumous  affections,  is  more  common  in  early  years.  Ro- 
dent ulcers  occur  most  commonly  on  the  face  and  head,  though  tliey  are 
found  also  on  the  female  organs  of  geneiation  and  breast,  as  well  as  in 
other  parts.  The}'  spread  gradually,  with  little  acute  pain,  but  sometimes 
with  constant  aching,  destroying  all  the  parts  with  which  they  come  in 
contact,  so  as  sometimes  to  remove  every  feature  of  the  face.''  The}'  are, 
therefore,  sometimes  classed  with  the  cancers ;  •'  but  the}'  lack  the  solid 
deposit  and  characteristic  cells  of  epithelioma,  and  the}'  are  not  attended 
with  glandular  disease  or  with  deposit  in  remote  parts. 

Their  edges  are  usually  smooth,  hard  and  rounded,  sometimes  slightly 
tubercular.  The  base  is  tough  and  hard,  smooth,  yellowish-red,  halt-dry 
and  glossy ;  but  when  any  granulations  are  present  they  are  sometimes 
exuberant.  In  rare  cases  there  is  a  warty,  lobed  mass  like  epithelioma, 
and  such  cases  can  only  be  distinguished  from  epitlielial  cancers  by  the 
microscope.  The  ulcer  is  indistinguishable  by  the  naked  eye  from  epi- 
theliomatous  ulceration,  and  cases  are  given  by  Moore  and  others  in 
which  "  epithelial  cells,  and  brood  cells,  like  the  section  of  an  onion," 
were  found,  as  in  epithelioma,  but  such  cases  would  by  most  surgeons  be 
called  ei)ithelial  cancer.  The  cases  which  are  most  satisfactorily  distin- 
guished from  epithelioma  are  those  in  which  "the  disease  is  made  up  of 
such  innocent  microscopic  corpuscles  that  it  has  been  likened  tp  a  chronic 
ulcer  of  the  leg  and  to  a  perforating  ulcer  of  the  stomach."    (Moore,  p.  13.) 

The  most  perfect  general  health  is  quite  compatible  with  the  most  ex- 
tensive destruction  of  the  tissues  by  rodent  ulcer.  In  tlie  case  above 
referred  to  the  patient  lived  for  years  in  good  health  with  almost  the  whole 
face  destroyed,  and  then  died  of  old  age.  Further,  it  lias  been  abun- 
dantly i)roved  that  if  the  parts  concerned  in  the  rodent  ulcer  be  entirely 
removed,  so  that  nothing  but  healthy  parts  are  left,  the  patient  may  live 
for  an  unlimited  period  without  the  return  of  tlie  disease.  In  other  cases, 
however,  it  has  returned,  probalily  on  account  of  incomi)lcte  removal. 

'^i'he  indication,  therefore,  is  to  remove  the  disease  thoroughly  and  com- 
pletely, and  tills  is  best  done  by  a  combination  of  the  knife  and  caustics. 
All  the  visiljle  ulcer  having  been  cut  out  freely,  the  part  sliouhl  be  lelt  for 
a  day  or  two,  till  tlie  bleeding  lias  quite  ceased,  and  then  an  active  caus- 
tic, such  as  the  chloride  of  zinc,  spread  on  lint,  is  to  be  freely  applied  to 
the  exposed  soft  parts.     If  the  bones  are  implicated  they  must  be  soaked 

1  Sec  cppecinlly  Nayler  in  Diseases  of  tlie  Skin,  2d  ed.,  for  a  very  careful  descrip- 
tion of  th(!  various  foi  nis  of  lupus. 

*  See  a  preparation  at  St  (icort^e's  Hospital  Museum  (Ser.  xvi,  No.  57),  in  which 
the  patient  lived  for  a  long  time  with  every  feature  of  his  face  renioV(?d,  exi;ept  one 
eye  ;  the  eye  and  the  tongue  being  in  the  same  common  cavity. 

'  An  interesting  little  work  was  put)lished  in  18(j7,  on  Rodent  Cancer,  by  the  late 
Mr.  C.  H.  Moore,  which  is  well  worth  reading.  Mr.  Moore,  however,  clearly  dis- 
tinguishes between  the  local  malignity  of  rodimt  ulcer  and  the  constitutional  infec- 
tion of  cancer;  in  fact,  thi;  main  obj(?ctof  his  book  is  to  show  tlx;  possibility  of  eradi- 
cating rodent  ulcer  iicrmariently  b\'  adeijuale  surgical  operation. 


VARICOSE    ULCERS.  417 

in  strong  sulphuric  acid  until  they  come  away.  I  well  remember  seeing 
at  the  Middlesex  Hospital  a  case  which  had  been  thus  treated  with  suc- 
cess, in  which  a  great  part  of  the  side  of  tlie  face  and  one  eye  had  been 
removed,  and  the  neighboring  part  of  the  base  of  the  skull,  so  that  in 
looking  into  the  gap  the  pulsation  of  the  brain  was  perceptible  over  a 
large  surface.  The  hiatus  in  the  face  had  been  cleverly  filled  up  by  a 
mask  of  A'ulcanite  painted  to  resemble  the  natural  features. 

12.  Cancerous  alcen^  occur  either  from  the  adherence  of  the  skin  to  a 
cancerous  mass  or  from  the  deposit  and  softening  of  cancer  in  tlie  skin 
itself.  Those  which  commence  in  the  skin  are  generally  of  the  epithelial 
variet3^ 

The  edges  of  cancerous  ulcers  are  raised  and  everted,  hard,  nodular, 
and  wart3^  Their  granulations  are  coarse,  uneven,  deepest  in  the  centre 
of  the  sore,  and  they  bleed  spontaneously  ;  the  base  is  hard,  nodular, 
and  surrounded  by  the  cancerous  deposit ;  the  pus  is  foul  and  ichorous. 
There  are  often  enlarged  glands  or  other  cancerous  deposits  in  the  neigh- 
borhood. 

It  is  sometimes  of  importance,  and  especially  in  tumors  of  the  breast, 
to  distinguish  the  ulceration  produced  by  a  cancerous  tumor  from  that 
which  may  be  caused  by  any  other  formation. 

The  main  sign  is  that  cancerous  tumors  cause  ulceration  b}'  infiltrating 
the  skin  with  cancer,  which  then  breaks  down,  while  innocent  tumors 
cause  ulceration  by  pressure  only.  Therefore,  in  the  latter  case,  besides 
the  absence  of  all  other  signs  of  cancer,  it  will  be  noticed  that  the  skin 
is  merely  thinned,  and  retains  its  perfect  softness  and  flexibility  even  up 
to  the  edge  of  the  opening. 

The  treatment  of  cancerous  ulcers  consists  in  removing  the  whole  part 
on  which  they  are  situated  whenever  that  is  possible.  In  parts  which  do 
not  admit  of  amputation  the  skin  around  the  ulcers  may  be  freely  cut 
away,  and  in  some  instances  a  healthy  cicatrix  will  be  obtained,  and  the 
disease  at  any  rate  temporarily  checked.  If  this  also  is  impossible  only 
palliative  treatment  can  be  adopted  in  most  cases — i.  e.,  some  application 
which  will  keep  the  wound  clean,  and  a  sufficiency  of  opium  or  other  nar- 
cotic to  allay  the  pain — thougli  there  is  no  objection,  if  the  disease  has 
not  gone  too  far,  to  the  removal  of  the  ulcerated  surface  with  some  pow- 
erful caustic,  of  which  the  sulphuric  acid  made  into  a  paste  with  asbestos 
seems  the  least  painful.  This  treatment,  indeed,  can  only  be  regarded  as 
palliative,  for  the  disease  is  almost  sure  to  return  soon,  even  if  the  caustic 
should  succeed  in  removing  it  for  a  time. 

II.  The  following  varieties  of  ulcer  depend  on  local  conditions: 

13.  Varicose  ulcers  are  such  as  are  occasioned  by  the  pressure  of  the 
blood  in  varicose  veins  above,  rendering  the  skin  congested  and  prone 
to  low  inflammation.  These  ulcers  are  of  the  ordinary  chronic,  inflam- 
matory, eczematous  kind,  and  are  situated  usually  above  the  inner  ankle. 
Well-regulated  pressure,  and  the  maintenance  of  the  elevated  position  of 
the  limb,  are  necessary  adjuncts  to  the  ordinary  treatment  above  de- 
scribed; or  the  veins  maybe  obliterated  by  operation  (see  the  chapter 
on  Diseases  of  Veins).  Tonic  medicines  are  indicated,  and  opium  is 
useful  where  there  is  pain  or  inflammation. 

14.  (Edematous  or  iveak  ulcers  are  such  as  occur  on  edematous  limbs, 
and  the  granulations  of  wliich  are  oedematous  from  partaking  of  the 
general  redema,  or  from  being  constricted  by  a  neighboring  scar  or  by 
tense  skin.  The  remedies  are  to  reduce  the  oedema,  to  apply  astringents 
to  the  granulations,  to  strap  and  bandage  the  ulcer  and  tlie  whole  limb 
below  it;  or,  in  some  cases,  to  divide  the  constricting  medium. 

27 


418  ULCERS. 

15.  Exuberant  ulcers  are  those  in  which  the  granulations  project  con- 
siderabl}'^  beyond  the  surface,  but  are  free  from  any  cancerous  deposit. 
In  sucli  cases  the  general  health  must  first  he  carefully  attended  to,  free 
purgation  being  usually  necessary  ;  the  granulations  are  to  be  repressed 
by  pressure  and  by  the  light  application  of  stick  caustic. 

1(5.  Heeinorrhaglc  ulcers  are  such  as  bleed  from  a  great  variety  of 
causes;  l)ursting  of  varicose  veins  and  venous  congestion  are  the  com- 
mon causes.  Phagedenic  and  cancerous  ulcers  not  unusually  bleed 
spontaneously.  Vicarious  menstruation  and  ulceration  into  a  blood- 
vessel are  other  but  much  rarer  causes  of  bleeding. 

The  appropriate  treatment  is  involved  in  the  discovery  of  the  cause. 

17.  Neuralgic  Ulcers. — In  neuralgic  ulcers  the  pain  generally  depends 
on  some  unhealthy  condition  of  the  ulcer  or  on  some  local  cause — true 
neuralgia  attacking  an  ulcer  is  much  rarer.  The  remedy  is  to  cure  the 
ulcer,  for  which  purpose  its  division  is  often  indicated.  The  painful 
ulcer  of  the  anus  is  an  example ;  but  painful  ulcers  of  the  legs  are  also 
often  brought  to  heal  by  complete  division,  under  anaesthesia,  the  knife 
being  carried  through  their  whole  extent  in  various  directions. 

is"  Inflamed  ulcers  are  distinguished  from  the  "inflammatory"  de- 
scriljed  above,  in  that  the  inflammation  in  these  depends  on  a  local  irri- 
tation, while  in  those  it  is  part  of  a  constitutional  condition. 

In  inflamed  ulcers  there  is  an  increase  of  pain  with  redness  and 
oedema  around  them — the  discharge  is  copious  and  bloody ;  the  granula- 
tions become  swollen  and  congested,  and  then  slough  ;  the  edges  are 
often  abrupt  or  jagged.  Sucli  inflammation  occurring  in  a  callous  ulcer 
is  often  curative,  as  in  the  treatment  by  blistering,  or  the  inflammation 
excited  by  erysipelas. 

The  indications  of  treatment  in  an  inflamed  ulcer  are  to  remove  any 
source  of  irritation,  to  apply  soothing  warm  lotions,  and  to  enforce  rest. 

19.  Callous  Ulcers. — The  callous,  chronic,  or  indolent  ulcer  is  usually 
situated  on  the  leg,  with  its  long  axis  parallel  to  that  of  the  limb.  Some- 
times it  encircles  the  leg.  Its  base  is  deej),  flat,  pale,  or  tawny,  and  ad- 
herent to  the  deei)est  parts;  the  granulations  are  very  small;  the  edges 
raised  and  callous,  with  heaped-up  white  ei)idermis;  the  pus  is  thin  and 
often  offensive.  The  kinds  of  ulcer  thus  modified  are  usually  the  syphi- 
litic, inflammatory,  and  eczematous;  but  any  kind  of  ulcer  may  become 
chronic,  and  when  a  specific  ulcer  does  so  the  specific  treatment  ceases 
to  lie  efficient. 

The  most  effective  plan  of  treatment  is  by  blistering — a  common 
blister  applied  over  the  whole  sore  and  its  edges  often  sets  up  an  inflam- 
matory action,  which  leads  to  cicatrization,  and  removes  the  heaped-up 
epidermis,  which  seems  to  interfere  with  the  healing  of  the  edges.  It  is 
not  very  jjainful,  and  the  ei)idermal  tissues,  or  their  scarlike  islands, 
which  the  blister  may  remove  from  tlie  surface  of  the  ulcer,  are  of  no 
real  value  in  closing  tlie  sore.  Slighter  cases  may  be  brought  to  heal  by 
strapping  and  bandage,  with  some  exercise  of  the  limb  ;  and  opium  in- 
ternally seems  often  of  service.  In  tlie  more  advanced  cases  incisions 
may  lie  made  through  the  ulcer  and  through  its  base  well  into  healthy 
parts  on  all  sides.  And  there  are  callous  ulcers  which  cannot  be  brought 
to  heal,  and  in  which  amputation  may  be  justifiable.  But  the  healing  of 
all  obstinate  forms  of  ulcer  has  lately  been  rendered  much  more  feasible 
by  the  introduction  of  the  method  of  skin-grafting — a  method  which  is 
often  used  to  expedite  the  process  of  iiealiiig  in  a  large  lUcer  or  to  sup- 
ply material  in  one  wliich  (like  the  surface  of  a  burn)  is  so  large  that  no 
iieallhy  scar  can  be  formed  on  it. 

20.  Phagedenic  ulcers  have  been  already  treated  of  (page  83). 


t  TUMORS    OF    SCARS.  419 

CicafTtces  and  their  Diseases. — The  healing  of  an  ulcer  produces  a  scar 
or  cicatrix.  The  process  has  been  described  above  (page  44) ;  and  when 
the  scar  tissue  remains  permanent,  altliough  the  scar  is  ugly  and  of  a 
lower  organization  than  the  natural  parts,  yet  it  causes  no  important 
inconvenience.  But  the  imperfect  vascularity  of  scars,  their  low  and 
abnormal  growth,  and  tlie  absence  from  tliem  of  the  sebaceous  and 
sweat-glands  which  lubricate  the  natural  skin,  render  them  peculiarly 
liable  to  yarious  disease  and  degenerations,  which  it  will  be  convenient 
to  describe  briefly  in  this  place. 

Ulceration  of  Scars. — The  most  common  surgical  complication  of  a 
large  scar  is  its  breaking  down  and  ulcerating,  a  very  common  event  in 
deep  and  extensive  scars. ^  Such  ulcers  are  slow  to  h^eal,  and  are  very 
prone  to  recur,  so  that  often  when  the  scar  is  seated  on  a  limb  amputa- 
tion becomes  necessary. 

The  scars  of  large  burns  are  peculiarly  liable  to  this  degeneration, 
which  is  best  combated  by  attempting  to  implant  fresh  tissue  in  the  sore 
by  means  of  skin-grafting.  Grafting,  however,  will  not,  in  all  probabilit}^, 
prove  successful  until  some  healthy  action  has  been  set  up  in  the  part, 
which  may  be  effected  by  some  active  stimulant,  as  iodine,  in  increasingly 
strong  solution,  or  perhaps  brushed  over  the  part  pure,  or  blistering 
fluid  ;  though  before  making  trial  of  such  powerful  irritants,  it  is  well  to 
try  the  gentler  stimulus  of  mercurial  lotions  or  some  of  the  balsams.  As 
proph^dactic  measures  against  this  tendency  to  ulceration  everything 
which  tends  to  promote  ra|)id  union  of  the  wound  may  be  reckoned,  and 
all  possible  means  should  be  used  to  protect  large  scars  from  cold  and 
from  any  accidental  friction  or  violence. 

Neuralgia  of  Scars. — Another  common  and  very  distressing  aflTection 
of  scars  is  neuralgia,  or  constantly  recurring  pain.  This  proceeds  some- 
times from  unknown  or  constitutional  causes,  in  which  case  it  must  be 
treated  like  any  other  neuralgia,  in  others  from  local  peculiarity,  as  from 
adhesion  of  the  scar  to  a  subjacent  bone,  or  from  implication  of  the 
enlarged  ends  of  nerves  in  the  cicatrix,  and  such  conditions  ma^^  in 
some  cases  be  relieved  bj'  subcutaneous  separation  of  the  scar  from  the 
underl3'ing  tissues,  or  by  removal  of  the  affected  nerve  or  nerves. 

Excessive  Formation  of  Scar. — A  defect  which  is  very  frequent  in 
slowly  forming  scars  (and  especially  those  that  follow  strumous  ulcers) 
is  their  excessive  formation.  Their  superficial  part  is  heaped  up,  cord- 
like, and  ver}^  hard,  and  they  adhere  in  an  unnatural  manner  to  the 
deeper  tissues.'*  This,  like  every  other  defect  of  scars,  is  best  obviated 
by  getting  the  wound  to  heal  rapidly  if  that  be  possible.  Otherwise  it 
becomes  very  difficult  to  correct  it,  the  only  available  means  being  to 
reduce  it  by  constant  blistering  or  painting  with  iodine. 

Keloid  of  Scars. — Closely  allied  to  this  is  the  limited  excess  by  which 
one  or  more  and  often  very  numerous  flat,  rounded  tumors  are  formed  on 
the  cicatrix.  When  such  keloid  growth  is  solitary  it  is  difficult  to  see 
any  diflerence  between  it  and  an  excess  of  scar  formation.  But  when  a 
number  of  small  scattered  tumors  occur  upon  a  large  scar  the  distinction 

1  "  Of  all  ?cars,"  shjs  Sir  J.  Pa^et,  "  none  are  so  ready  to  ulcerate  as  those  that 
adhere  to  bones ;  and  the  ulceration  may  happen  twenty  or  more  years  after  their 
formation." 

^  Sir  J.  Paget  points  out  that  even  after  the  deepest  wounds  which  can  never  heal 
by  first  intention — sucli  as  that  of  lithotnmy — though  the  scar  at  first  implicates  all 
the  tissues  for  a  great  depth,  yet  that  ultimately  only  a  ihin  cicatrix  should  be  left, 
wiiich,  when  examined,  will  be  found  to  be  perfectly  sujierlicial,  and  to  move  as  the 
skin  moves  over  the  deep  fascia. 


420  ULCEES. 

becomes  apparent.  The  structure  of  these  tumors  is  identical  with  that 
of  the  scar,  viz.,  a  lowly  organizecl  fibrous  tissue,  only  mingled  in  keloid 
with  ''cell  structures  in  progress  of  development,  or  arrested  and  de- 
generate in  their  incomplete  forms,"  to  an  extent  which  is  not  seen  in 
merely  thick  scars.  The  admixture  in  these  keloid  growths  of  cells  in 
process  of  development  corresponds  to  the  tendency  of  such  growths  to 
increase,  and  to  the  irritation  which  they  sometimes  cause,  and  their 
property  of  returning  after  removal,  which  is  sometimes  very  trouble- 
some. The  same  remedies  as  for  excessive  growth  may  be  tried,  but  are 
usually  of  little  avail;  and  the  excision  of  the  growth  is  often  followed 
b^'  its  return  of  a  larger  size,  so  that  it  is  very  doubtful  policy  to  operate, 
except  in  cases  wliere  the  whole  part  can  be  removed,  and  healthy  sur- 
faces brought  together  for  immediate  union.  This  can  usually  be  done 
in  the  growth  which  follows  occasionally  in  the  lobule  of  the  ear  after 
piercing  for  earrings,  though  no  such  operation  should  be  recommended 
unless  the  growth  is  really  of  a  size  to  cause  considerable  deformity,  and 
is  on  the  increase.  Tlie  keloid  of  scars  difters  from  the  "true  keloid  "  of 
Addison  in  certain  particulars,  which  will  be  pointed  out  in  the  chapter 
on  diseases  of  the  Skin. 

Other  forms  of  tumor  are'  occasionally  met  with  in  scars,  but  the  epi- 
thelial cancers  are  the  onl}^  tumors  of  much  practical  importance.  They 
were  first  minutely  and  accurately  described  by  Mr.  Csesar  Hawkins  as 
"wart}^  tumors  of  cicatrices."'  The  great  majority  of  such  tumors  are 
epithelial  cancers,  and  all  ought  to  be  regarded  and  treated  as  being  of 
this  nature,  though  in  some  rarer  cases  it  seems  that  their  course  is  that 
of  an  innocent  tumor;  in  fact,  a  mere  collection  of  large  warts  growing 
on  tlie  surface  of  the  scar.  Such  tumors  form  most  commonly  on  scars 
of  slow  formation,  as  those  of  burns,  and  especiall}^  oir  those  which  used 
to  follow  the  comi)licated  superficial  injuries  inflicted  in  a  military  flog- 
ging. As  in  other  cases  of  epithelioma,  the  complete  removal  of  the  part 
affected  holds  out  a  tolerably  good  prospect  of  complete  recover})-,  or  at 
least  of  a  considerable  period  of  immunity  from  return.  The  glands,  as 
Mr.  Hawkins  points  out,  are  rarely  affected  in  this  form  of  tumor. 

Contracted  Cicatrix. — The  most  troublesome  of  all  the  consequences 
of  scarring  is  the  contraction  which  slowly  forming  deep  cicatrices  are 
so  liable  to  undergo — a  contraction  so  powerful  that  it  will  bind  the  arms 
to  the  trunk,  distort  the  most  powerful  joints,  and  even  alter  the  shape 
of  tlie  bones.  The  worst  cases  of  this  deformity  occur  in  the  neck,  by 
which  the  chin  is  drawn  down  and  fixed  upon  the  chest,  all  the  features 
of  the  face  are  distorted,  the  shape  of  the  jaw  so  changed  that  its  body 
is  more  horizontal  than  vertical,  and  the  patient's  appearance  rendered 
in  tlie  iiighest  degree  repulsive. 

The  best  jjlan  in  these  as  in  all  other  progressive  disorders  is  to  en- 
deavor to  hinder  their  commencement,  or,  when  thTs  is  impossible,  to 
treat  them  before  they  l)ecome  inveterate.  In  all  deep  burns,  and  in  all 
other  injuries  which  destroy  the  whole  skin  to  any  great  extent,  the 
greatest  care  ought  to  be  taken  to  keep  the  parts  on  the  stretch  during 
the  whole  period  of  union  whenever  that  is  possible.  If  a  scar  which  has 
fully  formed  shows  a  tendency  to  contract,  that  tendency  is  to  be  coun- 
teracted either  b}'  gentle  and  constant  manual  extension,  the  scar  being 
well  oiled,  and  gently  but  very  frequently  stretched  (which  seems  to  me 
the  best  plan  when  the  services  of  an  intelligent  nurse  or  mother  can  be 

1  Mcd.-Chir.  Tran.s.,  vol.  xix.  Conlribution?  to  I'allioloicy  and  Surgery,  vol.  i,  ])p. 
14y-lG9. 


SKIN-GRAFTING.  421 

secured),  or  by  the  action  of  a  constant  extending  force,  as  a  rack  and 
pinion  apparatus,  or  a  weiglit.  But  when  contraction  is  inveterate  and 
very  tirm,  or  when  mechanical  extension  is  impi-acticable,  some  of  the 
autoplastic  operations  described  in  the  section  on  Plastic  Surgery  may 
become  necessary,  for  which  I  must  refer  the  reader  to  that  place. 

Skin-grafting. — What  has  been  said  about  scars  and  their  diseases  illus- 
trates in  every  topic  of  which  I  have  treated  the  absolute  necessity  of 
rapid  union.  This  is  one  of  the  many  reasons  which  induce  English  sur- 
geons utterly  to  repudiate  the  foreign  practice  of  stuffing  wounds  with 
charpie,  and,  on  the  contrary,  to  seek  to  remove  every  obstacle  to  their 
immediate  union.  But  in  cases  where  large  granulating  surfaces  must 
be  left  exposed  for  an  indefinite  period  (as  after  a  large  burn)  we  have 
only  recently  obtained  any  means  of  artificially  hastening  their  cicatri- 
zation. This  is  now  most  happily  effected,  at  least  in  many  cases,  by  the 
method  of  skin-grafting,  invented  by  M.  Reverdin,  of  Geneva,  and  intro- 
duced into  this  country  by  Mr.  Pollock.^  For  the  success  of  this  process 
it  is  essential  that  the  granulations  should  be  perfectly  healthy,  and  that 
all  irritation  in  the  sore  should  have  ceased — ^.e.,  that  the  ulcer  should 
be  prepared  to  cicatrize — and  it  is  at  any  rate  desirable  that  the  patient's 
general  health  should  be  good.  Then,  if  a  small  piece  of  the  surface  of 
the  skin,  consisting  of  little  more  than  its  epithelial  layer,  be  laid  on  the 
granulations  and  left  undisturbed  for  a  few  days,  it  will  often  form  a 
nucleus,  from  which  cicatrization  will  extend  rapidly  in  all  directions,  as 
it  sometimes  does  from  the  islands  of  skin  which  maybe  left  undestroyed 
in  the  centre  of  an  ulcer.  The  pieces  grow  best  when  planted  not  far 
from  the  edge  of  the  sore  (say  about  half  an  inch),  so  that  the  sore  can  first 
be  diminished  by  a  zone  of  skin-grafts  planted  all  round  its  margin,  and 
then  the  operation  be  repeated,  and  so  on,  until  it  is  all  covered.  The 
growth  of  the  graft  seems  to  depend  on  the  cells  of  the  rete  Malpigliii. 
These  are  newly  formed  and  growing,  and  possess  the  power  of  prolifera- 
tion. Attempts  have  been  made  to  produce  the  same  effect  by  grafting 
merely  the  cells  scraped  from  the  surface  or  loosened  by  a  blister,  but 
such  cells  are  as  a  rule  effete  and  will  not  grow.'*  Nor  is  there  any  proof 
that  the  tissues  of  the  cutis  itself,  and  still  less  the  subcutaneous  cellular 
tissue,  take  any  part  in  the  new  formation.  The  red  budlike  appearance 
which  the  graft  presents  for  the  first  few  days  after  its  insertion  is  doubt- 
less due,  as  Dr.  Page  points  out,  to  the  desquamation  of  the  effete  super- 
ficial layers  of  the  transplanted  epidermis,  and  to  the  transparency  of  the 
cells  of  the  rete  mucosum,  allowing  the  color  of  the  subjacent  parts  to 
show  through  them. 

It  is  best,  I  think,  to  take  up  a  small  portion  of  the  true  skin  as  well  as 
the  epidermis,  in  order  to  make  sure  of  removing  tlie  rete  mucosum,  but 
on  no  account  should  the  whole  thickness  of  the  skin  be  cut  through.  An 
ingenious  combination  of  fine  forceps  with  scissors  enables  the  surgeon 
to  remove  a  small  piece  with  hardly  any  pain  at  all :  but  when  this  is  not 
at  hand  a  pair  of  fine  forceps  and  sharp  curved  scissors  answer  the  pur- 
pose.^    The  grafts  should  be  very  small,  hardly  larger  than  a  pin's  head. 


^  M.  Reverdin's  original  psitient  was  presented  to  the  Soc.  de  Chirurgie  de  Paris 
on  Dec.  8,  1869  (Ball,  de  la  Soc.  de  Chir.,  Nov.  27,  1871).  Mr.  Pollock's  first  case 
was  published  in  the  year  1870. 

'■^  See  an  interesting  paper  on  this  subject  by  Dr.  Page,  of  Edinburgh,  Brit.  Med. 
Jour.,  March  27,1871. 

3  The  pieces  are  generally  taken  from  some  other  part  of  the  patient's  own  body  ; 
but  the  process  of  cutting  them  is  so  little  painful,  that  often  a  bystander  oflers  his 


422 


DISEASES    OF    THE    BONES. 


They  should  be  laid  firml}'  on  the  granulations,  about  an  inch  apart;  and 
if  the  patient  can  be  trusted  not  to  disturb  them  in  any  vvay,  I  think  they 

are  be.-t  left  exposed  for  a 
Fig-  i'^^-  few  hours.     After  this,  or 

at  once,  if  there  is  any 
danger  of  their  being  dis- 
turbed, they  should  be  cov- 
ered with  oiled  silk,  mois- 
tened with  oil,  to  prevent 
its  sticking  when  removed, 
and  the  whole  fixed  with 
strapping  and  covered  with 
cotton-wool.  The,y  siiould 
then  be  left  undisturbed 
for  three  or  four  days  and 
redressed  as  before.  At 
first  they  change  into  little  round  vascular-looking  buds,  which  some- 
times become  almost  imperceptible  at  first  in  the  neighboring  granula- 
tions, but  afterwards  the  new  cuticle  is  seen  extending  in  all  directions 
from  the  bud.  That  this  new  cuticle  is  formed  by  growth  from  the  old 
is  proved  b}^  the  fact  that  when  black  skin  is  engrafted  on  an  ulcer  in  a 
white  man,  as  recorded  by  Mr.  Bryant,  or  when  the  reverse  experiment 
is  made,  as  in  a  case  in  my  own  practice,  the  newly  formed  skin  is  of  the 
color  of  the  graft  to  the  extent  due  to  the  action  of  the  latter.  M}'  own 
experience  as  far  as  it  has  gone  leads  me  to  believe  that  the  cicatrix 
formed  by  skin-grafting  is  more  highly  organized  and  less  liable  to  all 
forms  of  degeneration  than  that  which  is  produced  by  the  slower  natural 
processes. 


Skin-grafting  scissors.  Tlie  piece  of  skin  which  is  shown  in 
the  grasp  of  tlie  forceps  is  larger  than  -would  be  taken  in  prac- 
tice. 


CHAPTEK  XXII. 


DISEASES    OF    THE    BONES. 


Inflammation  in  bone  is  strictly  analogous  to  the  same  process  in  soft 
parts  ;  in  fact  it  occurs  in  the  soft  parts  of  the  bone.  Its  first  effect  is  to 
increase  the  size  of  the  vascular  channels  of  the  bone,  which  also  become 
more  irregular  in  shape  and  outline  ;  the  union  which  previousl}'  existed 
between  the  earthy  salts  and  the  vascular  network  in  which  they  are  con- 
tained is  loosened  and  the  salts  partially  removed,  while  their  place  is 
occupied  by  inflammatory  products  (leucocytes,  serous  effusion,  pus- 
globules,  newly  formed  fibrous  tissue),  and  thus  the  compact  is  converted 
into  a  kind  of  cancellous  tissue,  while  the  cells  of  the  cancellous  tissue  are 
much  enlarged  and  the  bone  becomes  soft,  light,  fragile,  and  much  moister 
than  in  its  Jiatural  state.' 

arm  for  the  purpose.     They  should  be  taken  from  a  part  where  the  skin  is  quite 
healthy,  thin,  and  .supple. 

•  For  more  detailed  accounts  of  the  early  phenomena  of  inflammation  in   bone  I 


PERIOSTITIS.  423 

To  this  early  softenins;  stage  of  ostitis  succeed  other  stages  equally 
analogous  witli  the  results  of  the  inflammation  in  soft  parts,  but  modi- 
fied by  the  peculiar  condition  of  the  parts.  Thus  the  inflammatory  prod- 
ucts ma}'  pass  through  the  stage  of  fibrous  organizatiou  into  that  of  ossi- 
fication, and  so  new  bone  l)e  produced,  just  as  it  is  in  the  union  of  frac- 
tures. In  fact,  the  ordinary  process  of  repair  of  fractures  is  that  of  "  first 
intention"  in  union  of  wounds  of  bone,  while  the  repair  of  compound 
fractures  exhibits  the  process  of  union  by  granulation.  Just  so  after 
common  inflammation.  The  leucocytes  which  have  been  effused  into  the 
intervascular  spaces  of  the  bone  itself,  into  the  cells  of  the  cancellous 
tissue,  medullary  canal,  or  still  more  frequently  the  interval  between  the 
periosteum  and  the  surface  of  the  bone,  become  developed  first  into 
fibrous  tissue,  and  next  (in  some  cases,  as  it  seems  almost  simultane- 
ously) the  earthy  constituents  of  the  bone  are  deposited  in  this  tissue,  in 
a  manner  similar  to  that  of  the  iutra-membranous  ossification. 

Pe7-iosfitis. — We  know  how  slight  a  stimulus  will  produce  ossification 
on  the  deep  surface  of  the  periosteum,  which,  in  fact,  is  the  source  of  the 
greater  part  of  the  growth  of  the  bone  ;  so  that,  as  M.  Oilier  has  shown, 
the  periosteum  in  animals,  even  when  transplanted  into  other  parts  of  the 
body  or  into  the  bodies  of  other  animals,  will  produce  bone  from  its 
deeper  surface.  This  form  of  inflammation  is  called  Periostitis.  It  is 
almost  alvvays  associated  with  more  or  less  inflammation  of  the  substance 
of  the  bone  itself,  and  ought  perhaps  only  to  be  regarded  as  one  of  the 
forms  of  ostitis  ;  yet,  as  it  is  always  spoken  of  as  a  sei>arate  disease,  it 
may  be  better  for  practical  purposes  so  to  regard  it.  Periostitis  occurs 
in  two  very  distinct  manners,  viz.,  the  common  or  chronic,  and  the  acute 
or  diffuse  periostitis. 

Nodes. — The  former  is  a  very  common  affection  ;  it  occurs  very  often 
as  a  consequence  of  syphilis,  and  when  limited  to  a  small  extent  of  sur- 
face constitutes  the  affection  called  Node,  from  the  lump  or  "  knot  " 
(nodus)  which  it  produces  on  the  surface  of  the  bone.  Nodes  are  most 
common  on  the  most  superficial  bones,  as  the  cranium,  tibia,  clavicle,  etc. 
They  are  formed  of  thickened  and  inflamed  periosteum,  raised  up  and 
separated  from  the  surface  of  the  bone  by  more  or  less  fibrinous  eff'usiou. 
The  surface  of  the  bono  is  also  probabl}^  inflamed.  Their  usual  causes 
are  syphilis,  rheumatism,  and  struma. 

The  symptoms  are  pain  in  the  part,  increasing — as  all  other  "  rheu- 
matic "  pains  are  apt  to  do — when  the  patient  begins  to  get  warm  in  bed, 
swelling  and  apparent  softening  of  the  affected  bone,  which  is  really  due 
to  fluid  effused  over  it.  The  swelling  is  usually  round  and  small,  like  a 
half-marble. 

If  left  alone  such  nodes  pursue  one  of  three  courses, — many  are  absorbed, 
i.  e.,  the  fluid  is  absorbed  as  the  inflammation  sulisides  and  the  swelling 
disappears;  or  the  inflamniatoiy  effusion  ossifies,  and  a  periosteal  thick- 
ening of  the  bone  remains  permanently  ;  or  finally  suppuration  follows, 
and  an  ulcerating  carious  surface  is  exposed.  Syphilitic  nodes  occur 
either  in  the  secondary  or  tertiary  stage,  and,  as  may  be  inferred  from 
what  has  been  said  on  p.  405,  those  which  are  secondary  are  more  prone 
to  resolution  or  ossification,  while  the  tertiary  nodes,  like  other  gummata, 
are  more  prone  to  suppuration  and  caries. 

must  refer  the  reader  to  Von  Bihra,  On  the  Decomposition  of  the  Bone  by  Caries,  in 
Lieliig  Q  Wohler'a  Annalcn,  vol.  Ivii ;  Barvveli,  in  Brit,  and  For.  Med.-Chir.  Rev., 
April,  1860;  Black,  On  the  Pathology  of  Tuberculous  Bone,  Edin.,  1859;  and  my 
own  essay,  in  vol.  iii  of  the  Syst.  of  8urg. 


424 


DISEASES    OF    THE    BONES. 


The  treatment  consists  in  the  proper  remedies  for  the  general  constitu- 
tional state,  combined  with  connter-irritation.  Iodide  of  potassium  in 
moderately  large  doses,  combined  with  opium,  certainly  seems  to  relieve 
the  pain  both  of  syphilitic  and  rheumatic  nodes.  Five  grains  of  the 
iodide  three  times  a  day  may  be  combined  with  10  or  20  drops  of  lauda- 


FlG.  178. 


A  internal  and  b  external  view  of  a  preparation  illustrating  the  ordinary  anatomy  of  periostitis, 
from  a  well-marked  example  of  that  disease,  in  the  Museum  of  St.  George's  Hospital. — System  of 
Surgery,  2d  edition,  vol.  iii,  p.  739. 


num,  according  to  the  severity  of  the  pain,  and  the  dose  may  be  raised 
to  10  or  15  grains  of  the  salt  if  it  is  judged  necessary.  There  are  cases 
where  the  formation  of  a  node,  especially  if  the  inflammation  is  severe 
and  suppuration  is  threatening,  is  accompanied  with  so  great  pain  that 
the  division  of  the  periosteum  by  an  incision  reaching  fcom  one  side  of 
the  tumor  to  the  other  is  called  for,  and  this  measure  often  gives  instant 
and  permanent  relief.  The  ordinary  cases  of  "chronic  periostitis,"  so 
called,  are  really  cases  of  inflammation  of  the  whole  bone,  in  wliich  there 
is  more  or  less  deposit  on  its  surface,  which  may  be  perceptible  to  the 
hand  during  life,  but  in  wliich  there  is  also  induration  and  thickening 
('•  .s-c/ero«i.s ")  of  the  whole  bone.  The  s^'inptoms  are  wearing  ])ain, 
heaviness  of  the  limb,  prol)ably  some  increase  of  the  temperature,  little 
if  anj'  redness,  and  irregular  deposit  on  the  surface  of  the  bone. 

The  only  treatment  which  is  available  is  the  same  as  was  recommended 
for  nodes,  but  it  seems  uncertain  whether  such  treatment  has  really  much 


PERIOSTITIS. 


425 


specific  effect  on  the  disease,  though  rest  and 
shelter  and  good  medical  supervision  no  doubt 
do  much  for  its  cure. 

Difl^'um  or  suppurative  periostitis,  leading  to 
the  condition  known  as  acute  periosteal  abscess, 
is  one  of  the  gravest  affections  of  bone,  fre- 
quently producing  a  general  pyjeraic  condition, 
and,  indeed,  sometimes  itself  only  a  manifesta- 
tion of  general  pyremia.  Very  often,  however, 
it  occurs  simply  as  a  result  of  local  injury,  and 
is  perfectly  curable. 

It  is  an  affection  of  early  life,  much  more  com- 
mon about  puberty  than  at  any  other, age;  not 
very  rare  at  earlier  periods  of  life,  l)ut  hardly 
seen  after  middle  age.  It  affects  more  often  the 
long  bones,  and  especially  the  tibia  and  femur, 
but  any  bone  may  be  the  subject  of  the  disease. 
It  follows  usually  on  slight  injuries,  sometimes 
from  no  known  cause,  and  in  these  latter  cases 
the  constitutional  affection  is  often  severe,  and 
general  pypemia  may  he  suspected.  The  disease 
commences  by  the  effusion  of  lymph  between 
the  periosteum  and  the  bone,  which  is  not  at 
first  purulent,  but  in  the  actiter  cases  soon  be- 
comes so.^  This  is  accompanied  by  a  good  deal 
of  pain,  heat,  and  swelling,  often  mistaken  for 
acute  rheumatism.  If  the  disease  is  acute  the 
inflammatory  effusion  soon  softens  and  forms  a 
large  abscess  surrounding  the  bone,  sometimes 
over  its  whole  surface,  necessarily  depriving  it 
of  its  nutrition,  so  that  it  dies,  and  often  tiie 
whole  shaft  thus  perishes  in  a  very  short  time. 
The  articular  ends  are  usually  unaffected.^ 

The  treatment  of  this  formidable  affection  in 
its  acutest  forms  must  be  very  energetic  and 
decided.  A  free  incision  should  be  made  down 
to  the  bone  as  soon  as  suppuration  is  detected  ; 
and  if  the  pain  and  tension  are  severe,  it  is  well 
to  do  this  even  though  the  presence  of  fluid  is 
not  established.  The  patient  must  be  supported 
through  the  ensuing  fever  and  exhaustion,  a 
sharj)  watch  must  be  kept  for  any  secondary 
abscesses,  and  they  must  also  be  opened  as  soon 
as  they  occur.     If  the  bone  become  dead  it  is 


K  ''>^ 


Fig.  179. — The  entire  diaphysis  of  the  tibia,  necrosed,  in  a  case 
of  acute  periostitis.  The  wliole  bone  was  removed  by  subperiosteal 
resection  a  month  after  the  commencement  of  tlie  disease.  (See 
Lancet,  1866,  vol.  i,  p.  340.)  The  line  (a)  indicates  where  the  bone 
was  sawn  across  in  order  to  remove  it.  The  patient,  a  hoy  aged  10, 
recovered,  with  perfect  use  of  the  limb,  which,  however,  was  some- 
what shortened,  and  the  knee  anchylosed. — From  Holmes's  Surg. 
Dis.  of  Childhood,  2d  edition,  p.  392. 


^  See  a  case  in  my  essay,  op.  cit.,  p.  741,  footnote. 

2  The  joint,  however,  does  not  always  e.^^cape.  A  girl  aged  fifteen  was  admitted 
into  hospital  four  days  after  an  injury  with  groat  swelling  of  the  forearm,  evidently 
depending  on  the  formation  of  matter.     A  grating  sensation,  perceived  on  rotating 


426  DISEASES    OF    THE    BONES. 

desirable  to  remove  it  as  soon  as  practicable.  It  is  neither  necessary  nor 
advisable  to  wrJt  in  such  cases  for  the  formation  of  the  periosteal  sheath. 
I  have  removed  the  whole  diaphysis  of  the  tibia,  and  in  anotlier  case 
several  inches  of  the  shaft  of  the  femur,  in  this  condition,  and  satisfactory 
reo-eneration  has  taken  place.  It  is  to  be  recollected  that  young  persons 
will  recover  in  conditions  which  in  after-life  would  be  hopeless.  I  have 
even  known  recover}-  take  place  after  the  occurrence  of  pya^mic  pericar- 
ditis ;  so  that  any  measure  which  can  give  an  additional  chance  should  be 
adopted  even  in  very  desperate  cases.  At  the  same  time  no  such  active 
treatment  is  required  in  the  snliacute  cases  where  there  is  no  great  pain 
or  tension  and  no  constitutional  sympathy.  Here  local  depletion  and 
iodide  of  potassium  will  usually  lead  to  a  cure  without  suppuration. 
Before  quitting  the  subject  I  would  notice  that  I  have  seen  tolerably 
often  the  diffused  swelling  of  subacute  periostitis,  particularly'  of  the 
femur,  mistaken  for  a  malignant  tumor.^ 

Oateo-myelitis. — When  the  inflammation  affects  chiefly  or  entirely  the 
medullary  cavitj'  and  the  lining  membrane  of  the  cancelli  the  disease  is 
called  osteo-myelitis.  It  is  an  affection  well  known  by  its  post-mortem 
appearances,  which  show  in  the  first  stage  of  the  disease  the  whole 
medullary  membrane,  including  in  some  cases  that  lining  the  cancelli, 
injected,  thickened,  sprinkled  here  and  there  with  ecchyraoses,  and  very 
soon  permeated  with  purulent  extravasa'tion.  In  acute  osteo-myelitis 
the  disease  generally  proves  fatal  at  this  point.  But  if  it  does  not  do  so, 
or  if  the  action  is  more  chronic,  the  matter  must  make  its  way  to  the  ex- 
terior through  some  sinus,  the  interior  of  the  bone  will  die  and  form  a 
slough  or  sequestrum,  the  com[)act  tissue  being  thickened  and  pei'iosteal 
de|)Osit  formed  on  the  surface,  or  the  whole  thickness  of  the  bone  may 
die  (Figs.  182,  183).^  All  this  forcibly  reminds  the  surgeon  of  diffuse 
inflammation  in  the  soft  parts  ;  in  fact,  the  two  diseases  are  analogous 
in  all  essential  characters. 

The  symptoms  during  life  are  not  equally  familiar;  in  fact,  it  is  not 
often  distinctly  diagnosed,  except  in  the  case  of  amputations,  where  the 
cut  end  of  the  medullary  cavity  is  exposed  to  view.  In  such  cases,  if 
the  medullary  tissue  becomes  inflamed,  there  will  be  seen  sprouting  from 
the  cut  end  of  the  bone  a  large  fungous  granulation,  in  which  specks  of 
bone  can  be  recognized;  but  in  other  instances,  where  the  medullary 
cavity  cannot  be  examined,  we  must  endeavor  to  recognize  the  disease 
b}-  its  general  symptoms.  These  are  best  studied  in  such  a  case  as  an 
excision  of  the  hip-joint  or  of  the  knee,  where  the  cancellous  interior'  of 
the  bone  has  been  laid  open,  but  the  wound  is  buried  in  the  soft  i)arts. 
In  such  cases,  in  the  acute  form  of  the  disease,  the  symptoms  vvill  much 
resemble  those  of  pyaemia,  viz.,  rigors  and  acute  traumatic  fever,  but  with 
the  addition  of  more  or  less  pain  in  the  part  and  swelling  of  the  whole 
limb,  not  due  to  superficial  a-dcma.  Sometimes,  as  in  the  case  shown  in 
Figs.  180,  181,  phlel)itis  is  developed  at  the  same  time.  If  the  liml)  be 
examined  by  a  free  incision  down  to  the  bone,  under  chloroform,  which 


the  hand,  to<:ji'thor  with  the  hi.story  of  the  acoident,  led  to  the  belief  that  fracture  had 
occurred  She  died  of  pyemia;  then  it  was  discovered  that  a  periosteal  abscess,  ex- 
tending from  the  shaft  of  tlie  radius  into  th(^  wrist-joint,  had  so  (eroded  the  articular 
cartilages  as  to  occasion  the  stir.sation  of  crei>itus. 

1  Holmes's  Surt;  ,  Treatment  of  Children's  I)is.,  '2d  ed.,  p   832. 

2  Sec  my  work  On  the  Surgical  Treatment  of  Children's  Diseases,  2d  ed.,  p.  401,  for 
a  colored  illustration  of  the  I'emur  after  chronic  osteo-myelitis. 

■"*  It  is  not  absolutely  nec(!ssary  that  iIh;  medullary  canal  itself  should  have  been 
wounded.  No  doubt  wounds  of  that  onal  are  more  dans^erous  than  those  in  which 
only  the  cancelli  arc  involved,  but  the  latter  may  also  be  followed  by  osteo-myelitis. 


OSTEO-MYELITIS. 


427 


under  such  circumstances  is  usually  justifiable,  it  will  be  found  that  the 
periosteum  has  receded  or  is  receding  from  the  bone  ;  and  if  the  niedid- 
lary  tissue  can  be  exposed  it  will  be  found  to  be  suppurating.  Now,  in 
the  acuter  cases  of  this  formidable  disease  there  can  be  no  question  of 
the  advisability,  in  fact,  the  absolute  necessity,  of  instant  amputation  of 


Fig. ISO. 


'm 


Fig.  181. 


Fig.  180. — Osteo-myelitis  of  the  femur. — From  a  drawing  in  the  Museum  of  St.  George's  Hospital. 

Fig.  181. — Inflammation  of  the  femoral  vein  from  the  same  case. 

Fig.  182. — Upper  portion  of  humerus  amputated  for  necrosis  after  osteo-myelitis.  The  necrosis  does 
not  extend  into  the  tuberosities,  neck,  or  head  of  the  bone,  which,  however,  are  expanded  by  inflam- 
mation (osteo-porosis). — After  Longmore,  in  Med.-Chir.  Trans  ,  vol.  xlviii. 

the  limb  above  the  inflamed  bone,  if  the  patient  is  to  have  any  chance  of 
life,  for  tlie  disease  has  a  great  affinity  with  pyaamia,  which  rapidly  fol- 
lows in  the  great  majority  of  cases,  if  the}'  survive  long  enough  for  the 
symptoms  to  develop  themselves  complete!}'.  Unfortunately  it  is  ex- 
tremely difficult  to  distinguish  the  symptoms  at  the  outset,  and  in  many 
cases  whicli  are  taken  for  mere  osteo-myelitis  pyaemia  has  really  com- 
menced.^ 


^  The  reader  who  wislies  to  follow  up  this  question  of  reamputation  in  cases  of 
acute  osteo-myelitis  following  on  operations  on  bone  is  referred  to  Profe.'sor  Fayrer's 
Clinical  and  Pathological  Observations,  pp.  48-94;  and  to  some  ob.«ervations  of  mine 
in  Surg.  Dis.  of  Childhood,  2d  ed  ,  p.  53G,  and  !St.  George's  Hospital  Keports,  vol.  i, 
p.  152. 


428 


DISEASES    OF    THE    EONES. 


Chronic  osteo-myelitis  is  more  common  than  the  acute  form,  or,  per- 
haps, is  only  more  commonly  recognized,  the  osteo-myelitis  being  passed 
over  in  acute  cases  as  only  one  (and  that  possibly  an  unrecognized)  phe- 
nomenon of  pyaemia.  It  causes  total  disorganization  of  the  internal 
part  of  the  bone,  frequently  extending  througli  its  entire  thickness,  and 
ultimately  leading  to  death  of  the  whole  shaft  for  a  variable  length. 
Thus  are  produced  those  long  tubular  sequestra  which  separate  from  the 
femur  or  other  bones  after  amputation  (Fig.  182).  This  disease  I'equires 
no  such  active  or  immediate  treatment  as  acute  osteo-myelitis.  All  that 
is  necessary  is  to  provide  for  the  free  exit  of  discharges  and  wait  until 
the  dead  bone  is  felt  to  be  loose,  or  until  the  lapse  of  time  renders  it 
probable  that  it  will  be  found  so.     Then  the  soft  parts  are  to  be  freely 

Fig.  183.  Fig.  184 


V^ 


.9/ J 


K^-. 


Fig.  isrj. — a  !•  imn  showing  the  wliole  shaft  in  a  state  of  necrosis  after  osteo-myolitis  from  injury- 
X,  Y  sliow  the  limits  of  tlie  necrosi.s.  The  sequestra  (which  do  not  extend  into  the  epiphyses)  are  vis- 
ible through  the  cloaca;. — After  Longniore,  ibid. 

Fifi.  184. — Chronic  al).scpss  in  the  lower  end  of  the  tibia.    From  the  original  case,  in  which  Sir  B. 
Brodie  first  described  this  affection.    (.Sec  his  works,  vol.  iii,  p.  404.) — St.  George's  Hospital  Museum, ' 
Ser.  ii.  No.  'iO. 

dissected  off  the  end  of  the  bone,  and  the  sequestrum  twisted  out  with 
a  pair  of  strong  bone  forceps.' 

Chronic  Abscess. — One  of  the  most  curious  local  results  of  ostitis  is 


'  On  thn  snbjpct  of  osteo-inyolitis  a  paper  by  Mr  Longmoro,  in  tho  48th  vol.  of  the 
jNIed.-Chir.  Tran.s.,  will  wi-il  rcfiiiy  ponisal,  Ijoth  u.s  a  clear  staleiiifiit  of  tlie  .symptoms 
of  the.«o  two  forms  of  osteo-myelitis  or  diffu.sc  inflammation  of  bone  occurring  after 
gunshot  wounds,  and  us  a  pri)of  of  the  success  of  the  expectant  treatment  in  tho 
milder  form. 


CHRONIC    ABSCESS    OF    BONE. 


429 


the  formation  of  a  chronic  abscess  in  the  cancellous  tissue.  Tliis  occurs 
most  often  in  the  head  of  the  tibia — not  unfrequently  in  its  lower  end, 
the  part  in  which  it  was  first  discovered  by  Sir  B.  IJrodie — or  in  the 
lower  end  of  the  femur.  It  has,  however,  also  been  noticed  in  many 
other  parts  of  the  skeleton,  and  occasionally  occupies  a  circumscribed 
part  of  the  medullary  cavity. 

The  symptoms  are  obscure,  and  the  diagnosis  is  formed  more  by  their 
persistence  and  by  their  resisting  the  treatment  which  usually  relieves 
rheumatic  pain  in  the  bone  than  by  an}'  striking  pathognomonic  sign. 
There  is  constant  wearing  pain  referred  to  the  part,  with  little  or  no  ex- 
ternal inflammation,  perhaps  a  little  enlargement,  and  usually  some  local 
tenderness.  When  the  abscess  lies  very  near  the  cavity  of  a  joint  the 
inflammation  may  be  propagated  to  the  joint,  giving  rise  to  occasional 
attacks  of  synovitis,  and  in  such  cases  there  is  considerable  risk  that  the 
abscess  may  burst  into  the  joint,  and  so  lead,  in  all  probability,  to  the 
loss  of  the  limb  or  joint  (Fig.  185). 

The  abscess  is  almost  always  seated  superficiall}',  covered  by  little 
more  than  the  cortical  part  of  the  bone  (which  perhaps  may  be  somewhat 
thickened  by  inflammation,  as  in  Fig.  186),  and  it  seems  to  be  due  in 


Fig.  185. 


Fig.  185. — Drawing  of  the  lower  end  of  the  femur  from  a  case  of  excision  of  the  knee.  An  abscess 
which  lias  formed  above  the  position  of  the  epiphysial  line  has  made  its  way  into  the  joint.  The  car- 
tilages are  seen  ulcerated.  A  probe  passed  through  the  track  of  the  abscess  shows  its  opening  into  the 
articular  cavity. — From  a  drawing  in  the  Museum  of  St.  George's  Hospital,  Ser.  xxi,  No.  55  b. 

Fig.  186. — Unsuccessful  trephining  in  abscess  of  bone.  a.  The  point  where  the  trephine  was  applied, 
about  half  an  inch  from  the  abscess.  6.  The  wall  of  the  bone,  thickened  by  inflammation,  c.  The 
cavity  of  the  abscess,  d.  The  pyogenic  membrane. — St.  George's  Hospital  Museum,  Ser.  ii.  No.  31. 
From  Syst.  of  Surg.,  2d  ed.,  vol.  iii,  p.  751. 


most  cases  at  any  rate  to  contusion  of  the  surftice.  In  a  striking  case 
which  occurred  to  me  some  years  ago  the  disease  dated  from  a  contusion 
by  spent  shot  received  at  the  battle  of  the  Alma,  more  than  fifteen  years 
previously.  In  some  of  these  cases  the  abscess  contains  a  nodule  of 
dead  bone,  and  it  seems  very  probable  that  in  such  cases  a  portion  of 
the  interior  of  the  bone  has  been  so  far  detached  from  the  neighboring 
parts  as  to  have  perished.  There  are,  however,  many  cases  in  which 
there  has  been  no  injury  whatever,  and  where  the  affection  niust  be  at- 


430  DISEASES    OF    THE    BONES. 

tributed  to  iiiflanimation  of  a  rheumatic  nature,  the  result  of  cold.^  The 
pus  ma}'  remain  encysted  in  the  cavity  for  a  very  long  period,  possibly 
for  the  whole  of  life,  since  one  of  the  earliest  effects  of  the  inflammation 
is  to  produce  hardening  ("  sclerosis  ")  of  the  bony  walls  of  the  cavity. 
But  in  other  cases  it  does  slowly  make  its  way  either  to  the  cutaneous  or 
the  articular  surface  (Fig.  185),  and  I  have  known  a  case  in  which,  on 
turning  down  the  periosteum,  a  small  opening  was  perceived  leading  into 
the  abscess. 

It  is  of  great  importance  to  diagnose  this  affection  with  at  any  rate 
such  an  api)roach  towards  certaint}'  as  will  justify  the  surgeon  in  apply- 
ing the  trephine.  When  once  the  abscess  has  been  opened  the  pain  will 
cease,  the  cavit}'  slowly  fill  up,  and  the  patient  be  restored  to  perfect 
health.  Mr.  Carr  Jackson  (op.  cit.)  justly  relies  principally  on  the  se- 
verity, the  continuance,  and  the  paroxysmal  character  of  the  pain,  and 
on  the  localized  tenderness,  sometimes  referred  to  a  single  definite  spot, 
pressure  on  which  gives  rise  to  the  most  agonizing  sensation.  It  must 
be  admitted,  however,  that  the  diagnosis  is  not  easy.  Sir  B.  Brodie  re- 
lates a  case  in  which  he  applied  the  trephine  and  found  no  pus ;  and  Mr. 
C.  Jackson  has  recorded  a  similar  instance.  In  both  these  cases  it  is 
true  that  the  operation  did  good,  and  it  may  be  conjectured  either,  as 
Mr.  Jackson  seems  to  think,  that  there  was  a  minute  quantity  of  pus, 
which  was  not  seen  at  the  operation,,but  the  evacuation  of  which  re- 
lieved the  pain,  or  that  the  relief  was  due  to  the  incision  of  the  tense 
and  indurated  periosteum  and  shell  of  the  bone.  In  such  cases,  however, 
there  has  been,  at  any  rate,  ostitis,  and  the  treatment  by  incision  is  a 
rational  one,  whether  necessary  or  not.  But  there  can  be  no  doubt  that 
in  many  instances  the  mistake  has  been  made  of  taking  what  is  merely 
a  neuralgic  or  hysterical  affection  for  abscess  of  bone.  Therefore  the 
greatest  care  should  be  taken  by  the  surgeon  to  assure  himself  of  the 
reality  of  organic  lesion,  or  at  least  to  have  the  strongest  evidence  of  it 
before  undertaking  an  operation  which  is  certainly  serious,  though  not 
often  fatal.  The  operation  is  a  simple  one.  The  surgeon,  as  Mr.  Jack- 
son recommends,  would  do  well  to  mark  out  on  the  skin  previously  the 
precise  spot  to  which  the  pain  or  tenderness  is  referred.  The  patient 
being  fully  narcotized,  a  crucial  incision  should  be  made  down  to  the 
bone,  the  periosteum  turned  down  by  a  similar  crucial  incision,  and  the 
trephine  applied  at  the  spot  marked.  If  no  pus  be  found  it  is  well  to 
perforate  the  walls  of  the  trephine-hole  in  various  directions  with  a  brad- 
awl or  small  chisel,  in  order  to  see  whether  the  matter  ma}'^  be  situated 
in  the  immediate  neigl)l)orii()od.  This  was  the  case  in  the  patient  from 
whom  the  above  drawing  (Fig.  180)  was  taken.  The  trephine  has  been 
ap[)li('d  close  to  tlie  collection  of  matter,  but  the  latter  was  not  opened, 
and  the  i)atient  remained  unrelieved  till  his  death.^ 

The  figure  illustrates  almost  every  point  in  the  sui'gery  of  the  disease — 


^  Sep  the  tliii'd  ca.«e  in  Jlr.  (Jarr  Jackson's  pamphlet,  On  Circumscribed  Abscess  of 
Bono,   L-indon,  1807. 

2  Or  pMS-ihly  till  the  limb  wiis  amputated.  In  the  hospital  catalogue  it  is  said  that 
"  the  p!iti''iU  died  .';omo  short  time  afterwards,  and  the  ab.'^cess  was  then  discovered." 
Yet  Sir  J3  Brodie  alludes  as  follows  to  an  exactly  similar  case,  and  Mr.  Carr  -Jackson 
says  that  tlii.s  jireparation  is  taken  from  that  case:  "  A  very  experienced  hospital 
suryeon  ajiplied  the  trephine  for  a  sufjposed  abscess  in  the  head  of  tlie  tibia.  No 
ab.sces.s,  however,  was  di>covered,  and  in  consequence  the  limb  was  amputated.  On 
the  parts  bi-inij  examined  afterwards  the  abscess  was  discovered  at  a  small  distance 
from  the  pi'i-foralion  made  in  tiie  operation,  and  it  was  ]ilain  that  the  removal  of  a 
amnll  purtioii  more  of  the  bone  would  have  preserved  the  patient's  limb." 


CARIES. 


431 


Fig.   187. 


the  small  cavity  in  the  head  of  the  bone,  lined  (as  these  abscesses  almost 
always  are)  by  a  very  definite  pyogenic  membrane,  the  slight  tumefac- 
tion of  the  bone  caused  by  the  thickening  of  its  periosteum,  the  indura- 
tion oftlie  bone  around,  and  the  tendency  which  the  matter  has  to  make 
its  way,  however  slowly,  to  the  surface,  for  all  the  bone  which  covered  the 
matter  has  been  removed  at  one  point;  and  the  wall  is  formed  by  the 
thickened  periosteum  only. 

Carien.- — The  term  "  caries  "  is  used  in  the  context  as  being  synonymous 
with  "  ulceration  of  bone,"  just  as  necrosis  is  used  as  synonymous  with 
gangrene  of  bone.  Some  pathologists  make  a  ditterence  between  caiious 
ulceration  and  healthy  ulceration  of  hone,  and  in  the  wi'itings  of  these 
authors  the  term  is  used  in  the  same  sense  as  w^e  use  "  strumous  caries." 

Caries  is  the  stage  which  succeeds  to  the  softening  stage  of  ostitis,  when 
the  intlammatory  process  pursues  its  course  towards  disintegi'ation  in- 
stead of  being  arrested  and  repaired,  in  which  case  it  is  followed  by  con- 
densation, or  sclerosis.  The  inflammatory  exudation  breaks  down  into 
pus,  the  connection  between  the  solid  particles  of 
the  bone  and  their  fibrous  stroma  is  dissolved,  and 
the  bon^^  particles  are  removed  in  imperceptible 
portions  in  the  discharge.  When  the  disease  oc- 
curs on  the  surface  of  the  bone  the  periosteum 
will  be  found  to  be  thick,  and  loosened  from  the 
bone ;  in  the  more  advanced  stage  of  tlie  disease 
it  is  converted  into  a  villous  mass  of  a  pink  color, 
resembling  a  mass  of  granulations.  When  this  is 
raised  from  tlie  bone  the  latter  will  be  found  ex- 
cavated into  pits,  into  whicli  this  granulation-tis- 
sue dips,  and  around  these  i)its  the  bone  is  softened 
and  rarefied  by  inflammation.  Other  neighboring 
parts  of  the  bone  may,  on  the  contrary,  be  en- 
larged and  hardened,  the  inflammation  there  hav- 
ing shown  itself  in  the  reproductive  form.  Most 
of  these  points  are  illustrated  by  the  accompanying 
engraving,  which  shows  the  deep  pits  worn  into 
the  tissue  of  the  bone,  the  change  of  sliape  of  the 
head,  the  attenuation  of  the  shaft,  so  that  it  has 
given  way  at  one  part,  and  the  attempt  at  repro- 
duction or  consolidatinginflammation  in  the  neigh- 
borhood of  this  injury. 

Strumous  caries  differs  from  ordinary  caries  less  The  iiead  and  upper  part  of 
in  essentials  than  in  degree  ;  there  is  more  soften-  '^;;^  uLorat,S"The  he^ 
ing,  less  attempt  at  repair,  more  extensive  disin-  is  iu  great  part  destroyed,  a 
tegration  of  the  neighboring  l)one.  In  some  cases  transverse  fracture  of  the  shaft 
there  is  a  distinct  deposit  of  tubercle  in  the  can-   "^  ti'e  bone  has  taken  phice 

,,  .  1  •        T     1  •    1        •  immediately  below   tlie  head. 

CellOUS  tissue,  but    this,  1   think,    is    not    common;    Below  the  part  wlierr  the  shaft 

tile  clieesy  masses  which  are  seen  sometimes  in  of  the  bone  has  been  broken  a 
the  head  of  the  til)ia,  the  bones  of  the  tarsus,  the   considerable  amount  of  new 

^    ,  T        ,1  1  1  bone  is    thrown   out     in    the 

veitebrai.  and  other  large  porous  bones,  are  re-  neighborhood  of  the  frag- 
garded  with  more  probability,  I  think,  by  some  of  ments,  which  are  only  siighiiy 

the  best  pathologists  as  collections  of  lymph  or  displaced.  The  medullary  ca- 
; •         t     1  nal  is   open    throughout. — St. 

inspissated  pus.  q^^^^^,^'  H^^pi^^i"  j^j^^^^,^^ 

The  symptoms  of  caries  are  merely  those  ot  in-  ser.  ii,  No.  46. 
flammation  of  bone  with  an  abscess  or  sinus  leading 
down  to  exposed,  softened,  rough  bone,  which   bleeds   readily  under  the 


432  DISEASES    OF    THE    BONES. 

touch  of  the  probe.  The  discharge  h.is  sometimes  the  fetid,  offensive 
smell  of  putrefying  bone,  but  by  no  means  always.  The  chemical  cliar- 
acter  of  the  discharge  is  said  in  some  cases  to  assist  in  the  diagnosis  by 
showing  a  larger  quantity  of  phosphate  of  lime  than  is  contained  in 
matter  derived  from  soft  parts  ;^  but  if  these  observations  be  allowed  to 
be  correct,  the  fact  is  hardly  clear  enough  to  afford  a  basis  for  satisfac- 
tory diagnosis.  Indeed,  in  deepseated  caries  the  diagnosis  is  often  only 
inferential ;  i.  e.,  no  other  cause  can  be  assigned  for  the  persistence  of 
discharge,  with  perhaps  some  pain  or  symptoms  of  inflammation  around 
the  bone.  Often,  also,  the  prominence  of  the  granulations  around  the 
opening  of  a  sinus  gives  indication  of  the  presence  of  an  abiding  source 
of  irritation  below,  which,  if  not  a  foreign  bod}'',  can  hardly  be  anything 
excei)t  a  piece  of  dead  or  diseased  bone. 

The  repair  of  health}^  ulceration  of  bone  is  constant,  and  even  in  stru- 
mous ulceration  it  may  occur  when  the  disease  is  not  too  extensive.  The 
ulceration  gives  place  to  condensing  inflammation  ;  the  bones,  if  more  than 
one  is  affected  (as  in  the  spine  and  tarsus),  grovv  together  by  bony  anchy- 
losis ;  new  bone  is  thrown  out  to  defend  and  support  weak  parts,  and 
there  results  a  hard,  irregular  mass  of  bone,  often  much  more  solid  than 
the  parts  which  it  has  replaced.  \ 

This  is  well  illustrated  in  the  repair  of  caries  of  the  spine,  leading  to 
angular  curvature. 

The  treatment  of  cairies  must  often  be  expectant  merely,  as  in  the  in- 
stance just  gi\en  of  carious  spine,  where  no  application  to  the  ulcerated 
surface  is  possible,  and  many  good  surgeons  are  inclined  to  believe  that 
the  expectant  treatment  is  in  most  cases  the  best.  However,  it  is  unde- 
niably tedious,  and  either  the  urgency  of  the  patient  or  the  impatience  of 
the  surgeon  often  leads  him  to  endeavor  to  accelerate  matters  ;  and  this 
is  i\\d  more  reasonable  in  cases  where  neighboring  parts  may  be  involved 
in  the  progress  of  the  disease,  as  in  the  case  of  diseased  bone  in  the  tarsus, 
where  the  disease,  if  not  early  treated,  may  very  probably  extend  from 
one  bone  to  another  till  the  whole  foot  is  incurably  diseased. 

The  methods  of  local  treatment  are  various.  The  most  common  one  is 
to  expose  the  diseased  bone  and  to  remove  as  much  as  is  found  to  be  dis- 
eased with  the  chisel,  gouge,  or  some  other  cutting  instrument,  until  a 
surface  of  bone  is  exposed  suflficiently  healthy  to  take  on  reparative  ac- 
tion ;  and  this  plan  is  often  successful,  particularly  when  the  ulceration 
is  of  a  health}' nature,  as  in  that  which  follows  on  accidental  injuries. 
But  it  is  liable  to  the  danger  of  extending  the  disease  instead  of  stopping- 
it,  by  the  inevitable  contusion  and  crushing  of  the  portion  of  bone  left 
behind.  M.  Sedillot^  has  proposed  a  method,  to  which  he  gives  the  name 
of  "evidement  des  os,"  by  which  the  whole  inflamed  and  softened  bone 
is  to  be  gouged  out  from  the  jjeriosteal  case,  leaving  nothing  but  the  soft 
parts  from  which  the  bone  is  to  be  rei>roduced.  I  have  no  experience  of 
this  method,  believing  the  total  extirpation  of  bones  which  are  so  com- 
pletely disintegrated  as  to  require  such  a  plan  of  treatment  to  be  prefer- 
able. Most  of  the  excisions  of  joints  and  resections  of  bones  which  are 
performed  are  necessitated  by  caries  of  the  bones  which  has  entirely  de- 
stroyed the  utility  of  the  part ;  but  before  so  grave  a  step  is  taken  it  is 
desiral)le  to  try  all  appropriate  means  of  local  treatment.  In  aid  of  the 
treatment  b}'  rest  (or  the  expectant  treatment)  various  local  applications 

1  Bransby  Cooper's  Lectures  on  Surgery;   Barwell,  Dis.  of  Joints,  p.  L'38. 

2  Gaz.  des  Hop.,  Jan.  19,  1875. 


NECROSIS.  433 

are  in  use  for  removing  the  ulcerated  bone  and  exposing  sound  tissue  by 
a  process  less  dangerous  than  gouging  to  the  integrity  of  the  bone  left 
behind.  The  most  successful  of  these  is,  I  think,  the  application  of  sul- 
pluiric  acid  after  the  manner  described  by  Mr.  Pollock,  in  the  Lancet^ 
May  28,  1870.  The  carious  bone  being  thoroughly  exposed  l)y  incision  or 
removal  of  the  soft  parts  which  cover  it,  a  solution  of  equal  parts  of  sul- 
phuric acid  and  water  is  applied  to  it  with  a  glass  brush,  or  a  lotion  of 
five  or  six  parts  of  water  to  one  of  the  strong  acid  is  kept  in  constant 
contact  with  the  bone  by  impregnating  a  piece  of  lint  with  it  and  pushing 
it  down  to  the  diseased  part.  The  former  plan  is  the  more  efficient  when 
the  carious  surface  is  actually  superficial.  The  strength  of  the  acid  is 
gradually  raised  till  at  lengtli  it  is  applied  pure.  As  the  diseased  bone 
is  dissolved  out  healthy  granulations  spring  up  here  and  there  till  the 
whole  surface  seems  healthy,  when  it  mav  be  left  to  heal. 

Dr.  Kirkpatrick^  eflects  the  same  object  by  the  caustic  action  of  Vienna 
paste  (potassa  cum  calce).  He  destroys  the  soft  parts  with  this  paste  till 
a  large  funnel-shaped  opening  is  left,  leading  down  to  the  bone,  which  is 
then  to  be  perforated  with  astrong  knife,  chisel,  or  trephine,  and  into 
these  perforations  the  caustic  is  to  be  introduced.  As  the  bone  which  is 
thus  destroyed  and  cauterized  comes  away  the  parts  around  are  consoli- 
dated by  healthy  inflammation.  This  plan  is  more  easily  applied  to  deep- 
seated  caries  than  the  sulphuric  acid  treatment,  but  is  otherwise,  as  far 
as  I  have  seen,  less  successful. 

Other  local  applications  are  the  actual  cautery,  which,  however,  can 
only  be  used  in  rare  cases  in  which  the  whole  carious  surface  is  exposed, 
and  seems  to  me  less  energetic  and  penetrating  than  the  acid  ;  the  injec- 
tion of  iodine,  much  recommended  at  one  time  but  now  fallen  into  de- 
served disrepute,  and  injections  of  dilute  mineral  acid,  which,  however, 
are  superseded  b}^  the  more  methodical  use  of  the  strong  acid. 

Phagedenic  Ulceration. — I  need  only  refer  here  in  the  most  cursory 
manner  to  cases  in  which  the  inflamed  bone  is  removed  with  great  rapidit}'. 
Mr.  Stanley  ^  describes  this  under  the  name  of  "  phagedenic  ulceration 
of  bone,"  likening  it  to  phagedena  of  the  soft  parts;  but  Mr.  Stanley's 
cases  appear  to  have  been  instances  of  epithelioma  or  rodent  ulcer.  Mr. 
Cffisar  Hawkins^  has  recorded  two  striking  cases  of  extensive  destruc- 
tion of  the  bones  of  the  head,  accompanied,  in  one  instance,  by  suppura- 
tion, in  the  other  not,  which  shows  how  rapid  sometimes  is  the  absorption 
of  inflamed  bone.  But  the  cases  of  this  disease  are  so  rare  that  I  must 
content  myself  with  this  brief  mention  of  it. 

JVecro.s■^■^^,  or  the  total  death  of  a  considerable  portion  of  bone,  is  dis- 
tinguished from  caries,  or  the  ulceration  of  bone  and  its  disintegration  in 
invisible  molecules,  just  as  the  gangrene  or  death  of  a  visible  portion  of 
the  soft  tissues  is  distinguished  from  ulceration,  or  "  molecular  gangrene." 
The  phenomena  of  necrosis,  also,  are  strictly  analogous  to  those  of  gan- 
grene. It  may  be  produced,  as  gangrene  is,  either  by  inflammation  or 
by  loss  of  blood-supply  or  by  chemical  disintegration  of  the  tissues  ;  but 
in  the  bones  inflammation  is  a  far  more  common  precursor  of  necrosis 

1  Dub.  Quart.  Journal.     New  Syd.  Soc.  Bien.  Rep  ,  1807-8,  p.  259. 

2  Diseases  of  the  Bones,  p.  65. 

3  Med.-Chir.  Trans.,  vol.  xxxix.  Contributions  to  Pathology  and  Surgery,  vol.  i, 
p.  349. 

28 


434 


DISEASES    OF    THE    BONES. 


than  it  is  in  soft  parts: 


Fig.  1S8. 


in  fact,  the  cases  where  necrosis  does  not  depend  on 
inflammation  are  only  exceptional,  while  in 
the  soft  parts,  thou<2;h  inflammation  usnall}'' 
bears  its  part  in  indncing  gangrene,  yet 
other  causes  almost  always  co-operate.  The 
reason  of  this  is  obvious  :  the  soft  parts 
easily  accommodate  themselves  to  the  en- 
largement of  the  vessels  and  to  the  inter- 
vascular  effusions  which  are  necessary  ac- 
companiments of  inflammation,  whilst  in 
the  bones  the  vessels  are  confined  in  rigid 
canals;  and  any  such  attempt  at  expansion 
being  checked  at  once,  the  circulation  comes 
to  a  standstill.  The  dead  bone  then  turns 
white  (unless  it  is  exposed  to  the  air  and 
bathed  in  the  products  of  putrefaction,  when 
it  may  be  perfectly  black) ;  if  cut  into  it  will 
not  bleed  ;  the  periosteum  and  soft  parts 
recede  from  it,  leaving  its  surface  smooth, 
hard,  and  ringing  when  struck;  the  living 
bone  in  the  neighborhood  becomes  inflamed, 
leading  to  condensation  of  its  tissue  for  some 
distance,  and  to  periosteal  deposit,  both  on 
the  surface  of  the  living  bone  and  especially 
over  the  dead  bone,  so  that  the  dead  bone  is 
roofed  in  or  invaglnated  (as  the  technical 
term  is)  b^^  a  cover  or  sheath  of  living  peri- 
osteal bone.  While  this  is  going  on  the  irri- 
tation of  the  dead  bone  sets  up  inflammation 
in  all  the  parts  with  which  it  is  in  contact, 
viz.,  the  living  bone  and  the  deep  surface  of 
the  periosteum.  The  pus  so  furnished  finds 
its  way  to  the  surface  through  the  sheath 
of  new  bone,  which  thus  is  interrupted  by 
holes  or  sinuses,  through  which  the  pus 
burrows  to  the  surface  of  the  bod}-.     These 


Necrosis  of  the  lower  part  of  the  sliaft  and  cfiiphysial  extremity  of  the  lihia.  The  larger  fipture 
shows  the  .sequestrimi  surrounded  by  its  sheath  of  new  hone,  the  latter  gradually  merging  above  into 
the  healthy  .surface  of  the  bone.  A  seelion  ha.s  been  made  through  the  se(|uestrum  and  its  eavity  near 
the  articular  surface.  The  smaller  figure  t.hows  the  articular  end  of  the  bone,  where  the  e.xtremity  of 
the  sequestrum  is  seen,  surrounded  by  an  ulcerated  surface  of  bone,  from  which  the  articular  cartilages 
were  completely  removed.  The  sequestrum  was  here  perfectly  accessible,  and  could  have  been  removed 
by  a  free  incision  into  the  joint. — From  a  drawing  in  the  Museum  of  St.  George's  Hospital,  presented 
by  Sir  B.  Hrodie. 

sinuses  are  technically  called  doacfje,  and  the  piece  of  invaginated  dead 
bone    thus    sequestrated  from   the    soft   parts  is   called   a   sequestrum. 


NECROSIS. 


435 


When  the  periosteum  is  destroyed  there  is  iisualh'  no  sheath,  though 
it  is  j)ossil)le  that  new  bone  may  be  pro- 
duced by  tlie  soft  parts.  Tliis,  however, 
is  a  far  slower  and  more  imperfect  process. 
Wlien  there  is  no  sheath  and  the  dead 
bone  is  exposed  on  the  surface  the  process 
of  separation  and  tlie  piece  of  dead  bone 
which  separates  are  botli  described  by  tlie 
name  of  exfoliation.  As  the  inflamma- 
tion proceeds  it  digs  a  trench  around  the 
dead  bone  by  a  line  of  demarcation,  as 
in  the  soft  parts,  and  thus  the  sequestrum 
becomes  loose  in  its  cavity,  and  if  the 
cloaca^  are  large  enough  it  may  escape 
through  one  of  them.  But  this  rarely 
happens,  and  for  the  most  part  it  is  nec- 
essary to  enlarge  the  opening  of  the 
cloacjie  before  the  sequestrum  can  be  re- 
moved. 

This  descrii)tion  applies  to  necrosis  of 
the  superficial  part  of  the  bone,  and  this 
is  by  far  the  most  common  situation. 
Central  necrosis,  however,  is  occasionally 
though  not  very  frequently  met  with,  as 
the  result  of  inflammation  of  tlie  medul- 
lary tissue,  and  possibly  sometimes  of 
contusion  of  the  substance  of  the  bone. 
The  s^'mptoms  are  very  obscure,  and  are, 
in  fact,  usually  merged  in  those  of  chronic 
abscess  ;  since  the  resulting  inflammation, 
supposing  the  affection  to  be  seated  in  a 
part  such  as  the  head  of  the  tibia  (where 
there  is  abundance  of  cancellous  tissue), 
will  set  up  suppuration  around  the  dead 

bone.  In  the  sliaftS  of  the  long  bones  with  a  deposit  of  new  porous  bone.  The 
the  same  thing  may  occur.  The  pus  will  large  irregular  cavity  which  is  seen  in  the 
,  ,.^.  1        ■  .1  1  i>i\         tibia  lias  lesulteJ  from  the  necrosis  and  re- 

become  diffused  among  the  meshes  of  the  ,„ovai  of  the  whole  thickness  of  the  shaftof 
medullary  tissue,  and  the  disease  has  been   the  bone,  with  the  exception  of  two  small 

known  to  be    many  years  in    progress  be-    bridges  or  pillars,  which  extend  from  the 

fore  tlie  dead  bone  has  become  loose.^         ''?^.'\  'V'","  '"T/  "f,  V'VT'  J""^ 

.  tibia  IS  tirmly  soldered  to  the  tibula,  above, 

1  he  bones  most  subject  to  necrosis  are     below,  and  opposite  to  the  cavity.-From  a 

those    which     are     most     exposed     to     the    preparation   in  St.  George's  Hospital  Mu- 

various  causes  of  inflammation,  of  which   seum,  Ser.  li,  No.  si. 
syphilis,  struma,  and  local  violence  are 

the  commonest.  Hence  the  superficial  bones  are  found  affected  more 
commonly  than  those  which  are  further  removed  from  participation  in 
the  various  afl'eetions  of  the  surface.  The  cranium,  the  tibia,  the  clavicle, 
the  bones  of  the  forearm  and  hand  are  most  commonly  the  subjects  of 
the  affection;  but  it  is  by  no  means  uncommon  in  the  femur  or  humerus. 
The  denudation  of  the  bone  by  destruction  of  its  periosteum  is  very  fre- 


Extensive  ulceration  of  the  tibia  and  fib- 
ula, with  necrosis.  Botli  bones  are  much 
thickened   by  inflammation,   and  covered 


^  In  the  Museum  of  St.  Bartholomew's  Hospital,  Ser.  i,  No.  176,  is  a  specimen  of  a 
femur  removed  l>y  amputation,  in  which  there  was  a  small  necrosed  portion  of  the 
inner  layers  of  the  medullary  cavity.  The  bone  had  not  separated,  though  the  dis- 
ease had  been  in  progress  for  thirty-iive  years. 


436  DISEASES    OF    THE    BONES. 

quently  ft)lloNved  by  necrosis,  but  not  always,  since  the  exposed  bone  may 
derive  suflicient  nutriment  from  the  neigliboring  soft  parts  of  tlie  bone, 
and  to  some  extent  from  the  neighboring  soft  i)arts,  to  preserve  its  vitality. 
Thus,  after  a  severe  scalp-wound  large  portions  of  exposed  bone  may  be 
seen  to  become  gradually  vascular,  small  granulations  springing  from  the 
surface  here  and  there,  and  ultimately  forming  a  cicatrix  by  which  the 
whole  is  covered  without  au}^  visible  exfoliation.  And  in  the  bones  of 
the  face  large  denudations  of  the  periosteum  are  perfectly  compatible 
with  the  regular  nutrition  of  the  bone.  Thus,  in  the  operation  for  cleft 
of  the  liard  palate  the  surgeon  denudes  the  bones  of  their  periosteum, 
without  any  apprehension  whatever  of  necrosis.  But  in  bones  which  are 
less  vascular  than  those  of  the  head  and  face,  or  in  bad  conditions  of 
health,  or  where  the  denudation  is  very  extensive,  the  outer  table  of  the 
bone  will  usuall^y  exfoliate,  though  not  to  so  great  an  extent  as  would  at 
first  appear  probable.  The  soft  parts  almost  always  adhere  around  the 
edges  of  the  wound  to  some  extent,  and  preserve  the  life  of  the  circum- 
ferential portions. 

Acute  Neci^osis. — Necrosis  sometimes  occurs  with  almost  as  much 
rapidity  as  gangrene  of  the  soft  parts,  and  then  the  constitutional  dis- 
turbance may  be  great,  and  pysemia  is  yery  likel^y  to  ensue.  I  have 
spoken  of  this  in  connection  with  diffuse  or  acute  periostitis,  which  is  the 
common  cause  of  acute  necrosis.  The  next  most  common  cause  is  de- 
struction of  the  periosteum  and  injur}'  to  the  surface  of  the  bone,  either 
by  contusions,  chemical  injuries,  or  fire.  But  there  are  rare  cases  in 
which  acute  necrosis  ensues  from  obscure  causes,  and  without  any  visible 
affection  of  the  periosteum  or  medullary  membrane,  of  which  I  have 
related  a  striking  instance  in  the  essay  already  referred  to  in  the  System 
of  Surgery  (p.  11 C^).  Such  cases  must  be  treated  in  the  same  way  as 
those  of  acute  periostitis. 

Treatment. — The  treatment  of  necrosis  is,  as  a  general  rule,  to  wait 
until  the  bone  is  loose  and  then  to  remove  it.  In  the  case  of  an  exfolia- 
tion nothing  more  is  necessary  than  to  lift  out  the  loose  portion  b}'  put- 
ting an  elevator  beneath  its  edge  and  extract  it  with  a  pair  of  forceps. 
Very  often  when  the  soft  parts  lock  in  the  exfoliation  it  l)ecomes  neces- 
sar}-  to  cut  the  loose  part  across  in  order  to  remove  it  piecemeal,  and 
this  is  effected  by  a  pair  of  cutting  forceps  or  bone  scissors.  But  under 
certain  circumstances  this  usually  simple  operation  becomes  a  very  com- 
plicated, rlifiicult,  and  dangerous  proceeding.  The  most  familiar  instance 
is  in  that  necrosis  of  the  popliteal  space  of  the  femur  which  occurs  so 
often,  and  in  which  for  some  reason  not  very  obvious  there  is  rarel}',  if 
ever,  any  periosteal  sheath,  so  that  the  exfoliated  bone  lies  close  under 
the  popliteal  artery,  and  may  easily  wound  it,  as  happened  to  a  young 
man  the  subject  of  this  affection,  who  in  dancing  ran  the  loose  splinter  of 
bone  into  the  poi)liteal  artery  and  bled  to  death.'  The  same  accident  may 
occur  in  removing  the  bone,  or  the  knee  joint  may  be  opened,  or  the 
arter}-  may  lie  wounded  by  the  knife,  trephine,  or  cutting  pliers.  It  is 
necessary,  therefore,  to  proceed  with  great  care,  making  the  incision  on 
the  outer  side  and  somewliat  to  tlie  back,  so  as  to  avoid  the  synovial 
membrane,  yet  not  to  wound  the  external  popliteal  nerve  ;  then  to  dissect 
witli  great  care  along  the  l)ack  of  the  femur  and  use  the  bone  scissors,  if 
necessary,  with  great  caution.  In  withdrawing  the  bone  all  rough  manip- 
ulation should  be  avoided,  and  the  parts  scratched  and  pushed  off  it  with 

'  Byron  in  Med.-Chir.  Kev.,  vol.  xxiv,  p.  259.  Jacob,  Diss.  Med  -Chir.,  de  Arieur., 
Edin.,  1814. 


NECROSIS.  437 

the  finger-nail  and  handle  of  tlie  scalpel  in  preference  to  any  cutting 
instrument. 

When  the  dead  bone  is  invaginated  it  is  necessary,  in  the  first  i)!ace,  to 
endeavor  to  ascertain  whether  it  is  loose,  but  this  is  by  no  means  easy. 
The  length  of  time  during  which  it  has  been  exposed  will  of  course  justify 
a  guess — but  only  a  guess — for  the  period  at  which  the  dead  bone  sepa- 
rates depends  on  many  causes  of  which  the  surgeon  can  hardly  have  any 
knowledge,  and  in  great  part  on  the  acute  or  chronic  nature  of  the  origi- 
nal action.  Still,  if  the  disease  has  been  long  in  progress,  and  there  is 
not  much  risk  in  cutting  down  on  the  bone,  it  should  certainly  be  done, 
if  only  to  get  a  perfect  knowledge  of  its  condition.  The  sequestrum  may 
be  (piite  detached  from  the  bone  around  it,  yet  so  locked  in  that  no  move- 
ment can  be  impressed  on  it  by  the  probe.  Sometimes  the  groove  of  de- 
marcation between  the  living  and  dead  bone  can  be  felt,  and  if  so  it  is  a 
valuable  sign  the  sequestrum  is  loose.  The  operation  consists  in  freel}' 
exposing  tlie  invaginating  bone  with  its  cloacoe  and  enlarging  one  or  more 
of  the  latter  by  cutting  the  new  bone  away,  either  with  the  trephine 
applied  round  one  of  the  openings  or  by  cutting  through  the  bridge 
between  two  neighboring  cloac.ne  with  chisel  or  forceps,  and  so  obtaining 
free  access  to  the  sequestrum,  which  is  then  to  be  taken  out  with  the  for- 
ceps, or,  if  too  large,  to  be  cut  through  with  the  cutting  pliers,  trephine, 
or  an}-  handy  instrument,  and  so  removed.  The  surgeon  must  be  careful 
to  leave  none  of  the  dead  bone  behind  in  the  cavity.  The  wound  need 
not  be  closed,  since  it  can  only  fill  up  by  granulations.  The  discharge  is 
often  most  putrid,  and  the  pit  in  the  bone  requires  for  some  time  to  be 
very  freely  washed  out  with  some  disinfecting  solution. 

It  used  to  be  recommended  in  surgical  lectures  to  defer  this  operation 
till  the  periosteal  sheath  might  be  presumed  to  have  acquired  strength 
enough  to  preserve  the  continuity  of  the  limb,  but  this  is  not  now  con- 
sidered advisable.  In  the  leg  and  forearm,  where  there  is  a  second  bone, 
the  peri(>steal  inflammation  will  be  sure  to  unite  the  affected  to  the  sound 
bone,  if  the  necrosed  portion  be  at  all  large  (see  Fig.  Is9)  ;  and  even  if 
this  does  not  occur,  or  if  there  is  only  one  bone,  it  seems  better  to  remove 
the  sequestrum  at  once,  since  it  is  a  permanent  source  of  irritation,  and 
to  trust  to  careful  splinting  and  bandaging  to  maintain  the  parts  in  posi- 
tion and  prevent  any  fracture.  However,  it  cannot  be  denied  that  the 
danger  of  fracture  from  necrosis  is  a  real  one,  and  particularly  if  the 
neighboring  bone  has  been  cut  away  to  some  extent;  and  when  this  acci- 
dent has  happened  in  the  case  of  the  femur  amputation  will  usually  be- 
come necessary  (Fig.  190).  In  the  arm  careful  treatment  will  probably 
preserve  the  limb. 

Some  other  plans  of  dealing  with  necrosed  bone  are  occasionally  useful. 
They  consist  chiefly  in  applying  chemical  solvents,  by  which  the  dead 
bone  may  be  dissolved  out  and  thus  its  removal  lie  effected  more  quickly 
than  by  waiting  for  its  separation.  Of  these  the  sulphuric  acid  is  the 
best  (see  page  433),  and  by  its  means  I  luive  seen  large  portions  of  the 
skull  removed,  and  certainly  with  the  effect  of  much  diminishing  the  fetor 
of  the  discharge.  The  difl^iculty  is  when  tlie  limits  between  the  dead  and 
the  living  bone  are  reached,  since  any  substance  strong  enough  to  dis- 
solve the  tissue  of  the  bone  may  easily  kill  the  living  but  inflamed  bone 
in  the  neighborhood  of  the  exfoliating  portion. 

The  complications  of  necrosis  are  very  numerous;  but  as  the  majority 
of  them  are  merely  the  results  of  inflammation  propagated  from  the  in- 
flamed bone  to  the  soft  parts  in  its  neighborhood,  and  are  marked  by 
the  symptoms  peculiar  to  such  inflammations,  it  would  be  impossible  to 


438 


DISEASES    OF    THE    BONES. 


speak  of  all  of  them   here,  nor  would  it  be  necessar}'.     It  ma}'  perhaps, 
however,  be  proper  to  take  notice  of  the  fact  that  necrosis  is  not  an 


Fig.  190. 


^Ik1i|\^|; 


''H  ih'f 


\\ 


Fu;.  190.— Fracture  In  consequence  of  necrosis,  necessitating  amputation,  from  which  the  patient  (a 
boy  aged  15)  recovercfl.  a  refers  to  the  necrosed  bone;  \>  to  tlie  new  bone,  wliicli  (along  wltli  the 
remains  of  tlic  old  sluift)  has  given  way.  The  patient  had  liad  diseased  l)one  for  more  than  four  years, 
and  had  been  frequently  operated  upon.  At  length  he  again  came  into  the  hospital  in  1861.  The  femur 
was  trephined  and  some  more  dead  bone  removed.  He  went  on  well,  and  the  wound  was  nearly  closed, 
when,  six  weeks  after  the  operation,  he  fell  in  running  across  the  ward  and  fractured  the  thigh.  It 
was  put  up  in  the  usual  way,  l)Ut  no  union  could  be  procured.  The  wound  discharged  a  large'  quantity 
of  thin  unhiallhy  pus,  and  it  l)ecame  necessary  to  amputate.  The  fracture  has  passed  tlirough  the 
trephlne-hole,  a  part  of  the  outline  of  which  is  seen  on  the  necrosed  bone.  The  artery  lay  to  the  inner 
side  of  the  broken  end.s — it  was  uninjured.  The  intersi)ace  between  the  fragments  was  filled  witli  white 
fibrous  tissue,  In  which  many  ossifying  specks  were  visible  under  the  microscope. — St.  George's  Hospital 
Museum,  Ser.  ii.  No.  100. 

FifJ.  101. — Necrosis  of  the  whole  shaft  of  the  til)ia,  from  a  patient  aged  18.  The  upper  eijiphysis  is 
unafTectcd,  but  the  disease  extends  into  the  ankle-joint,  an<l  a  small  loose  portion  of  bone  can  be  seen 
on  the  lower  artieular  surface.  The  patient  was  originally  admitted  in  tlie  year  18;is,  the  disease  having 
then  existed  for  four  years,  and  iieing  referred  to  an  accident.  Some  dead  bone  was  tlu'n  removed,  and 
he  was  sent  into  the  country,  as  his  health  was  failing.  Next  year  he  was  readmitted,  and  the  greater 
part  of  the  necrosed  bone  was  extracted,  through  the  large  ap(;rture  (maile  by  the  trephine  and  other 
instruments)  seen  at  the  upper  part  of  the  Mlial't  of  tin'  bone.  Numerous  other  openings  are  seen,  most 
of  wliicb  are  cloaca;,  one  of  them  of  a  rounded  form,  probably  the  former  trcphiiuvhole.  The  lad  died 
shortly  after  the  last  operation  from  another  cause. — St.  George'a  Hospital  Museum,  Ser.  ii,  No.  80. 


SCROFULA    IN    BONE. 


439 


uncommon  cause  of  destructive  inflammation  of  joints.  Usually,  indeed, 
the  inflammation  of  the  shaft  of  a  long  bone  is  not  communicated  to  the 
articular  end,  but  this  is  not  always  the  case.  The  articular  end  itself 
may  share  in  the  death  of  the  shaft,  or  the  suppuration  which  is  excited 
b}'  the  sequestrum  may  perforate  the  articular  lamella,  and  make  its  way 
into  the  joint  as  in  Fig.  191  ;  or,  again,  the  necrosis  may  be  confined  to 
the  articular  end,  the  shaft  being  free,  so  that  the  whole  or  a  portion  of 
the  epiphysis  may  become  loose  in  the  joint  and  act  as  a  foreign  bod3^ 
The  joint  under  any  of  those  conditions  must  be  considered,  as  a  general 
rule,  to  be  destroyed,  and  it  becomes  merely  a  question  whether  amputa- 
tion is  necessar}'  or  excision  may  be  A^entured  on,  or  the  loose  bone  only 
be  extracted  by  incision  into  the  cavity  of  the  joint,  and  the  latter  left  to 
anchylose. 

Bcrufula  in  Bone. — I  must  now  give  a  very  brief  account  of  the  modi- 
fications of  the  inflammatory  process  caused  by  the  various  constitutional 
cachexias. 

In  scrofulous  disease  of  the  bones  there  is  sometimes  seen  a  deposit  of 
crude  cheesy  tubercle  in  the  can- 
cellous tissue  ;  the  articulating  F'*^'-  ^^-• 
ends  (Figs.  192,  193),  or  the 
short  bones,  are  the  most  com- 
mon seat  of  this  deposit.  More 
commonly,  however,  strumous 
disease  in  a  bone  produces  mere- 
ly a  low  inflammatory  condition, 
in  which  the  bony  tissue  is  so 
softened  as  to  be  easily  cut  with 
a  knife;  the  cancellous  portion 
of  the  bone  is  looser  and  lighter 
than  natural,  and  its  cancelli 
filled  with  fluid,  the  product  of 
inflammation,  sometimes  mixed 
with  pus,  and  the  compact  tis- 
sue thinned  and  rarefied.  On 
microscopic  examination  the 
lacunar  and  canaliculi  are  found 
filled  with  exudation,  and  occa- 
sionally minute  bony  projections 
from  the  walls  of  tlie  dilated 
cancelli  indicate  an  attemjit  at 

the  reproduction  of  bone  and  deiiosited  in  the  cancellous  tlssu 
that  healing  by  sclerosis  which 
has  already  been  described  as  one  of  the  usual  events  of  healthy  inflam- 
mation.^ The  leading  features,  then,  of  the  pathological  anatomy  of  stru- 
mous inflammation  are  the  same  as  those  of  ostitis  in  general ;  and  the 
only  distinctive  anatomical  peculiarity  consists  in  the  nature  of  the  exu- 
dation which  chokes  up  the  spaces  in  the  bone.  Dr.  Black  has  given 
several  analyses  tending  to  establish  these  four  conclusions — that  tuber- 
culosis gives  rise  to  (I)  a  considerable  increase  of  fat  in  the  diseased 
bone;  (2)  a  large  diminution  of  the  salts  of  lime;  (3)  a  diminution  of  the 
organic  matrix;  and  (4)  an  increase  of  the  soluble  salts.  In  general 
terms,  strumous  is  distinguished  from  common  inflammation  by  the  soft- 


Scrol'ulnns  luberotc  deposited  in  the  head  of  the  right 
femur.  "  The  eiirtilagts  hud  been  deslroytd  by  ulcera- 
tion, and  the  bones  were  in  a  state  of  caries.'"  The  sec- 
tion of  the  bone  shows  a  large  mass  of  yellow  substance 


^  See  Black,  On  the  Pathology  of  Tuberculous  Bone,  Edin.,  1859. 


440 


DISEASES    OF    THE    BONES. 


Diseases  of  the  Joints,  Works,  edited  by  C.  Hawkins,  vol. 
ii,  \).  198. 


ness,  lightness,  and  oiliness  of  the  afTected  bone,  by  the  greater  diffusion  of 

the  morbid  clianges,  and  by  the 
I'^K'- 1^^-  less  tendenc}'  to  cure.     The  ob- 

vious effect  on  the  bone  consists 
either  in  chronic  enlargement 
witliout  suppuration  or  in  in- 
flammation followed  by  ulcera- 
tion or  caries.  The  former  is 
sometimes,  though  with  doubt- 
ful correctness  called  ''a  stru- 
mous node."  It  differs  from  the 
common  nodes  which  are  usually 
syphilitic  in  the  fact  that  they 
are  often  purely  periosteal, 
wliile  the  strumous  node  hardly 
ever  is  so.  It  is  formed  by  en- 
-  largement  and  expansion  of  the 

Pepositoftuberclelu  the  head  of  the  left  femur,  from  boU}''    tisSUe,    in    part,    but    alsO 

the  same  case  as  the  preceding.    No  disease  had  been  and  generally  in  greater  part  by 

supposed  to  exist  in  this  joint  before  death,  and  the  draw-  encorcred     and      infiltrated     SOft 

ing  sliows  the  cartilage  and  ligamentuni  teres  intact,  but  ^•'^''01^,  1     .   • 

the  bone  was  softer  than  natural,  and  its  vascularity  in-  tlSSUeS.    bucn  StrumOUS  enlargC- 

creased.— From  drawings  presented  by  Sir  B.  Brodie  to  mcuts    Or    nodeS    SOlUetimeS    re- 

the  Museum  of  St.  George's  Hospital.    The  case  (that  of  main  indolent  and  witllOUt  mUCh 

Captain  D.,  case  xxxi)  is  to  be  found  in  his  Treatise  <.n  ^^^^^^^^  foj.  ^  j^.^g  period.       They 

are  cliiefly  seen  in  the  articular 
ends  of  the  bones,  sometimes 
in  the  clavicle  or  skull,  and  occasionally  in  any  other  bone.  The  more 
active  inflammation  which  tends  to  softening  and  suppuration  (strumous 
caries  and  necrosis)  is  very  common  in  tlie  joints,  in  the  foot,  and  in 
the  spine,  but  it  is  met  with  in  all  parts  of  the  body.  It  is  not  accom- 
panied b}'  mucli  pain,  unless  from  irritation  of  nerves  lying  near  the  dis- 
eased bone,  and  is  remarkabl}-  obstinate,  seldom  stopping  until  the  whole 
of  the  affected  bone  lias  become  disintegrated.  The  necrosis  is  generally 
induced  hy  the  caries — i.  e.^  a  portion  of  bone  perishes  in  consequence  of 
the  disintegration  of  some  neighlioring  part  from  which  its  vessels  are 
derived,  so  that  the  removal  of  the  dead  part  does  not  stop  the  disease. 
So  obstinate  is  this  strumous  caries,  that  Mr.  Syme  spoke  of  it  as  an 
incurable  affection  ;  but  this  seems  going  too  far. 

The  treatment  of  strumous  disease  in  bone  should  be  chiefly  expectant, 
as  far  as  the  local  disease  goes.  Strumous  nodes  will  sometimes  disapi)ear 
rapidly  under  the  iodides — especially  iodide  of  iron — combined  with  con- 
stitutional treatment.  Country,  especiall_y  sea,  air  is  of  great  importance 
in  such  cases.  When  suppuration  has  occurred,  and  carious  bone  is  ex- 
posed, its  seiiaralion  may  be  hastened  by  caustic  applications,  such  as 
sulphuric  acid  or  the  actual  cauteiy;  but  after  all  such  l(;cal  measures 
can  only  be  regarded  as  adjuvants  to  constitutional  treatment.  When 
the  bone  is  greatly  disintegrated  its  removal  by  excision  or  amputation 
becomes  necessary. 

Si/philiH  as  it  attacks  the  bones  leads  either  to  periostitis  or  to  ostitis, 
caries,  and  necrosis.  Enough  has  lieen  said  above  on  the  siilyect  of 
nodes,  and  I  must  refer  the  reader  to  tiie  previous  pages  and  to  the 
chapter  on  Sy[)hilis  for  all  that  seems  necessary  as  to  caries  and  necrosis. 
I  will  add  here  a  few  oi)servations  on  the  usual  forms  of  syphilitic  ulcera- 
tion, as  contradistinguished  from  the  other  forms  of  ulcer  which  we  And 
in  i)one. 


SYPHILITIC    AFFECTIONS.  441 

Mr.  Stanley  says  that  "the  varieties  of  ulcer  in  bone  are  as  distinctly 
marived  as  they  are  in  other  tissues.'"  Without  going  quite  so  for  as  this, 
I  think  there  can  be  no  doubt  that  there  are  s[)ecific  differences  between 
certain  forms  of  ulceration  in  bone  which  are  recognizable  from  each 
other,  though  tliere  are  many  forms  of  ulceration  in  which  the  most  acute 
pathologist  would  be  unable  to  say  from  an  inspection  of  the  ulcer  what 
the  constitutional  condition  had  been  on  which  it  depended. 

Syphilitic  ulceration  occurs  in  two  chief  forms,  which  bear  an  analogy 
to  the  affections  of  the  skin  in  constitutional  syphilis,  as  Paget  has  pointed 
out  in  the  Catalogue  of  the  Museum  of  the  College  of  Surgeons.  They 
are  the  annular  and  the  tuberculated  ;  the  former  likened  to  the  rupial 
ulcers  of  the  skin,  and  the  latter  to  the  syphilitic  tubercle.-  In  the 
annular  ulceration  "a  small  round  spot  is  seen  where  the  surface  of  the 
bone  is  worm-eaten  from  the  presence  of  numerous  minute  depressions, 
and  in  some  cases  the  bone  around  this  worm-eaten  central  portion  is 
marked  by  arborescent  grooves,  the  traces  of  increased  vascularity. 
Later  on  a  circular  trench  is  marked  around  the  worm-eaten  spot,  and  as 
this  widens  and  deepens  it  undermines  and  finall}'  chisels  out  the  piece, 
which  separates  as  a  sequestrum,  and  then  the  bone  scars  over,  leaving  a 
rounded  depression  much  larger  than  the  original  spot."  The  tuberculated 
form  "appears  to  commence  b}'  a  tubercular  thickening  of  the  external 
wall  of  the  bone,  due  not  to  periosteal  deposit,  but  to  chronic  inflamma- 
tion of  the  compact  tissue  itself.  This  inflamed  bone  soon  becomes  dotted 
over  with  numerous  little  pits  or  depressions  which  coalesce  and  form 
ulcers,  usually  oval  or  round,  penetrating  deeply  into  the  interior  of  the 
bone."  As  sub-varieties  of  syphilitic  ulcer  Sir  J.  Paget  has  described  (1) 
the  reticulated^  in  which  the  disease  commences  by  reticular  deposit  of 
periosteal  bone,  which  then  becomes  perforated  by  annular  ulcers;  so 
that  tliis  seems  to  be  a  mixture  of  secondarj^  and  tertiary  syphilis — a 
node  perforated  l)y  ulceration ;  and  (2)  the  penetrating,  in  which  the 
whole  thickness  of  the  bone  is  removed  to  a  considerable  extent  by  one 
or  other  of  the  previously  descril)ed  forms  of  ulcer. 

The  main  peculiarities  of  syphilitic  as  distinguished  from  the  other 
forms  of  ulceration  in  bone  would  appear  to  be  its  tendency  to  assume 
the  annular  or  crescentic  form,  together  with  the  circumscribed  (and 
often  also  circular)  induration  or  tuberculation  of  the  exterior  of  the 
bone.  Simple  ulceration,  on  the  other  hand  (of  which  perhaps  the  best 
examples  are  to  be  found  in  the  articular  ends  during  abscess  of  the 
joints),  forms  merely  a  worm-eaten  surface  of  no  particular  shape,  and 
extending  to  an  indefinite  extent  superficiall}',  but  affecting  little  of  the 
substance  of  the  bone.  In  strumous  ulceration  the  whole  of  the  bone  is 
softened,  light,  oily,  and  enlarged,  while  the  surface  is  worn  away  by  a 
ragged,  irregular  ulceration,  usually  deep  in  places  and  extending  in- 
definitely. The  main  characteristic  of  rheumatic  ulceration  is  the  stalac- 
tilic  or  foliaceous  deposit  on  the  surface  of  the  bone  coexisting  with 
sclerosis  of  its  superficial  portion,  and  this  deposit  peneti'ated  by  irregular 
ulceration,  but  to  no  great  extent.  In  malignant  ulceration  the  bone  is 
removed  in  an  irregular  manner  and  to  any  extent,  sometimes  almost 
entirely;  but  what  characterizes  it  unmistakably  is  the  deposit  of  cancer 
in  the  neighboring  bone  and  soft  parts.  In  the  macerated  bone  these 
extensive  and   irregular  cancerous  erosions  are   recognizable  from  the 

1  Diseases  of  the  Bones,  p.  50. 

2  The  reiider  will  find  In  my  essay  on  Diseases  of  the  Bones,  already  referred  to, 
characteristic  illustrations  of  these  and  the  other  recognized  varieties  of  ulcer  in  bone, 
for  which  I  cannot  here  find  space. 


442 


DISEASES    OF    THE    BONES. 


forms  of  ulcer  above  described  ;  but  they  can  hardly  be  di.stinguished 
from  the  rodent  or  lupoid  ulceration,  to  which  bones  are  also  liable,  ex- 
cept in  the  fresh  state  by  the  cancerous  deposit — usually  epithelial — to 
be  found  around  the  ulcerated  spot. 

I  think  it  unnecessary  to  add  anything  here  on  the  subject  of  the  treat- 
ment of  syphilis  in  bone  to  what  has  been  said  (pages  404,  406)  on  the 
general  subject  of  constitutional  syphilis.  Nor  need  I  speak  further 
about  the  rheumatic  and  gouty  affections  of  bone.  So  far  as  they  come 
within  the  province  of  the  surgeon  they  will  be  treated  in  the  next  chapter, 
since  thej^  are  found  chiefly  in  the  articular  ends  of  the  bones. 

Cancer  in  Bone The  soft  or  encephaloid  form  of  cancer  is  that  which 

is  generally  met  with  in  bone,  especially  as  a  primary  affection  ;  the  scir- 
rhous, melanotic,  and  epithelial  forms,  when  they  affect  bones,  do  so 
almost  always  either  as  secondary  formations  or  by  extension  from  the 
soft  parts. 

Osteoid  Cancer. — Primary  cancer  in  the  bones  sometimes  affects  the 
osteoid  form,  and  in  such  cases  reproduces  itself  in  the  same  form  in  the 
glands  and  lungs;  and  it  does  even  happen,  in  A^ery  rare  cases,  that 
osteoid  cancer  occurs  as  a  primary  disease  in  the  soft  parts  ;^  but  for  prac- 
tical purposes  osteoid  cancer  may  be  regarded  as  one  affecting  the  bones 
only,  and  as  being  a  sub-variet}''  of  encephaloid.  Many  malignant  tumors 
of  bone  have  a  base  of  ill-formed,  hard  bone,  but  it  is  only  to  those  in 
■which  the  bony  mass  seems  diffused  throughout  the  cancer,  and  especially 
to  those  in  which  it  is  deposited  in  the  glands,  that  the  name  of  osteoid 
cancer  is  undeniably  appropriate. 

Soft  Cancer. — The  common  kind  of  cancer  of  bones  is  seen  in  three 
different  forms, — periosteal,  interstitial,  and  infiltrated.  The  latter  is  very 
rare.  The  whole  bone  is  replaced  by  a  mass  of  cancer,  in  which,  possibl,y, 
a  few  granular  portions  of  the  original  bone  may  be  formed.  This  con- 
stitutes  one  form  of  mollities  ossium,  for  the  bone   can  now  be  bent 


A  section  of  a  malignant  tumor,  springing  from  tlu'  iicriosteiini  of  the  luimci-us,  and  infiltrating  the 
muscles  and  parts  in  the  neighborhood.  The  bone  ajipears  unafl'ected.  The  arm  was  removed  at  the 
shoulder-joint.— St.  George's  Hospital  Museum,  Ser.  ii,  No.  22.5. 

in  any  direction  ;  but  it  is  too  rare  an  event,  and  the  diagnosis  is  too 
obscure,  to  render  it  worth  while  to  spend  further  time  on  it  here. 

'  Paget,  Surg.  Path.,  vol.  ii,  p.  49G,  ed.  1853. 


CANCER    OF    BONE. 


443 


Fig.  1'J5. 


The  interstitial  form  of  cancer  is  that  in  which  a  noduhir  mass  of  can- 
cerous material  is  deposited  in  the  cancellous  tissue,  which,  as  it  grows, 
infiltrates  and  expands  the  periosteum,  and  finally  bursts  out  into  the 
soft  tissues  until  it  reaches  tlie  skin,  which  is  then  rapidly  disintegrated 
and  gives  way,  allowing  the  cancer  to  fungate  througli  it. 

The  cancellous  tissue  is  sometimes  extensively  eroded  by  these  can- 
cerous deposits,  which,  after  maceration,  leave  irregular  worm-eaten  cavi- 
ties in  the  dry  bone. 

In  the  periosteal  form,  on  the  other  hand,  thebone  may  be  perfectly 
sound,  the  tumor  having  grown  wholly 
outwards,  as  in  the  annexed  figure. 

Diagnofsis. — But  it  is  practically 
impossible  in  mostcases  todistinguish 
one  of  these  forms  from  the  other ; 
nor  is  it  of  much  importance,  since 
both  require  amputation.  The  only 
important  matter  is  to  diagnose  a 
malignant  tumor  from  an  abscess 
and  from  an  innocent  tumor.  The 
former  is  by  no  means  easy,  for  an 
abscess  in  connection  with  the  bone 
is  at  first  tightly  bound  down  by  the 
periosteum  and  other  parts,  so  that 
its  fluctuation  is  not  very  marked  ; 
and  a  malignant  tumor  is  often  so 
soft  that  it  is  very  doubtful  whether 
to  call  the  sensation  fluctuation  or 
not.  Any  small  soft  swelling  appear- 
ing near  the  head  of  the  tibia  is  to 
be  looked  upon  with  suspicion,  as 
this  is  a  very  favorite  seat  of  malig- 
nant disease;  and  in  case  the  ordi- 
nary symptoms  of  abscess  are  ab- 
sent, viz.,  inflammatory  oedema  of  the 
skin,  pain,  and  pointing  of  matter, 
no  confident  opinion  should  be  ex- 
pressed before  exploration  with  a 
grooved  needle.' 

The  diagnosis  between  cancerous 
and  innocent  or  semi-innocent  tumors 
is  very  difficult,  and  is,  perhaps,  we 
may  say,  becoming  more  difficult,  as 
the  distinction  between  malignant 
and  innocent  tumors  is  seen  to  be  less 
marked  than  used  to  be  taught.  Nor 
ought  a  surgeon  to  hesitate  in  saying 
that  he  does  not  know  whether  to  call 


Periosteal  cancer  of  the  tibia.  Tlic  cancer  is 
a  mixture  of  the  hicmatoirl  and  niecUillary  va- 
rieties. The  chief  dejiosit  exists  between  the 
periosteum  and  tlie  hone,  tlie  surface  of  wliich 
has  been  slightly  destroyed.  Corresponding  to 
the  situation  of  the  tumor,  the  cancellous  tissue 
and  medullary  canal  were,  however,  infiltrated 
to  a  very  slight  extent. — St.  George's  Hospital 
Museum,  Ser.  ii,  No.  244. 


1  I  have  seen  even  this  exploration  mislead.  A  very  skilful  surgeon,  believing  tliat 
a  swelling  near  the  os  calcis  was  an  abscess,  but  not  being  sure,  made  a  puncture  with 
a  grooved  needle.  A  lew  drops  of  pus,  or  a  fluid  which  was  taken  for  pus,  escaped. 
Asmail  incision  was  made.  This  gave  rise  to  such  copious  hicmorrhage  that  it  was 
believed  the  posterior  tibial  artery  had  been  wounded.  Accordingly  the  patient  was 
brought  under  the  influence  of  chloroform  and  the  part  freely  laid  t^pen,  when  the 
supposed  abscess  turned  out  to  be  a  malignant  tumor,  and  it  became  necessary  to 
amputate  the  foot. 


444  DISEASES    OF    THE    BONES. 

a  tumor  before  removal  cancerous  or  sarcomatous.  Practically  the  ques- 
tion resolves  itsclfinto  the  necessity  for  amputation  and  into  the  prognosis 
which  must  be  given  of  the  case  afterwards.  Now,  I  think  we  shall  not  be 
wrong  in  saying  that  a  tumor  of  bone  is  to  be  regarded  as  malignant,  and 
amputation  is  to  be  pressed  upon  the  patient  as  being  necessarj',  when- 
ever the  tumor  is  large,  soft,  growing  rapidly,  covered  with  large  veins 
(which,  indeed,  are  only  an  evidence  of  its  rapid  growth  and  tlie  conse- 
quent profuse  blood-supi)l_y  with  obstructed  return),  and  involves  a  con- 
sidei'able  surface  of  the  bone.  But  there  are  other  considerations  also 
which  ought  not  to  be  laid  out  of  sight,  and  which  Sir  J.  Paget  has  thus 
expressed  ■? 

''1.  The  tumor  is  probabl}^  cancerous  if  its  growth  commenced  before 
puberty  or  after  middle  age,  unless  it  be  a  cartilaginous  or  bony  tumor 
on  a  finger  or  toe  or  near  an  articulation. 

"  2.  If  a  tumor  has  existed  on  or  in  a  bone  for  two  or  more  years,  and 
is  still  of  doubtful  nature,  it  is  probabl}'  not  cancerous  or  recurrent,  and 
this  probability  increases  with  the  increasing  duration  of  the  tumor. 

"o.  If  a  tumor  on  or  in  a  bone  has  doubled  or  more  than  doubled  its 
size  in  six  months,  and  is  not  inflamed,  it  is  probably  cancerous  or  recur- 
rent; and  this  probability  is  increased  if,  among  the  usual  coincidences 
of  rapid  growth,  the  veins  over  the  tumor  have  much  enlarged,  or  the 
tumor  has  protruded  far  through  ulcerated  openings  and  bleeds  and  pro- 
fusely discharges  ichor. 

"4.  If  with  any  such  tumor,  not  being  inflamed,  the  lym])h-glands 
near  it  are  enlarged,  it  is  probably  cancerous,  and  still  more  probabl}-  if 
the  patient  have  lost  weight  and  strength  to  amounts  more  than  propor- 
tionate to  the  damage  of  health  by  pain,  or  fever,  or  other  accident  of  the 
tumor. 

"5.  A  tumor  on  the  shaft  of  any  bone  but  a  phalanx  is  rarely  innocent, 
and  so  are  any  but  cartilaginous  outgrowths  on  the  pelvis,  or  any  but 
the  hard  Ijou}'  tumors  on  the  bones  of  the  skull." 

If  a  tumor  in  bone  be  diagnosed  as  being  cancerous,  and  there  is  no 
evidence  of  cancer  in  other  j^arts,  nor  of  cancerous  cachexia,  its  removal 
is  plainly  indicated.  It  is  safer  to  amputate  the  member,  if  possil)le,  above 
the  affected  bone;  thus,  in  cancer  of  the  tibia  amputation  should  be  per- 
formed through  the  thigh,  and  in  cancel-  of  tlie  femur  some  surgeons 
dwell  much  on  the  importance  of  removing  the  whole  femur  by  amjjuta- 
tion  at  the  hip.  But  the  immediate  danger  of  nmputation  at  the  hip  is 
very  great,  and  the  immunitv  which  it  gives  from  the  return  of  the  dis- 
ease is  certainly  not  proved  to  be  greater  than  in  amputation  through  the 
<^ontinuity  of  the  femur.  I  have  seen  several  cases  in  which  the  cancer 
recurred  in  the  lungs  very  shortly  after  recover}'  from  amputation  at  the 
hip.  On  the  other  hand  I  am  now  watching  a  case  where  a  young  man 
has  remained  free  from  any  recurrence  for  four  years  after  amputation 
through  the  middle  of  the  femur,  though  the  disease  was  well-marked  soft 
cancer. 

Much  more  promising  as  far  as  prognosis  goes  are  those  cases  of  epi- 
thelioma of  the  soft  parts  spreading  down  into  the  bone,  which  furnish 
the  only  examples  whicii  I  iiave  met  witii  of  e[)ithelial  cancer  of  bone. 
The  tibia  is  the' usual  seat  of  tlie  aflection  (Fig.  IDO).  It  is  essentially 
chronic  in  its  course,  and  it  is  often  a  very  long  time  before  the  bone 
is  attected.  I  have  now  under  treatment  a  patient  with  epithelioma  (jf  the 
scalp,  originating  in  a  wound  received  in  the  Crimean  war,  and  wliich 

1  Med.-Chir.  Trans.,  vol.  liv,  p.  260. 


INNOCENT    TUMORS. 


445 


Fig.  196. 


has  never  healed,  in  vvlioin  the  cranium  has  not  yet  become  implicated. 
And  when  the  bone  is  affected  repeated 
partial  removals  may  be  practiced  (as  in 
the  case  referred  to  in  the  fioure)  withont 
causing  the  evil  results  which  in  other 
forms  of  cancer  such  inadequate  opera- 
tions entail.  But  it  is,  no  doubt,  much 
better  to  amputate  far  away  from  the  dis- 
ease ;  and  if  this  is  done  before  the  glands 
are  affected  the  patient  has  a  fair  chance 
of  remaining  free  from  a  return  of  the 
tumor  for  a  long  time. 

Myeloid  and  Sarcomatous  Tuviors. — 
Many  of  the  tumors  which  in  former  days 
would  have  been  unhesitatingly  described 
as  cancerous  are  now  regarded  as  sar- 
coma, especially  that  form  of  sarcoma  de- 
scribed on  page  oG5  as  myeloid  or  "giant- 
celled''  sarcoma.  In  fact,  many  modern 
pathologists  teach  that  the  tumors  formerly 
described  as  "cancer"  of  the  bones  are 
almost  always  sarcomatous,  and  that  true 
carcinoma  hardly  ever  affects  the  bones. 
The    distinctive    characters    of    m^'eloid 

or     sarcomatous    tumors    from    carcinoma       a  section  of  the  skin  and  of  the  shaft 
are    to    be    found     in    their    slower    rate    of    of  the  tibia  in  a  case  of  epithelial  cancer 

growth,  in   their  not  affecting  the    parts   ^°":  ^.'"'^^  ^^"^  ^'^  ^^^  amputated.   The 

°  '.         i-i  !•  !•        skin  IS  seen  to  present  a  large  ulcerated 

around,  in  their  lower  vascularity,  and  m   space,  which  is  continued  downwards  into 

the   freedom   from    contamination   of  the 

glands.     After  removal  a  myeloid  tumor 

will  be  found  to   be  more  circumscribed, 

growing  from  a  single  centre  (while  cancer 

is  frequently    deposited    in   several   inde-    ,.        , 

,        .  "t     1       \  T  11  diseased   part,   and   its   medullary  canal 

pendent    nodules),    and     much    less    prone     obliterated  for  some  distance.    The  ulcer 


a  cavity  hollowed  out  in  the  shaft  of  the 
bone.  The  cavity  is  of  large  size,  irregu- 
lar in  form,  and  lined  by  a  thick  layer 
of  firm  substance,  which  is  continuous 
with  the  ulcer  on  the  surface  of  the  skin. 
The  bone  is  much  thickened  around  the 


on  the  surface,  the  firm  lining  of  the 
cavity  in  the  shaft  of  the  bone,  and  the 
soft  matter  infiltrated  in  the  cancelli 
above  that  part,  consist  entirely  of  scaly 
epithelium    packed    together    by   a    fine 


to  break  down  and  to  ulcerate.     The  mi 
croscope  will  complete  the  diagnosis. 

Innocent     Tumors. — The    innocent   tu 
mors  of  bone  are   cartilaginous  (enclion 

droma),    bony    (exostosis),    fibrous    (fibro-  g'-a""lar  substance.    The  patient  was  a 

..    /  1  i-  /-I      i-1        •  ^  man  aged  54,  and  the  disea.se  was  referred 

cystic),  and  cystic.      Cartilaginous  tumors,  ^^  a  blow  received  two  years  previously, 

or    enchondromata,    have    been     spoken    of  six  months  after  which  a  tumor  formed 

above  (page  351),  in  their  general  aspect  ^^  the  part  struck  and  rapidly  sprouted 

„„    tl.„,r  ^l.,..,„    ;.,    ^i\,„..   ,^„..t^.        riM,„ „  out   of  the  skin.    This  tumor  had  been 

as  tney  occur  in  otlier  parts.      Ihey  are,  , ..       ..       ,    .i    i    ■<•      j 

•'  i  «'  '  removed  three  times  by  the  knite,  and  a 

however,  more  common  in  the  bones  than  fourth  time  by  caustic,  along  with  a  scale 

in    any    other    part,  and    they    grow    slowly  of  bone,  before  the  limb  was  amputated. 

and  often    to  a  very  large    Size,i  displacing  "^   recovered  from  the  amputation,  but 

,,,  i-ii  1  J    •  the  subsequent  progress  of  the  case  is  not 

all    the    structures  of    the    part,  but    not  in-  known.-St.  George's   Hospital   Museum, 

filtrating  them,  and  showing  no  tendency  ser.  ii.  No.  238. 


1  In  Mr.  Gatngee's  case  a  cartilasjinous  tumor  growing  from  the  femur  had  at- 
tained so  large  a  size  that  the  bmb  after  amputation  at  the  hip-joint  weighed  99  lbs. 
See  Mr.  Gamgee's  History  of  a  Successful  Case  of  Amputation  at  the  Hip-joint, 
1865,  where  similar  ca.«es  of  large  enchondroma  are  referred  to  under  the  care  of 
Mr.  Frogley  and  Sir  P.  Crampton. 


446 


DISEASES    OF    THE    BONES. 


to  recur  when  completely  removed.  They  are  either  multiple  or  solitary, 
they  either  do  or  do  not  ossify,  and  they  occur  either  in  the  difl\ised  or 
the  circumscribed  form.     It  is  the  solitary  and  the  circumscribed  enchon- 

dromata  which   show  the  greatest 
^Fio.  lav.  tendency  to  ossification  ;    the   dif- 

fused and  multiple  enchondromata, 
such  as  are  seen  tolerably  often 
on  the  phalanges  (Fig.  197),  show 
little  or  no  tendency  to  the  formation 
of  bone,  though  in  the  process  of 
time  they  degenerate  into  a  low,  cal- 
careous, or  fibro-calcareous- forma- 
tion, in  which  cysts  are  often  found. 
Such  enchondromata  in  the  hand 
sometimes  reach  an  enormous  size. 
Dr.  Martyn^    has  recorded  one  in 

EnclioiKlroiuataof  the  fingers  and  hand,  from  a  wlijch  the  weight  of  the    liauds  be- 
east  in  the  Museum  of  St.  George's  Hospital.    The  i  i"!     4.  i.1  J.-       ^  ij 

patient  was  a  lad  about  15  years  of  age.    There  is  a  '•^'^"^_  ^O  great  that  the  patient  COuld 

large  tumor  on  the  thumi>,  and  a  swelling  of  the  UOt  lift  them,  and  in  which  the  feet 

end  of  the  radius,  due  probably  to  the  same  cause.  were    simultaneously    affected,    but 

this  is  unusual.  No  treatment  can 
be  proposed  in  such  cases  except  amputation,  which  is  necessary  when,  the 
hand  or  foot  has  become  entirely  useless.  The  tarsus  would  be  left  in 
the  case  of  the  foot,  or  a  portion  of  it,  if  the  extent  of  the  disease  pre- 
vented the  formation  of  a  flap  entirely  in  front  of  the  tarsus. 

Cysts  ai'e  also  often  found  iu  enchondromatous  tumors  which  show  no 
trace  of  degeneration.^  The  structure  of  enchondroma  is  usually  that  of 
pure  hyaline  cartilage,  indistinguishable  from  the  normal  tissue. 

The  diagnosis  of  enchondromata  depends  on  their  hard,  lobulated  sur- 
face (sometimes,  however,  with  a  certain  amount  of  elasticity,  if  the  car- 
tilaginous tissue  is  soft,  or  if  there  is  a  cyst  in  the  interior  of  tlie  tumor), 
their  slow  growth,  and  the  absence  of  all  other  s3Mnptoms.  When  they 
grow  (as  they  often  do)  from  the  interior  of  a  bone,  the  shell  of  the  bone 
may  be  expanded  over  the  surface,  and  may  be  felt  to  yield  with  a  crepi- 
tating sensation.  Generally  there  is  little  difficulty  about  the  diagnosis, 
for  the  symptoms  are  usually  quite  different  from  those  of  cancer;  there 
is  not  the  hardness  of  exostosis,  and  the  otlier  innocent  tumors  of  bone 
are  very  rare. 

The  treatment  must  be  by  amputation  or  enucleation.  The  former  is 
required  in  cases  of  multiple  enchondromata,  when  any  treatment  is  indi- 
cated, in  very  large  tumors,  and  generally  when  the  operation  for  removal 
of  the  tumor  would  leave  the  member  useless.  Sir  J.  Paget'  has  shown 
how  much  better  the  prospects  of  recovery  by  enucleation  are  than  used 
to  be  believed  ;  and  since  the  publication  of  his  paper  amputation  will  be 
less  frequently  resorted  to,  at  any  rate  without  preliminary  incision,  in 
order  to  ascertain  the  nature  of  the  tumor.  It  is  in  sucli  exploratory 
operations  tliat  the  ''bloodless  method"  recommended  by  Professor 
Esmarch   (see  the  chapter  on  Operative  Surgery)  finds  one  of  its  most 


*  Path.  Trans  ,  vol.  xxii.  j).  252. 

2  Soe  a  bountiful  ])r('paration  in  the  Museum  of  the  Royal  College  of  Surgeons, 
No.  20;^  A,  which  is,  I  believe,  Mr.  Frogley's  preparation,  described  and  lij;ured  in 
the  Mcd.-Chir.  Trans.,  vol.  xxvi  ;  and  in  Syst.  of  Surgery,  vol.  iii,  p.  816. 

'  Med.-Chir.  Trans.,  vol.  liv,  cases  1  to  3,  pp.  254-5. 


EXOSTOSIS. 


447 


striking  uses.  Under  the  elastic  bandage,  properly  applied,  the  tissue 
and  the  relations  of  the  tu- 
mor can  be  studied  on  the  ^^*^'  ^^^• 
living  subject  almost  as 
easily  as  on  the  dead,  and 
any  vessels,  nerves,  or  other 
important  structures,  as 
easily  dissected  oft'  the  tu- 
mor. Such  operations,  how- 
ever, will  occasionally  ter- 
minate in  amputation,  a 
contingency  which  must  be 
provided  for  before  com- 
mencing. I  would  refer  to 
Fig.  198,  whicli  shows  a 
very  large  en  chondroma 
springing  from  the  humerus 
outside  the  shoulder-joint. 
At  the  period  of  the  opera- 
tion the  large  size  of  the 
growth  left  the  operator  no 
choice ;  but  at  an  earlier 
stage  of  the  disease  it  would 
have  been  a  perfectly  justi- 
fiable proceeding  to  have 
attempted  the  removal  of 
the  tumor  alone,  preserving 
the  arm.  Yet  the  operator 
might  easily  have  been  baf- 
fled in  the  attempt  by  find- 
ing the  great  vessels  and 
nerves  so  buried  in  the  mass 


A  cartilaginous  tumor  of  the  humerus,  of  two  years' 
growth,  springing  from  the  compact  tissue,  and  encroaching 
on  the  cancellous  structure.  It  was  removed  by  amputation 
at  the  shoulder-joint,  and  the  patient  was  seen  quite  well, 
two  years  afterwards.  On  microscopic  examination  the  tu- 
mor was  found  to  consist  of  large  oval  cells,  with  one  or  two 
nuclei,  the  wall  of  many  being  indistinct.  These  were  closely 
placed  in  a  finely  granular  matrix,  which  in  some  parts  was 
dimly  fibrillated. — St.  George's  Hospital  Museum,  Ser.  ii,  No. 
176  a. 


that  he  coidd  not  hope  for 

any  usefulness  in  the  member  after  the  operation,  and  would  find  himself 

compelled  to  resort  to  amputation. 

Exostoi^is^  or  bony  tumor  springing  from  a  bone,  is  a  comparatively 
common  aflTection  in  some  parts  of  the  body,  and  occurs  under  three  chief 
forms.  The  first  is  the  ivory  or  hard  exostosis,  which  is  composed  of 
})one  resembling  the  compact  shell  of  the  long  bones  or  the  external  table 
of  the  skull,  from  which  it  often  springs,  but  even  more  compact,  so  that 
it  exactl}'  resembles  ivory,  no  pores  or  bone-fibres  being  visible  in  its 
section.  On  microscopic  examination  these  ivory  exostoses  show  the 
lacunae  and  the  vascular  canals  of  true  bone,  but  the  lacunse  are  more 
irregularly  distributed,  and  the  vascular  canals  are  more  numerous  and 
smaller  than  the  Haversian  canals.^ 

This  form  of  exostosis  is  met  with  only  in  connection  with  the  bones 
of  the  skull  and  face,  and  especially  on  the  vertex  of  the  skull  and  on  the 
lower  jaw  (Fig.  199).  It  never  attains  a  larger  size  except  when  it  grows 
into  one  of  the  cavities, — the  orbit  or  the  antrum.  Its  growth  is  very  slow, 
and  as  a  oreneral  rule  such  tumors  are  best  left  alone.     Their  removal  is 


1  See  Path.  Trans.,  vol.  xvii,  plate  13,  for  drawings  and  description  of  the  micro- 
scopic examination  of  Dr.  Duka's  case  of  ivory  exostosis,  figured  below,  p.  448. 


448 


DISEASES    OF    THE    BONES. 


often  extremely  difficult,  in  consequence  of  their  great  hardness;  and 

the  violence  which  is  neces- 
sary for  this  purpose  in- 
volves very  great  danger; 
while  the  tumor  can  lead  to 
no  ill  consequences,  apart 
from  the  trifling  deformity 
which  it  causes.  But  to 
this  rule  an  exception  must 
certainly  be  made  in  the 
case  of  ivory  exostosis  of 
the  orbit.  The  gradual 
growth  of  such  a  tumor 
displaces  the  e3'e,  causing 
blindness  by  the  stretching 
of  the  optic  nerve,  and  a 
very  hideous  squint.  The 
base  (which  is  usually  at- 
tached to  the  inner  or  outer 
angle  of  the  root  of  the  or- 
bit) is  often  of  no  large  size, 
and  when  full}^  exposed  can 
be  partially  cut  tlirough 
with  a  fine  saw,  and  then 
broken  with  a  few  blows  of  a 
chisel  and  hammer.  If  the  operation  have  not  been  too  long  delayed  the 
eye  will  return  into  position  and  sight  will  be  restored.  It  is  well  not  to 
go  too  near  to  the  skull  in  making  the  section,  though  this  must,  of  course, 
depend  on  the  shape  of  the  tumor's  neck.  Again,  an  exception  may  be 
made  in  ivory  exostosis  of  the  antrum.  These  exostoses  often  have  very 
small  bases,  and  are  found  to  have  undergone  fracture  at  their  neck  and 
to  be  lying  loose  in  the  antrum.  Such  was  the  case  in  the  instance  which 
furnished  the  preparation  here  figured,  and  which  occurred  in  a  native 
of  India,  a  patient  of  Dr.  Duka.^  On  removing  the  front  wall  of  the  lower 
jaw  the  large  mass  of  ivory-like  bone  here  figured  was  found  lying  quite 


Ivory  exostosis  of  the  lower  jaw.  There  is  no  history,  but 
the  preparation  has  evidently  been  taken  from  the  body  of  a 
Tery  old  person. — St.  George's  Hospital  Museum,  Ser.  ii,  No. 


A  shows  the  general  appearance  and  n  the  appearance  on  section  of  the  bony  tumor  removed  from 
the  antrum  by  Dr.  Duka,  the  account  of  which  is  to  be  found  in  the  Path.  Trans.,  vol.  xvii,  p.  256.  The 
position  of  the  tumor  during  life  was  the  reverse  of  that  here  shown  —St.  George's  Hospital  Museum, 
Ser.  ii.  No.  191  a. 

loose,  its  attachments  having  been  separated  either  by  the  weight  of  the 
mass  or  by  some  accidental  violence. 

It  may  l)e  mentioned,  as  some  encouragement  to  the  attempt  to  remove 
such  tumors  when  it  is  otherwise  indicated,  that  the  neck  of  the  tumor  is 


^  Path.  Soc.  Tran.s.,  vol.  xvii. 


EXOSTOSIS. 


449 


Fig.  201. 


sometimes  much  smaller  than  its  size  would  lead  one  to  expect,  and  also 
that  the  interior  may  be  cancellous,  while  the  exterior  appears  perfectly 
ivory-like.  Such  was  the  case  in  a  remarkal)le  tumor  of  the  skull  de- 
scribed and  figured  by  Mr.  Ilott.'  The  patient  had  consulted  many  emi- 
nent surgeons^  but  all  had  shrunk  from  the  apparent  danger  of  removing 
it,  believing  that  the  neck  was  of  great  breadth,  and  of  ivory-like  consist- 
ence. On  the  contrary,  when  the  patient  died  it  was  found  that  the 
tumor  was  of  a  mushroom-shape,  the  neck  comparatively  small,  and  the 
interior  of  the  tumor  wholly  cancellous.  The  tumor  might,  therefore, 
probably  have  been  removed  with  safety.  On  the  other  hand,  many  his- 
tories show  the  risks  that  may  be  encountered  in  such  attempts.  There  are 
in  St.  George's  Hospital  Museum  two  preparations,  one  showing  a  small 
bony  tumor  with  the  marks 
of  a  trephine  with  which  and 
other  instruments  Mr.  Keate 
strove  in  vain  for  more  than 
an  hour  to  take  away  the  little 
lump,  but  was  obliged  to  desist. 
The  patient  obstinately  refused 
to  submit  to  the  slight  deform- 
it}^,  and  was  ultimately  re- 
warded for  his  perseverance  by 
its  removal.  Repeated  applica- 
tions of  strong  nitric  acid  and 

potassa  fusa  at  intervals  during        ivory  exostosis,  winch  was  trephined,  unsuccessfully, 
several    VearS    produced    its  ex-    on  account  of  its  great  hardness.     Exfoliation  was  after- 

foliation,  but  at  an  expense  of  '''''^y^'^t^f  ""^  ''" -T^TfZtt.T^^^^^^^^^ 

'  .     '    ,.  caustics,  chiefly  nitrio  acid. — St.  Georges  Hospital  Mu- 

pain    and    danger    quite  dispro-    seum,  Ser.  li,  No.  ISO.    From  Syst.  of  Surg.,  2d  edition 

portionate    to    the    result.     In    vol.  iii,  p.  822. 

the  other  case  Sir  A.  Cooper 

had  tried  to  saw  off  a  small  ivory  exostosis  from  the  margin  of  the  orbit, 

but  in  vain.     This  also  exfoliated  after  repeated  applications  of  caustic, 

and  the  marks  of  the  saw  are  still  to  be  seen  upon  the  little  tumor. 

The  soft  or  cancellous  exostosis  is  a  much  more  manageable  disease, 
and  operations  for  its  removal  are  at  any  rate  under  certain  circumstances 
justifiable.  It  grows  either 

as  an  outgrowth,  consist-  fig.  202. 

ing  primarily  of  bone,  or 
as  the  result  of  the  ossifi- 
cation of  a  cartilaginous 
tumor.  In  the  latter  case 
the  internal  tumor,  com- 
posed of  cancellous  bone, 
is  surrounded  and  encased 
by  a  layer  of  cartilage. 
The  favorite  seats  of  ex- 
ostosis are  in  the  neigh- 
borhood of  the  epiphyses, 

,•       1     .1  ,    fl                 f   tVi  A  small  exostosis  of  the  femur,  situated  just  above  the  internal 

particularly    tnose    01    tne  condyle.    The  neck- of  the  tumor,  shown  at  the  upper  part  of  the 

femur    and    humerus,   and  woodcut,  is  composed  of  firm  cancellated  bone;  the  part  marked 

on    the    extremity    of    the  <»  of  opaque  white  cartilage,  composed  of  large  cells,  of  an  oval 

last  phalanx   of   the  great  or  circular  form  closely  approximated^  The  surface  of  the  t^mor 

*                                      p  IS  covered  by  a  thin  incrustation  of  fibro-cartilage. — St.  Greorge's 

toe  ;   but  they  occur  in    all  Hospital  Museum,  Ser.  ii.  No.  178. 

1  Path.  Soc.  Trans.,  vol.  iii,  p.  149. 
29 


450 


DISEASES    OF    THE    BONES. 


parts  of  the  body.  They  should  only  be  removed  in  consequence  of  some 
symptom  caused  b}'  their  presence  greater  than  the  risk  of  removing 
tliem  would  be,  for  there  is  no  doubt  that,  as  a  rule,  if  not  always,  their 
tendency  is  to  stop  growing.  Hence  on  the  great  toe,  where  the  little  tumor 
causes  serious  inconvenience  in  walking,  and  it  can  be  removed  with  hardly 
any  danger,  this  should  always  be  done;  but  when  the  exostosis  is  deeply 
seated  (as  in  the  very  common  instance  of  that  which  grows  just  above  the 
internal  condyle  of  the  femur)  and  is  near  important  structures,'  it  is  ver}"" 
doubtful  whether  the  patient  is  well  advised  in  incurring  any  great  risk  in 
order  to  avoid  inconveniences  which  after  all  are  often  tritiing,  and  which 
may  be  trusted  not  to  increase.  If  the  surgeon  have  made  up  his  mind  to 
operate  he  may  be  certain  that  the  removal  of  the  surface  and  the  greater 
part  of  the  neck  of  the  tumor  will  perfectly  suffice  to  stop  the  disease; 
110  renewed  growth  need  be  apprehended.  In  the  cartilaginous  exostosis 
all  the  ossifying  material  is  removed  in  such  an  operation,  and  in  the 

bony  outgrowth  the  remains  of 
^i^'-  -^'^-  the  neck  never,  as  far  as  1  know, 

are  the  origin  of  any  renewed 
growth. 

It  has  often  been  noticed 
that  exostoses  sometimes  suffer 
fracture,  and  a  remarkable  case 
has  lately  been  pul)lished-  in 
which  an  exostosis  of  the  femur, 
having  been  thus  broken  off 
from  the  bone,  became  entirely 
absorbed,  so  that  a  tumor  which 
^  seemed  at  first  to  be  of  the  size 
and  sliape  of  a  walnut  left  no 
trace  whatever  of  its  existence; 

Exostosis  of  the  finger,  springins from  the  base  of  the  and  Mr.    Maundcr''    haS  related 
first  phahinx,  in  a  man  aged  58.    The  bone  is  seen  to  be  .  i  •    i      i        i         4.     ^ 

healthy.    The  whole  tumor  is  co.npletely  ossified  into  ^  ^ase  HI    whlch    he    treated    an 

spongy  bone,  with  the  exception  of  a  very  thin  layer  of  exOStOSis  in  this  rcgiou   by  fraC- 

cartilage  which  covers  its  surface  (on  the  unshaded  per-  turing  its  neck,  with  what  rcSult 

ier.nJo'isT^"""^'^''  '^'°''^'''  ""'"'"  ''"''"'"'  is  not  yet  known.  The  treat- 
ment, however,  is  eminentl}'' 
worthy  of  trial.  If  the  exostosis  is  not  absorbed  after  the  fracture  of  its 
neck,  and  its  presence  gives  the  patient  inconvenience,  it  might  be  re- 
moved when  loose  with  far  less  danger  than  is  involved  in  cutting  through 
its  base.  Fig.  203  will  illustrate  the  feasibility  of  tliis  method  of  treat- 
ment. A  tumor  so  large  as  this  relatively  to  its  neck  could  easily  be 
divided  from  its  attachments,  either  by  fracture  or  by  subcutaneous  section 
with  a  chisel  or  fine  saw,  and  passive  motion  would  prevent  any  tendency 
to  reunite. 

The  diffused  bony  tumor  is  illustrated  b}^  the  accompanying  figure 
(■204),  showing  a  large  lol)ulated  mass  of  bone  envelo|)ing  the  jaw  for  a  con- 
siderable distance,  and  only  removable  by  extirpation  of  the  whole  of  the 
Ijonefrom  which  it  grows.  Another  and  a  very  singular  case  is  illustrated 
by  a  series  of  three  preparations  in  the  Museum  of  the  College  of  Sur- 
geons, in  which  after  amputation  on  account  of  such  a  tumor,  situated 


'  The  knee-joint  hasoftcn  lieen  opened  in  removing  this  exostosLs,  for  in  such  case.s 
previou.*  attacks  of  inflammation  may  have  enlarged  the  synovial  membrane  beyond 
its  natural  limits. 

'•^  Dr.  Chicnc,  Ed.  Med.  Juur.,  July,  1874. 

3  Ibid  ,  Aug.,  1874. 


TUMORS    OF    BONE. 


451 


near  the  knee,  the  tumor  recurred  in  the  stump  five  years  afterwards ; 
reamputation  was  performed,  and  then  the  disease  again  recurred  in  the 
pelvis.  The  tumor  couhl  not  have  been  malignant,  for  the  duration  of 
the  affection  was  no  less  than  twenty-five  years,  and  the  patient  died  only 


A  cliffused  bony  tumor  of  the  lower  jaw  (diffused  exostosis),  removed  with  success  at  St.  George's 
Hospital,  by  Mr.  Tatum.  a  shows  the  articular  surface  of  the  jaw  ;  6,  the  symphysis.  The  operation 
consisted  in  the  removal  of  the  whole  of  that  side  of  the  bone.— Path.  Soc.  Trans.,  vol.  ii,  p.  59.  St. 
George's  Hospital  Museum,  Ser.  ii.  No.  185. 

of  the  local  consequences  of  the  pressure  of  the  tumor.^  Other  similar 
cases  have  been  noticed,  and  they  bear  a  remarkable  analogy  to  those  of 
the  recurrent  fibroid  tumor  of  soft  parts. 

Innocent  Soft  Solid  Tumors. — The  other  innocent  solid  tumors  are 
rare,  if  we  except  epulis  and  fibrous  or  naso-pharyngeal  polypus,  which 
are  treated  of  in  other  chapters.  They  generally  grow  from  the  perios- 
teum, and  are  of  the  fibrous,  "  fibro-cellular,"  or  fibro-cystic  variety.  Very 
commonly  they  are  mistaken  for  enchondroma  before  operation  ;  and  as 
tiie  treatment  and  the  prognosis  are  the  same,  the  mistake  is  of  no  impor- 
tance, nor  can  I  lay  down  any  trustwortiiy  rules  for  the  diagnosis.  The 
majority  of  such  tumors  seem  to  be  connected  with  the  femur.- 

Cystic  tumors  of  bone  are  serous  and  sanguineous.  The  former,  if  they 
are  not  confined  to  the  jaws  (as  Mr.  Stanley  believed  them  to  be),  are  at 
any  rate  only  known  in  that  situation,  and  these  are  in  all  probability 
always  caused  by  some  irritation  around  the  teeth-cavities.  They  form 
sometimes  enormous  tumors  in  the  jawbones  (usually  the  lower),  with 
the  wall  formed  in  some  parts  by  thin  crepitating  bone,  in  others  by 
fibrous  tissue,  and  containing  clear  fluid.  The  diagnosis  is  easily  made 
by  puncture. 

In  other  bones  the  presence  of  hydatids  has  given  rise  to  the  formation 
of  cavities  containing  a  thin  fluid,  but  whether  independently  of  hydatids 
serous  cysts  form  in  other  bones  seems  doubtful. 

Both  forms  require  similar  treatment,  viz.,  to  be  laid  open  pretty  freely, 


1  See  Syst.  of  Sure;  ,  vol.  iii,  p.  825,  2d  ed. 

2  See  Adams  and  Hewett,  in  Path.  Trans.,  vol. 


254. 


452  DISEASES    OF    THE    BONES. 

when  if  hydatids  are  found  they  are  to  be  evacuated,  otherwise  the  open- 
ing- is  to  be  kept  free  and  the  cyst  left  to  fill  up  gradually.  In  a  case 
which  furnished  a  preparation  to  the  Museum  of  St.  George's  Hospital, 
Sir  B.  Brodie  removed  the  whole  side  of  the  lower  jaw,  on  account  of  an 
unusually  large  cyst  of  this  nature,  but  the  operation  proved  fatal  from 
erysipelas.  I  never  saw  one  of  so  large  size,  but  have  seen  a  few  smaller 
ones  which  have  done  well  under  the  simpler  treatment. 

The  blood-cysts  in  bone  are  still  rarer,  and  many  of  the  cases  were 
clearly  only  instances  of  malignant  or  myeloid  (sarcomatous)  tumors, 
witli  blood-cysts  of  very  large  proportionate  size  formed  in  them.  I  must 
refer  the  reader  to  the  authorities  named  below'  for  illustrative  cases. 
The  treatment  would  generally  consist  in  laying  open  and  stuffing  the 
C3'st  if  no  tumor  formation  could  be  detected  in  the  walls,  otherwise  in 
excision  oi'  amputation. 

Pulf<afi7ig  Tumors. — One  remarkable  feature  of  tumors  of  bone  is  pul- 
sation. This  sj^mptom  when  seen  is  usually  taken  as  a  proof  that  the 
tumor  is  cancerous.  It  has,  however,  been  noticed  undeniabl}'  in  myeloid 
tumors,  and  in  others,  as  to  which  no  evidence  existed  of  malignancj-; 
nay,  in  some  where  the  course  of  the  disease  afterwards  showed  that  it 
could  not  have  been  cancerous.  Some  of  the  latter,  in  which  nothing 
but  vascular  tissue  was  discoA^ered,  are  regarded  as  being  examples  of 
the  disease  described  by  Breschet,  under  tiie  name  of  Aneurism  of  the 
bones  (osteo-aneurism),  and  which  he  believed  to  be  formed  entirely  of 
dilated  bony  capillaries,  just  like  the  aneurism  by  anastomosis  of  soft 
parts.  When  a  tumor  of  bone  pulsates  it  will  most  commonly  be  found 
to  be  a  cancer  in  which  there  is  a  space  or  more  commonly  several  spaces 
communicating  with  the  arteries  which  supply  the  tumor,  and  large  enough 
to  give  rise  to  pulsation  perceptible  to  the  eye  and  the  hand.  The  pulsa- 
tion is  also  sometimes,  though  more  rarel}',  perceptible  to  the  ear,  and 
thus  the  symptoms  resemble  those  of  aneurism  so  very  nearly,  that  when 
the  tumor  grows  in  the  neighborhood  of  some  large  artery,  as  in  the 
abdomen,  near  the  course  of  the  aorta  or  iliac  arteries,  in  the  buttock, 
near  the  gluteal,  or  in  the  femur,  near  the  popliteal  or  femoral  artery,  the 
mistake  has  been  committed  by  the  most  eminent  surgeons,  even  after 
deliberate  and  repeated  consultation,  and  that  in  both  wa^ys,  i.  e.,  aneu- 
rism has  been  mistaken  for  malignant  tumor,  as  well  as  the  reverse.  I 
think  tills  is  sufficient  evidence  that  in  the  present  state  of  surgery  the 
mistake  is  ine\ital)le.-  The  main  points  of  distinction  between  the  two 
diseases  are  tlie  following:  Aneurisms  usually  have  a  distinct  and  loud 
bruit,  i)ulsatile  tumors  none  at  all,  or  an  indistinct  one.  Aneurisms  have 
an  expansive  lateral  pulsation  (as  well  as  the  up  and  down  pulsation), 
and  this  is  not  usually  the  case  in  pulsatile  tumors.  Aneurism  does  not 
aflfect  the  bone  unless  it  has  eroded  or  absorbed  it  (which  is  rare  in  the 
limbs) ;  pulsatile  tumor  is  very  commonly  accompanied  by  some  expan- 
sion of  the  bone  on  which  it  grows.  Aneurism  can  usually  be  moved  to 
some  extent  on  the  subjacent  l^one  ;  pulsatile  tumors  are  hardly  known 
except  as  springing  from   l)ones,  and  therefore  incorporated  with  them. 

'  Traverp,  Med. -Chir.  Trans.,  vol.  xxi.  Stanley,  Dis.  of  the  Bones,  p  187.  Liston, 
so-callod  Ossified  Aneurism  of  tlio  Subclavian  Artory,  Ed.  Med.  and  Surg.  Journ.,  vol. 
xvi,  pp.  fJ6,  2ir).     N<;laton,  Patli.  Cliir.,  vol.  ii,  p. "48. 

'•^  Cases  of  erroneous  diaLcniisis  jiavo  been  publislnid  in  the  case  of  abdominal  tumor 
under  Sir  J.  Pai^et'ii  care,  of  u;luteal  under  Mr.  (iutbri(;'s,  of  popliteal  under  Mr. 
Pollock's;  and  are  referred  to  in  a  paper  of  mine,  On  the  Diagnosis  of  Aneurism,  in 
the  7th  vol.  of  the  St.  George's  Hospital  Reports. 


MOLLITIES    OSSIUM.  453 

Aneurisms  are  often  of  longer  duration  tiian  pulsatile  tumors  attain 
without  fungating  or  destroying  the  patient's  general  health. 

It  is  by  a  careful  consideration  of  all  these  symptoms  tliat  the  diagnosis 
must  be  made  ;  and  in  any  case  of  doubt  it  seems  the  surgeon's  clear  duty 
to  give  the  patient  the  benefit  of  it,  and  to  select  the  milder  operation  of 
ligature  of  the  main  artery  in  preference  to  amputation,  especially  con- 
sidering that  if  the  tumor  do  turn  out  to  be  malignant  even  the  latter 
operation  would  probably  give  only  a  brief  respite. 

If  the  case  is  evidently  one  of  pulsatile  tumor  of  a  bone,  amputation  is 
as  a  general  rule  to  be  advised  when  possible  ;  but  there  are  pulsating 
tumors  which  can  be  eradicated  with  success,  as  is  proved  by  the  cases 
related  by  Sir  J.  Paget  (op.  cit.,  pp.  25(5-7),  in  one  of  which  the  tumor 
turned  out  to  be  of  a  filirous  nature,  and  the  patient  was  known  to  have 
remained  in  good  health  ten  years  after  its  enucleation.  In  one  other 
case  a  tumor  believed  to  be  merely  an  aneurism  of  the  bone  was  success- 
fully enucleated  by  means  of  the  actual  canter}".^ 

Such  cases  do  undoubtedly' justify  the  surgeon  in  proposing  the  removal 
of  the  tumor  only,  when  the  latter  is  growing  very  slowly,  so  as  to  be 
evidently  not  cancerous,  and  especially  if  there  be  so  little  evidence  of 
solid  tissue  around  the  vascular  mass  that  it  may  be  hoped  that  it  is  a 
mere  aneurism  of  the  bone.  In  an}'  such  case,  however,  the  patient  should 
be  prepared  for  amputation  if  necessary. 

Mollifies  Ossium. — A  very  singular  and  rare  affection  in  bones  is  known 
by  the  name  of  Mollities  Ossium,  Osteomalacia  or  Malacosteon.  There 
is  no  doubt  that  under  this  designation  several  morbid  conditions  have 
been  described,  most  of  which  constitute  separate  diseases,  and  have  been 
noticed  above.  Thus  bones  become  softened  by  the  diffused  form  of  in- 
filtrating cancer  (see  p.  443).-  Again,  bones  have  been  known  to  be  so 
softened  by  inflammation  in  the  course  of  constitutional  syphilis  as  to  be 
described  by  the  name  of  Mollities.^  And  cases  of  spontaneous  fracture 
from  cancerous  deposit  or  from  other  causes  have  been,  incorrectly 
enough,  spoken  of  as  Mollities.  But  the  peculiar  disease  which  is  prop- 
erly so  designated  is  marked  by  the  gradual  softening,  bending,  and  very 
probably  the  ultimate  fracture  of  the  bones,  usually  of  several  parts  of 
the  body,  or  at  any  rate  of  a  great  extent  of  bone,  while  the  patient  is  not 
in  an}'  visible  condition  of  disease,  except  for  the  weakness  and  the  loss 
of  function  which  the  softening  of  the  skeleton  j)roduces.  Mollities  is, 
therefore,  distinguished  from  cancer  by  the  fact  that  in  the  one  numerous 
and  extensive  tracts  of  bone  gradually  soften,  bend,  and  perhaps  ulti- 
mately break,  while  in  cancer  deposit  generally  occurs  at  one  definite 
spot,  and  the  bone  yields  there  abruptly,  and  that  there  is  often  no  fatal 
cachexia  in  mollities;  in  fact,  in  many  cases  the  patient  has  died  of  old 
age.  From  rickets,  to  which  it  is  compared  by  some  authors,  who  speak 
of  it  as  "  senile  rickets,"  it  is  distinguished  by  the  essential  feature  that 

1  Mapotlier,  Dublin  Med.  Press,  Feb.  4,  1863.  In  ti  ease  where  Mr.  Bickersteth 
amputated  the  leg  for  pulsating  tumor  of  the  tibia,  the  di^^ease  on  examination  was 
believed  to  be  a  pure  example  of  osteo-aneurism,  and  no  return  took  place. — SeeSyst. 
of  Surg.,  2d  ed.,  vol.  ill,  p.  810. 

2  A  good  example  of  this  is  in  the  Museum  of  St.  George's  Hospital,  showing  two 
vertebraj  completely  softened  by  cancer,  which  has  entirely  replaced  their  natural 
structure. 

^  The  existence,  however,  of  any  softening  of  bones  in  syphilis  so  diffused  as  to  de- 
serve the  name  of  osteomalacia  is  doubted  by  Lancereaux,  Treatise  on  Syphilis,  trans, 
for  New  Syd.  Soc,  vol.  i,  p.  243. 


454  DISEASES    OF    THE    BONES. 

mollities  has  no  tendency  to  recovery,  while  rickets  always  disappears  if 
the  child  survives. 

The  symptoms  of  true  mollities  are  A'ery  striking.  The  disease  gener- 
ally commences  with  pain  mistaken  for  rheumatism,  and  sometimes  this 
{Jain  lasts  long  and  is  very  severe.  A  great  part  of  the  skelelon,  some- 
times the  whole  pelvis  or  thorax,  or  many  of  the  bones  of  the  limbs,  be- 
come so  soft  and  weak  tliat  tliey  l^eud  under  the  ordinary  muscular  ac- 
tions ;  till  sometimes  (as  in  the  often-quoted  case  of  Madame  Snpiot)  the 
feet  can  be  placed  above  the  head,  and  the  patient  is  quite  bedridden  from 
the  weakness  of  the  body;  and  the  stature  may  even  be  much  diminished 
from  the  falling  together  of  the  vertebrae.  Fracture  is  very  common,  but 
curiously  enough  the  bones  may  unite  again.  Dr.  Ormerod  published  a 
case'  in  which  there  were  a  great  number  of  fractures — atone  time  seven 
different  bones  were  fractured — and  yet  the  fractures  united  just  as 
readily  as  they  do  in  rickets.  Often,  however,  the  fractures  show  no 
tendenc}'  to  unite.  Most  of  the  patients  are  past  the  middle  period  of 
life,  and  are  of  the  female  sex,  though  men  also  suffer  from  the  disease.'^ 
They  usually  die  from  mere  decay  of  nature — sometimes  from  intercur- 
rent disorders,  as  pneunionia — sometimes  from  deficient  respiration,  in 
consequence  of  the  loss  of  motnlity  of  the  softened  chest-walls,  or  from 
pressure  on  the  spinal  cord  or  medulla. 

The  pathological  anatomy  of  the  softened  bones  bears  a  considerable 
resemblance  to  rickets,  and  also  to  fatty  degeneration.  In  some  cases  the 
fatty  degeneration  has  been  so  extreme  that  the  bone  resembled  "  rather 
a  portion  of  fatty  matter  inclosed  in  a  case  of  periosteum  than  a  bone." 
(Ormerod.)  At  other  times  the  outer  shell  has  been  healthy  while  the 
central  cancellous  tissue  has  been  softened.  The  cancelli  will  be  found 
enlarged,  sometimes  to  such  an  extent  that  the  whole  bone  is  expanded 
and  filled  with  a  peculiar  reddish  gelatiniform  matter  in  which  fat,  oil, 
and  blood-disks  will  be  found,  together  with  certain  cellular  bodies,  ac- 
cording to  Dalrymple." 

The  nature  of  the  morbid  change  in  mollities  is  by  no  means  clear. 
The  earthy  base  of  the  bone  is  absorbed,  and  much  of  it  may  be  found 
passing  away  in  the  urine,  but  how  or  why  this  occurs  we  are  at  present 
entirely  ignorant.  That  it  is  somehow  associated  with  a  generall}-  de- 
pressed condition  of  the  system,  caused  in  some  cases  by  repeated  preg- 
nancy, in  others  by  mental  suffering,  in  others  by  privation  of  various 
kinds,  seems  to  be  conceded,  but  nothing  is  knr)\vn  as  to  how  this  cause 
acts  nor  why  its  effect  should  be  so  strikingly  marked  on  the  bones,  while 
the  rest  of  the  body  is  unaffected.* 

A  more  interesting  question  is  whether  the  disease  is  curable,  and  how 
to  treat  it. 

Mr.  Duriiam  is  disposed  to  answer  the  former  question  in  the  affirma- 
tive ;  and  he  is  able  to  refer  to  two  cases  of  alleged  cure  which  rest  on 
the  authority  of  Bey  lard"  and  Trousseau.     And  in  several  other  cases, 


1  Brit.  Mod.  Journtil,  Sept.  10,  1859. 

2  Uiit  of  14.5  cases  wliicli  Mr.  Durhiim  refers  to,  13  only  wore  men,  but  then  in  a 
grout  mini bcr  of  those,  wliich  are  recorded  only  for  obstetric  purposes,  the  true  nature 
of  the  disea.so  is  very  doubtful. 

3  Dublin  Quarterly  Jour.,  1846.  A  very  full  account  of  the  microscopical  and 
chemical  chani^es  found  in  the  bones  in  mollities  is  contained  in  Mr.  Durham's  jjaper 
in  the  Guy's  Hospital  Reports,  vol.  x,  3d  series,  1804. 

*  I  think  it  is  a  pity  to  waste  space  here  (»n  mere  hypotheses.  The  reader  will  find 
them  all  stated  and  discussed  in  Mr.  Durham's  ()aper 

6  Beylard,  Du  Rachitis,  de  la  Fras^ilite  des  Os,  de  I'Osteomnlacie,  pp.  266,  274.  In 
one  of  these  oases  the  person  adected  managed  by  gradual  extension  to  increase  her 


RICKETS.  455 

wlilch  ultimately  proved  fatal,  a  considerable  temporary  improvement 
has  been  noticed  under  treatment.  The  treatment  must  be  stimulant 
and  su|)porting,  as  lar  as  tlie  digestion  will  permit;  and  the  use  of 
mineral  acids,  of  coui'se  with  due  reference  to  the  reaction  of  the  urine, 
phosphates  and  cod-liver  oil,  seems  to  be  indicated. 

Many  cases  of  deformity  of  the  pelvis  leading  to  difficulty  in  parturi- 
tion are  described  in  summary  terms  as  "mollities,"  but  the  great  ma- 
jority of  them  have  undoulitedly  been  instances,  not  of  the  disease  here 
describeci,  but  of  old  rickets,  though  some  have  probably  been  cases  of 
true  mollities. 

Bickets  is  a  constitutional  disease,  nearly  allied  to  struma,  the  chief 
manifestations  of  which  are  found  in  the  bones,  but  which  implicates 
other  organs,  especially  the  great  viscera,  a  fact  which  should  never  be 
left  out  of  sight  in  si)eaking  of  or  treating  rickets.^  But  the  important 
peculiarity  of  the  morbid  diathesis  in  rickets  is  that  it  is  not  permanent. 
If  the  child  survives  the  disease  will  disappear,  though  the  deformities 
pi'oduced  by  it  vvill  remain  for  life.  And  rickets  is  very  rarely  fatal  in 
itself,  although  it  is  pretty  often  indirectly  fatal ;  i.  e.,  the  child  is  so 
much  weakened  as  to  succumb  to  some  infantile  disorder  which  he  would 
otherwise  have  thrown  off.  It  may  be  combined  with  struma  or  con- 
genital sy[)hilis. 

Rickets  may  commence,  as  it  is  believed,  in  utero,  and  is  supposed  to 
be  one  of  the  causes  of  intra-uterine  fracture,  but  generally  it  does  not 
begin  till  about  the  time  when  the  child  is  beginning  to  walk,  and  often 
not  till  two  or  three  years  of  age,  or  even  later.  Its  causes  are  found  in 
anything  which  produces  weakness  :  bad  feeding,  bad  air,  want  of  clean- 
liness— poverty,  in  fact — are  the  common  causes.''  Hence  Sir  W.  Jenner 
says  that  rickets  is  the  commonest  constitutional  disease  among  the 
children  of  the  poor  in  London.  But  the  children  of  the  rich  are  not 
exempt  from  it,  and  in  them  it  shows  itself  chiefly  in  the  later  members 
of  large  families,  the  mothers  being  exhausted  by  repeated  pregnancies, 
or  in  tlie  children  of  parents  suffering  from  the  hereditary  taint  of  struma, 
or  possibly  syphilis. 

The  earl}'  s^nnptoras  of  rickets  are  not  alwajs  well  marked.  The  child 
appears  restless  and  out  of  health  ;  if  it  has  begun  to  walk  it  will  be 
"taken  off  its  feet,"  as  the  nurses  phrase  it;  its  dentition  is  probably 
retarded,  the  breath  fetid,  and  the  digestion  disordered;  but  these  symp- 
toms are  not  in  themselves  conclusive.  The  first  distinct  indication  of 
rickets  is  a  swelling  of  the  cartilaginous  extremities  of  the  long  bones, 
and  generally  near  tlie  wrist  or  ankle,  or  of  the  rilis  where  they  join  with 
the  costal  cartilages.  The  child  is  usually  also  noticed  to  be  restless  and 
to  throw  off  the  bedclothes,  and  often  the  head  sweats  profusely.  The 
fontanelles  are  often  very  late  in  closing,  and  the  head  large.     Now  be- 

statnre  by  half  a  metre — i.e.,  more  than  eighteen  iiiehes  from  what  it  was  at  the 
perit)d  of  greatest  curvature  of  the  spine.  The  duration  of  the  case  extends  over 
about  twenty  years,  and  the  patient  was  then  in  good  hi^alth,  though  deformed 

1  Sir  W.  Jenner  has  insisted,  perhaps  more  strongly  than  any  other  autlior,  on  the 
constitutional  origin  of  rickets.  Med.  Times  and  Gazette,  vol.  i,  18(50.  Dr.  Dickin- 
son has  described  the  enlargement  met  with  in  the  liver  and  spleen  chiefly,  but  also 
in  the  lymphatic  glands,  in  rickety  children,  as  an  increase  in  the  fibrous  and  epi- 
thelial tissues  of  the  organs,  producing  an  appearance  much  like  thutof  the  ordinary 
lardaceous  or  so-called  "amyloid"  degeneration,  but  not  giving  the  characteristic 
reaction  with  iodine. —  Med.-Chir.  Trans.,  vol.  lii. 

*  A  disea.se  believed  to  be  identical  with  rickets  was  produced  in  puppies  by  im- 
proper feeding. — Dick,  Path.  Soc.  Trans.,  vol.  xiv,  p.  289. 


45G  DISEASES    OF    THE     BONES. 

gins  a  stage  of  more  or  less  general  softening  of  tlie  bones — those  of 
the  limbs  become  bent,  the  cnrves  being  generalh'  an  exaogeration  of 
the  natural  curvature  of  the  hone,  and  due  partly  to  pressure  in  walking 
or  crawling,  parti}'  to  tlie  traction  of  the  muscles.  Fracture  is  very  com- 
mon in  the  stage  of  softening,  the  fractures  uniting  very  readily  and 
kindly.  In  man}' cases  the  periosteum  is  not  torn.  Sometimes  the  bone 
is  bent,  but  not  entirel}'  broken.  The  chest-walls  are  distorted,  the  lower 
ribs  being  drawn  in  somewhat,  as  though  a  string  had  been  tied  round 
the  chest  above  the  liver.  This  distortion  is  due  in  part  to  the  softness 
of  the  thoracic  parietes,  causing  them  to  yield  to  atmospheric  pressure, 
for  there  is  in  these  cases,  as  Sir  W.  Jenner  has  shown,  a  tendency  to 
colla[)se  of  the  upper  parts  of  the  lungs,  so  that  the  external  pressure  of 
the  atmosphere  is  not  balanced  by  the  air  inside;  and  the  same  result 
may  be  favored  by  attacks  of  "child-crowing"  or  laryngismus  stridulus, 
to  which  these  weakly  children  are  very  liable.  But  the  deformity  is  also 
due  in  part  to  the  lower  ribs  being  pushed  out  by  the  enlarged  liver  and 
spleen.  And  it  may  also  be  partly  due  to  the  diaphragm  pulling  inwards 
the  parts  of  tlie  rii)s  to  wliich  it  is  attached.  The  common  "pigeon- 
breast"  may  also  coexist  witli  tliis  rickety  deformity.  The  spine  is  not 
peculiarly  liable  to  distortion  in  rickets.  When  this  occurs  it  may  take 
place  in  any  direction,  the  most  common,  perhaps,  being  "kyphosis,"  or 
a  generally  diffused  curvature  backwards,  easily  distinguished  from  the 
abrupt,  limited,  projection  of  angular  deformity,  but  "lordosis,"  or  the 
forward  displacement  of  the  bodies  of  the  lumbar  vertebr;e,  may  be  pro- 
duced by  obliquity  of  the  pelvis  caused  by  the  deformity  of  the  lower 
extremities,  or  lateral  curvature  by  unequal  length  of  the  two  legs  from 
a  bend  or  fracture  of  one  of  them.  The  pelvis  is  often  grievously  de- 
formed, its  outlet  being  narrowed,  the  tuberosities  of  the  ischia  pressed 
towards  each  other,  and  the  pubic  arch  widened,  or  the  pubes  pressed 
backwards  towards  the  sacro-vertebral  angle,  and  the  ischia  thrust  out- 
wards.^ In  other  cases  the  pelvis  is  simply  retarded  in  development,  so 
as  to  retain  in  mature  life  the  small  relative  size  of  infancy.'^  This  latter 
condition  is  connected  witii  an  interesting  fact  noticed  by  Mr.  Shaw,  viz., 
that  in  cases  of  old  rickets  the  whole  adult  body  often  preserves  the  pro- 
portions natural  to  infancy — the  relatively  small  size  of  the  face,  of  the 
pelvis,  and  of  the  lower  limbs — irrespective  of  any  deformity  in  an}'  of 
these  parts. 

The  chief  features  of  the  pathological  anatomy  of  the  bones  in  the 
active  stage  of  rickets  are  a  large  production  of  growing  tissue  at  the 
epiph}sial  ends,  a  softening  of  tlie  bony  tissue  of  the  shaft,  with  enlarge- 
ment of  the  lacunie,  which  are  occupied  by  a  red  pulpy  substance,  and  a 
great  tliickening  of  the  periosteum.  These  morbid  appearances  will  be 
found  more  n)inutely  descrilted  than  tlie  scope  of  this  worlv  will  permit 
in  Kindlleisch's  Palhological  Jlislolof/i/  [Vo\.  ii,  p.  28^),  who  regards  them 
as  due  to  a  morbid  acceleration  of  those  changes  which  usher  in  and 
prepare  the  way  for  the  transformation  of  cartilage  into  bone,  and  the 
development  of  bone  from  periosteum.  As  the  old  bone  is  absorbed  the 
newly  pi-oduced  tissue  does  not  ossify,  or  only  very  imperfectly,  and 
hence  tlie  softening  of  the  bones. 

The  (!ffect  on  the  skull  is  worth}'  of  especial  mention.  The  exuberant 
and  imperfectly  ossified  tissue  causes  a  great  enlargement  of  the  cranial 

'  1  have  before  observcfl  llmt  many  cases  rehited  in  obstetrical  works  as  instances 
of  moUities  were  in  all  probability  ca^es  of  deformity  frc-m  rickets. 

'  Sec  a  very  interesting  case  describi'il  and  figured  by  Mr.  Shaw,  Syst.  of  Surgery, 
2d  ed.,  vol.  v,  p.  875. 


HYPERTROPHY.  457 

bones,  with  disappearance  of  the  distinction  between  the  two  tables  and 
the  diploe  till  the  whole  skull  presents  a  uniform  thick  layer  of  crumbly, 
porous  bone.  In  the  occipital  bone,  according  to  Rindfleisch,  the  pres- 
sure of  the  brain  and  counter- pressure  of  the  pillow  in  lying  often  cause 
absorption,  and  so  thinning  and  even  perforation  of  the  skull. 

To  the  softening  stage  succeeds  the  stage  of  induration,  in  which  the 
enlarged  and  bent  bones  ossify,  large  buttresses  of  compact  bone  being 
thrown  out  in  the  curves  (particularly  in  the  linea  aspera),  and  the  patient 
recovers,  but  with  permanent  deformity.  Growth  also  in  the  severer  cases 
is  more  or  less  stunted  over  the  whole  body. 

The  treatment  of  rickets  is  medical  and  surgical.  The  medical  treat- 
ment is,  no  doubt,  the  most  important,  and  if  commenced  earl}'  enough 
and  carried  through  with  care  it  usually  makes  all  but  the  simplest 
surgical  measures  unnecessary.  Great  attention  should  be  paid  to  the 
diet,  to  see  that  it  is  wholesome  and  sufficient,  to  the  action  of  the  bowels 
and  skin,  and  to  all  other  accessible  hygienic  measures.  During  the  soft- 
ening stage  the  child  should  be  carefully  nursed,  and  prevented,  as  far 
as  possible,  from  crawling  or  walking.  Cod-liver  oil,  iodide  and  phos- 
phate of  iron,  or  other  ferruginous  tonics,  usually  procure  rapid  improve- 
ment of  the  health  when  combined  with  proper  general  treatment.  But 
the  misfortune  of  these  cases  is  that  the  circumstances  of  the  poor  children 
often  prevent  them  from  having  proper  attention,  diet,  and  regimen,  or 
the  ignorance  of  the  parents  and  the  easy  assumption  that  the  child 
"  will  grow  out  of  it"  prevent  them  from  applying  for  advice  till  defor- 
mity has  far  advanced. 

The  use  of  splints  to  the  deformed  limbs  in  rickets  is  not  to  be  heed- 
lessly^ adopted  in  deference  to  routine.  It  is  useless  to  api)ly  ordinary 
splints  and  bandages  with  a  view  to  straighten  the  bent  bones,  except  in 
the  period  of  considerable  softening,  and  then  their  application  demands 
much  care.  If  the  pelvis  is  softened  it  is  believed  that  the  weight  of  the 
splint  on  the  legs  will  increase  the  pelvic  deformity.  However,  by  care- 
ful splinting  I  have  often  succeeded  in  redressing  incipient  deformity, 
and  have  no  doubt  of  the  propriety  of  the  practice.  Another  great  benefit 
in  splints  is  that  they  may  be  made  to  project  below  the  feet,  and  so 
effectually  prevent  the  child  from  walking — a  great  point  with  poor  chil- 
dren, who  have  no  special  nurses. 

Knock-knee  generally  requires  a  special  instrument,  which  must  be 
carefully  adai)ted  to  the  individual  case  ;  and  it  must  be  remembered  that 
in  inveterate  knock-knee  it  is  not  alone  the  ligaments  that  have  yielded, 
but  the  shape  of  the  bones  is  also  altered  by  pressure,  so  that  only  an 
imperfect  cure  is  possible. 

Finally,  there  are  cases  in  which  it  may  be  justifiable  to  perform 
osteotomy,  subcutaneously  or  otherwise,  and  put  the  leg  straight,  treat- 
ing it  somewhat  like  a  com[)ound  fracture.  Mr.  Marsh  has  recorded^ 
some  interesting  and  successful  cases  of  this  operation,  which,  however, 
it  will  be  readily  understood  is  only  occasionally  justifiable. 

Hypertrophi/  of  the  bones  is  a  result,  in  many  cases,  of  chronic  inflam- 
mation or  sclerosis  ;  but  here  the  propriety  of  the  terra  may  well  be 
questioned.  Such  cases  are  instances  of  chronic  ostitis,  and  ought  to  be 
so  described.^  There  are  other  cases  in  which  no  inflammatory  S3'mptoms 
are  known  to  have  ever  been  noticed,  as  in  the  skull  which  is  preserved 

'  Med.-Chir.  Trans.,  vol.  Ivii,  p.  145. 

^  See  Mr.  Stanley's  cases,  op.  cit.,  pp.  2,  3. 


458  DISEASES    OF    THE    BONES. 

in  tlio  ^[nseiini  of  the  College  of  Surgeons,  enormously  thickened,  the 
histor}^  of  which  states  that  the  patient  was  only  made  avvare  of  the  con- 
dition of  the  skull  by  finding  that  the  size  of  his  hat  was  constantly 
enlarging,  though  here  the  disease  certainly  resulted  from  injury.  It  is 
chietly  in  the  skull  that  specimens  of  hypertrophy  are  preserved  in  our 
museums.'  and  as  a  rule  nothing  is  known  about  the  patients  during  life, 
except  that  many  have  been  insane  or  of  weak  intellect.  Some  of  these 
skulls  are  grayish  in  color,  very  porous,  irregular  in  structure — aptly 
compared  by  Mr.  Durham'^  to  dried  mortar.  Others,  however,  are  much 
more  dense  and  hard,  though,  like  the  former,  "  the}'  have  a  certain 
rough  irregularity  of  texture."  The  former  are  described  under  the 
name  of  '' osteo-porosis."  The  latter  are  regarded  by  Rokitansky  as 
instances  of  consecutive  induration,  succeeding  on  this  osteo-porosis. 
But  Mr.  Durham  is  inclined  to  doubt  this,  and  to  conjecture  that  the 
light,  spongy  bones  are  examples  of  arrested  mollities  (which  he  regards 
as  a  curable  affection),  and  the  latter  as  the  result  of  cured  rickets.  The 
idea  must  be  regarded  as  a  conjecture  mei-ely  at  present,  but  it  is  an  in- 
teresting one,  and  deserves  to  be  elucidated  by  further  researches.  Mr. 
Stanley  has  pointed  out  an  interesting  fact  in  the  cases  which  he  describes 
as  hypertrophy  of  the  long  bones,  viz.,  that  the  affected  bone  often  in- 
creases in  length.  Sometimes  the  whole  limb  is  lengthened,  or  when  one 
bone  (as  the  tibia)  is  affected  and  the  other  is  not,  either  the  affected 
bone  will  be  observed  to  be  curved,  in  order  to  adapt  it  to  the  normal 
length  of  the  other,  or  the  ligaments  uniting  the  two  bones  will  3'ield. 

Atrophy  of  bone  ("  fragilitas  ossium  ")  is  not  so  much  a  disease  in 
itself  as  a  symptom  of  man}'  other  diseases,  the  chief  of  which  are  inflam- 
mation, fatty  degeneration,  anchylosis  leading  to  disease  of  the  limb,  and 
injury.  Senile  degeneration  is  also  a  frequent  cause  of  atroi)hy — a  fact 
illustrated  by  the  fracture  of  the  neck  of  the  femur,  spoken  of  on  p.  293 
(see  Fig.  103).  Atrophy,  strictly  speaking,  consists  in  the  mere  removal 
of  the  tissue  of  the  bone,  with  no  alteration  in  its  composition,  and  it  is 
best  illustrated  by  preparations  in  which,  from  the  anchylosis  of  the  joints 
or  from  prolonged  confinement,  the  limb  has  been  useless,  and  the  bones 
are  found  to  be  light  and  papery,  the  compact  shell  greatly  reduced  in 
thickness,  and  the  medullary  cavity  enormously  increased  in  size  by  the 
disappearance  of  most  of  the  cancellous  tissue.  Here  the  bone,  if  ex- 
amined microscopically,  would  appear  quite  healthy.  In  practice,  how- 
ever, some  amount  of  fatty  degeneration  usually  accompanies  atrophy, 
especially  when  due  to  old  age.  The  rarefying  stage  of  ostitis  is  a  kind 
of  atrophy,  and  this  may  be  continued  as  a  permanent  condition.  Such 
was  the  celebrated  instance  quoted  by  Norris,''  in  which  atrophy  of  the 
humerus  followed  on  fracture  twice  repeated,  and  where  the  whole  bone 
disai)peared,  leaving  the  forearm  "swinging  hither  and  thither  like  a 
thong,"  and  the  arm  shortened  six  inclies.  This  can  only  be  under- 
stood as  ])eing  the  result  of  chronic  ostitis.  In  other  cases  atrophy  after 
fracture  is  believed  to  depend  on  laceration  or  obstruction  of  the  medul- 
lary artery  of  the  bone.'  The  suspension  of  growth  which  follows  on 
separation  of  the  epiphyses,  as  well  as  the  cases  in  which  the  epiphyses 

*  Mr.  Sttinley  spoiiUs  also  of  hypertrophy  of  the  fiK-iiil  bones,  nnd  especially  of  the 
upper  jaw.  Cases  illiistratinjj;  this  condition  may  be  found  in  museums,  but  their 
exact  pathology  is  not  quite  clear. 

2  Guy's  Hospital  Reports,  1804,  p.  380. 

3  Amcr.  Jour.  iMed.Sci.,  Jan.  1842,  p.  39. 

*  Carling,  Med.-Chir.  Trans.,  vol.  xx. 


DISEASES    OF    THE    JOINTS.  459 

remain  uiuinited,  may  be  classed  along  with  atrophy  ;  and  the  absorption 
which  follows  pressure  is,  at  any  rate,  closely  related  to  atroi)hy.  Thus 
it  will  be  seen  that  as  hypertrophy  appears  to  be  often  only  a  very  chronic 
stage  of  ostitis,  considered  as  a  productive  process  (sclerosis),  so  atrophy 
bears  a  similar  relation  to  rarefying  ostitis. 

No  treatment  is  known  to  have  any  effect  on  either  of  these  patholog- 
ical processes. 

Spontaneous  fracture  \s  rather  aloose  term,  the  fracture  being,  in  fact, 
always  due  to  some  slight  force,  which  would  be  insufficient  to  fracture  a 
healthy  bone.  Its  common  causes  are  atroph}^,  malignant  disease,  mol- 
lities,  rickets,  necrosis  (especially  in  its  acute  form),  caries,  and  espe- 
cialW  strumous  deposit  in  the  bone,  whether  accompanied  by  suppuration 
or  not.  In  some  cases  fracture  occurs  from  such  slight  causes  that  it  may 
be  classed  as  spontaneous,  yet  it  unites  and  the  patient  remains  well.  But 
such  cases  should  be  watched  with  some  apprehension,  for  malignant  dis- 
ease may  afterwards  sprout  out  of  the  fractured  part,^  or  strumous  deposit 
may  make  its  appearance  elsewhere.  Spontaneous  fracture  from  any 
cause  does  not  preclude  the  possibility  of  repair,  but  in  cancer  amputa- 
tion is  required  unless  (as  is  very  commonly  the  case)  there  are  other 
cancerous  deposits  elsewhere.  In  all  the  other  cases  the  surgeon  should 
incline  to  preserve  the  limb,  though  in  extensive  necrosis,  and  especially 
in  the  lower  limb,  the  attempt  will  very  probably  fail. 


CHAPTER    XXIII. 

DISEASES  OF  THE  JOINTS. 

Diseases  of  the  joints  are  described  for  convenience  sake  under  the 
head  of  the  tissue  thought  to  be  chiefly  or  at  least  most  obviously  affected, 
and  are  therefore  divided  into  diseases  of  the  synovial  membrane  of  the 
cartilages,  and  of  the  articular  ends  of  the  bones.  The  classification  is, 
no  doubt,  an  imperfect  one;  in  fact,  the  affections  of  the  ligaments,  in- 
cluding the  fibrous  capsule  of  the  joint,  are  almost  passed  over  in  most 
of  the  formal  treatises,  though  no  one  can  doubt  that  they  are  very  com- 
monly the  starting-i^oint  of  inflammation  which  destroys  the  whole  articu- 
lation. It  appears  to  me  that  one  of  the  most  useful  ways  of  regarding 
the  subject  for  practical  purposes  is  to  consider  joint  diseases  under  two 
chief  heads,  viz.,  diseases  originating  in  the  bones  and  spreading  out- 
wards or  towards  the  surface,  and  diseases  originating  in  the  synovial 
membrane  or  capsule,  and  spreading  inwards  or  towards  the  bones.^    An- 


1  A  bone  which  gives  way  near  a  cancerous  tumor  may  nevertheless  unite.  See  Path. 
Trans.,  vol.  xi,  p.  219.  A  man  was  admitted  into  St."George's  Hospital  with  malig- 
nant disease  of  the  humerus.  The  bone  had  given  way  at  that  spot  ten  months  be- 
fore, but  the  fracture  had  united  before  the  tumor  was  noticed. — Path.  Trans.,  vol. 
X,  p.  249. 

*  See  Surg.  Treatment  of  Children's  Diseases,  p.  411,  2d  ed. 


460  DISEASES    OF    THE    JOINTS. 

Other  very  important  division  of  joint  diseases  is  into  acute  and  chronic,  a 
distinction  which  more  than  anything  else  governs  our  prognosis  and 
treatment.  Thus,  cases  will  be  met  vvith,  though  fortunately,  not  often, 
in  whicli  the  disease  comes  on  with  very  formidable  symptoms,  acute 
traumatic  fever,  rapid  suppuration  and  disintegration  of  the  joint,  speedily 
terminating  in  death,  either  by  exhaustion  or  by  pygemia  ;  whereas  the 
great  bulk  of  the  diseases  of  the  joints  which  we  are  called  upon  to  treat 
are  accompanied  by  no  constitutional  affection  whatever  and  involve  no 
danger  to  life.  They  often  cause  loss  of  activity  and  of  all  that  makes 
life  worth  having  to  the  possessor,  and  from  that  consideration  may  justify 
operations  which  are  extremely  dangerous.  But  in  making  up  his  mind 
to  perform  such  operations  the  surgeon  should  never  omit  the  consider- 
ation that  the  disease  exposes  the  patient  to  little  or  no  danger,  while  the 
operation  is  very  dangerous  indeed.  Those  surgeons  who  use  this  as  an 
argument  for  never  performing  amputation  or  excision  in  chronic  joint 
disease  are  in  my  opinion  wrong,  since  the  natural  cure  often  takes  many 
years,  during  which  the  patient,  if  a  poor  man,  is  debarred  from  earning 
ins  livelihood,  and  in  any  case  from  all  enjoyment  of  his  life  ;  but  there 
is  no  doubt  that  such  operations  are  always  to  be  regarded  rather  as 
operations  of  expediency  than  necessity.  This  does  not,  of  course, 
apply  to  cases  in  which  suppuration  is  visibly  pulling  the  patient  down  or 
in  which  hectic  has  set  in,  and  where  the  surgeon  has  reason  to  fear  that 
the  delay  of  amputation  or  excision  may  involve  danger  to  the  i)atient's 
life. 

Synovitis. — The  symptoms  of  acute  synovitis  are  pain,  inflammation, 
as  shown  by  increased  heat  of  the  part,  and  fluid  ett'usion  into  the  syno- 
vial capsule.  The  disease  is  due  either  to  injury  or  to  rheumatism  in 
most  cases,  and  the  pain  varies  accordingl}'.  It  is  usually  distensile  and 
burning  in  the  most  acute  cases,  but  is  not  complicated  with  those  painful 
spasms  which  are  characteristic  of  the  more  deeply  seated  affections.  Tlie 
effusion  is  serous,  i.  e.,  it  is  more  watery  than  the  natural  synovia,  with 
portions  of  lymph  and  epithelial  scales  floating  in  the  fluid,  mixed  some- 
times with  blood.  In  very  acute  cases  the  synovial  membrane  has  been 
found  partly  desti'oyed  by  ulceration.  In  recent  acute  cases,  before  the 
sac  has  become  too  tense,  the  sense  of  fluctuation  is  ver}-  plain,  and  the 
form  of  the  swelling,  taking  as  it  does  exactly  the  shape  of  the  synovial 
membrane,  is  perfectly  characteristic.  Thus,  in  the  knee-joint  there  is  a 
fluctuating  swelling  extending  up  the  limb  for  some  distance  in  front  of 
the  femur,  bulging  on  either  side  of  the  patella,  more  prominent  on  the 
inner  side,  and  floating  the  patella  up  as  if  in  a  water-bath.  On  the  other 
hand,  the  form  of  swelling  which  is  due  to  enlargement  of  the  bones  or 
of  the  fibrous  tissues  which  invest  them,  is  an  exaggeration  of  the  natu- 
ral outline  of  the  bones.  It  raises  and  pushes  forward  the  patella,  but  that 
bone  remains  still  in  contact  witli  tlie  femur.  This  form  of  swelling  also 
is  never  developed  so  rai)idly  as  synovial  eff'usion  often  is.  But  it  must 
be  remembered  that  some  amount  of  periosteal  eff'usion  or  swelling  of  the 
bones  themselves  is  often  mixed  with  synovitis. 

The  causes  of  synovitis  are  blows  and  sprains,  exposure  to  cold,  rheu- 
matism, gout,  gonorrhoL'a,  and  pyaemia,  or  blood-poisoning.  Gonorrlioeal 
and  pyaMnic  synovitis  will  be  found  treated  of  under  the  diseases  of  which 
they  are  symptoms.  The  surgical  treatment  of  gouty  synovitis  is  much 
the  same  as  that  of  the  rlieumatic  form  of  the  disease.  Cases  also  occur 
of  syphilitic  affection  of  joints  in  which  the  synovial  membrane  becomes 
implicated,  but  secondarily  to  affections  of  the  bones  or  fibrous  structures. 


SYNOVITIS.  461 

The  usual  course  of  synovitis  is  towards  recover}^,  if  the  parts  are  left 
at  rest.  There  are,  however,  exceptional  cases,  and  chiefly  tliose  follow- 
ing on  penetrating  wounds  of  the  joint,  which  will  go  on  to  suppuration 
and  disorganization  (so-called  ''abscess")  of  the  joint.  Using  still  the 
knee-joint  for  illustration,  the  symptoms  of  such  abscess  are  as  follows  : 
High  traumatic  fever,  rigors,  great  pain  and  starting  of  the  limb,  a^lema 
and  inflammation  of  the  soft  parts  covering  the  joint,  with  considerable 
rise  of  local  temperature,  exquisite  pain  on  motion  ;  and,  if  the  part  be 
not  well  supported,  displacement  of  the  bones  of  the  leg  backwards  will 
rapidly  ensue. 

Acute  abscess  is  a  formidable  malady,  due  very  commonly  to  injury, 
though  it  may  occur  spontaneously  in  weakly  .young  persons.  The  ab- 
scess may  either  commence  in  the  soft  tissues  around  the  joint,  bursting 
into  its  cavity  and  causing  rapid  disintegration,  or  in  a  wound  of  the 
joint,  or  in  acute  synovial  inflammation,  or  as  the  consequence  of  an 
abscess  which,  forming  either  in  the  bone  or  in  the  thickness  of  degen- 
erated synovial  membrane,  has  made  its  way  into  the  cavity  of  the  joint. 

The  treatment  ought  to  be  decided,  and  for  tliat  purpose  an  exact 
diagnosis  is  necessary.  This  must  be  made  by  an  exploratory  puncture, 
for  which  the  aspirator  is  the  most  convenient  instrument.  Should  the 
fluid  be  only  slightly  purulent,  or  should  there  be  no  pus  at  all,  tliere  will 
be  no  harm  in  withdrawing  the  whole  or  greater  part  of  the  fluid,  and 
carefidly  closing  the  j)uncture;  but  if  the  joint  contains  pus  pure  or  nearly 
so  an  exit  must  be  given  to  it,  and  tliis  is  done  either  by  a  free  incision 
or  by  passing  a  drainage-tube  through  the  joint.  The  former  is  the  course 
usually  recommended  and  adopted,  but  it  is  a  very  severe  measure  in  the 
case  of  the  knee-joint,  at  any  rate  in  adults.  In  children  I  have  fre- 
quently seen  the  knee-joint  opened  with  success,  but  the  great  majority 
certainly  of  the  cases  which  have  come  under  my  own  notice  in  later  life 
have  proved  fatal  from  traumatic  fever  or  pyiiemia.  In  smaller  joints  no 
such  hesitation  need  be  experienced  ;  but  in  the  knee  I  think  it  better  to 
pass  a  drainage-tube  through  the  articulation,  and  thus  evacuate  the 
abscess  with  less  constitutional  disturbance.  And  in  the  case  of  persons 
whose  general  health  and  constitutional  vigor  are  not  very  favorable  it  is 
questionable  whether  amputation  l)e  not  the  more  prudent  course.  After 
incision  of  the  joint  if  things  go  well  the  joint  will  anchylose — in  early 
life  perhaps  so  incompletely  that  considerable  motion  will  be  preserved. 
Indeed,  in  one  case  of  a  child  in  wliom  I  opened  the  knee-joint  very  freelj'^ 
hardly  any  impairment  of  motion  was  perceptible  after  her  recovery. 
But  in  adults  a  stiff  joint  is  the  best  event  which  can  be  anticipated. 

If  the  case  is  to  do  badly  the  fever  iuci'eases,  the  discliarge  becomes 
more  foul,  and  the  limb  more  swollen  and  painful.  If  the  surgeon  has 
used  a  drainage-tube  or  made  a  small  puncture  he  may  be  inclined  to  try 
the  eff'ect  of  freer  incisions,  failing  which  his  only  resource  is  to  ampu- 
tate ;  but  amputations  under  these  circumstances  are  veiy  unpromising, 
and,  if  definite  symptoms  of  pyiiemia  have  set  in,  are  liopeless. 

Tre.atiyient. — In  the  acuter  forms  of  synovitis  the  effect  of  local  blood- 
letting is  generally  very  beneficial.  The  limb  must  be  put  up  in  an  appa- 
ratus which  will  keep  it  perfectly  at  rest,  for  which  purpose,  in  the  case 
of  the  knee,  some  support  must  be  given  in  the  ham  by  means  of  a  pad 
or  stuffing,  or  by  a  bend  in  the  splint.  Ten  or  a  dozen  leeches  ma}'  be 
applied,  and  the  bleeding  encouraged  by  fomentation  afterwards,  and 
then  cold  must  be  assiduously  employed  ;  or,  if  cold  is  not  well  borne, 
the  application  of  a  large  poultice  enveloping  the  limb  is  often  very 
grateful. 


462  DISEASES    OF    THE    JOINTS. 

For  more  chronic  cases,  or  when  the  acute  has  given  way  to  chronic 
inflammation,  complete  local  rest  and  blistering  are  the  measures  chiefly 
indicated  ;  and  in  the  last  stage  of  the  disease,  when  little  is  left  ex- 
cept a  little  indolent  swelling,  pressure  is  very  useful.  This  is  often 
made  by  a  case  of  strapping,  inside  which  a  layer  of  camphorated  mer- 
curial ointment  is  placed,  and  the  whole  supported  by  a  bandage,  which 
can  be  gummed  if  necessary  (Scott's  bandage) ;  but  strapping  and  bandage 
in  the  ordinary  wa_y  answers  well  enough.  When  the  patient  discards  this 
and  gets  about  without  any  application,  gentle  shampooing  and  friction 
will  be  useful  in  removing  any  remains  of  swelling. 

Hydrops  Articidi. — To  the  most  chronic  form  of  sjmovial  effusion  the 
name  of  "  hydrops  articuli"  has  been  given.  It  forms  a  large  fluctuating 
swelling,  devoid  of  heat  or  pain.  It  is  almost  confined  to  the  knee-joint, 
and  the  patient  requires  relief  from  the  condition  on  acconnt  of  the 
stretching  of  the  ligaments  and  consequent  insecurity  of  the  joint,  ren- 
dering the  limb  useless.  The  fluid  differs  from  that  of  common  synovitis 
in  containing  little  if  any  lymph ;  but  it  coagulates  with  heat,  like  the 
fluid  of  hydrocele.  The  limits  between  chronic  synovitis  and  hydrops 
articuli  are  difficult  to  fix ;  consequently,  if  there  is  any  prospect  of  im- 
provement from  the  milder  methods  of  treatment  used  in  chronic  syno- 
vitis— rest,  blistering,  pressure,  absorbent  ointments,  etc. — a  careful  trial 
must  be  given  to  such  measures.  But  when  these  have  failed,  or  if  the 
complaint  is  so  inveterate  as  to  render  them  obviously  useless,  the  joint 
must  be  injected  with  iodine.  The  tincture  of  iodine  has  been  injected 
in  equal  proportions  with  water,  ^ss.  of  the  mixture,  or  ^iij-iv  of  a 
weaker  solution — one  part  of  the  tincture  to  four  of  water — as  much  of 
the  fluid  as  possible  being  allowed  to  escape  afterwards.  Care  must  be 
taken  to  exclude  the  air,  and  the  puncture  must  be  carefully  closed,  and 
strapping  and  bandage  applied  on  a  splint.  If  severe  reaction  follow,  as 
ma3'  easil}^  happen,  the  case  may  be  converted  into  one  of  acute  abscess. 
But  generall}'  it  does  well  and  the  patient  recovers,  with  more  or  less 
stiffening. 

Puljjy  Degeneration. — The  sjaiovial  membrane  becomes  more  or  less 
thickened  in  all  cases  of  chronic  synovitis,  but  this  thickening  disappears 
in  the  course  of  time,  and  no  remains  of  the  disease  are  to  be  found  ulti- 
matel}'  in  favorable  cases.  It  does  happen,  however,  not  uncommonly 
that  the  swelling  persists  as  an  indolent  pulpy  thickening,  taking  the 
shape  of  the  capsule  of  the  joint,  giving  here  and  there  an  obscure  sense 
of  fluctuation,  which  on  puncture  is  found  to  be  deceptive  ;  but  possibly 
in  other  situations  really  fluctuating,  either  from  synovial  fluid  in  the 
joint  cavity  or  from  pus  contained  in  the  thickness  of  the  diseased  mem- 
brane itself.  Such  abscesses  may  break  into  the  joint  and  set  up  acute 
symptoms,  or  they  ma}'  burst  externally,  and  a  sinus  may  remain,  which 
frequently  shows  no  tendency  to  heal. 

On  examination  the  synovial  membrane  is  found  to  be  converted  into 
a  pul})y,  gelatinous,  pinkish-gra}'  mass,  which  on  its  free  surface  some- 
wliat  resembles  granulation-tissue.  There  are  often  small  abscesses  scat- 
tered through  its  substance,  and  pus  is  frequently  found  in  the  articular 
cavity.  The  cartilages  may  be  eroded  and  the  bones  carious,  but  the 
disease  in  the  synovial  membrane  may  have  existed  for  a  long  time  with- 
out any  such  morbid  appearances. 

The  persistence  of  the  disease  hinders  the  use  of  the  joint,  and  as  the 
thickening  increases  the  ligamentous  capsule  becomes  distended,  the 
bones  pushed  away  from  eacli  other,  the  interarticular  ligaments  stretched 


DISEASES    OF    ARTICULAR    ENDS.  463 

and  softened,  more  or  less  displacement  follows,  and  the  limb  is  perma- 
nently crippled. 

The  nature  of  this  affection  is  not  absolntely  settled.  From  its  incur- 
able nature  Sir  B.  Brodie  was  at  first  disposed  to  regard  it  as  malignant  ; 
but  tliis  it  certainly  is  not.'  Olliers,  with  more  probability,  have  consid- 
ered that  it  is  "  strumous,"  but  of  this  there  seems  no  proof.  It  is  not 
proved  to  have  any  specific  character,  or  to  be  anything  more  than  the 
result  of  chronic  inflammation,  acting  perliaps  on  a  person  debilitated  by 
low  living  or  by  other  unfavorable  circumstances,  of  which  the  strumous 
constitution  may  be  one. 

The  diagnosis  does  not  generally  present  any  great  difficulty,  as  the 
long  persistence  of  the  disease,  the  absence  of  proof  of  any  mischief  about 
the  bones,  and  the  shape  of  the  swelling,  will  pretty  certainly  exclude 
any  other  supposition. 

If  there  is  no  motive  for  immediate  interference  the  cure  of  the  disease 
may  be  sought  by  steady,  gentle  pressure  (as  by  Scott's  bandage)  and 
the  improvement  of  the  general  health  ;  but  I  am  not  sure  that  the  pulpy 
thickening,  when  it  has  once  reached  a  high  degree,  so  as  to  constitute  of 
itself  a  substantial  disease,  is  ever  entirely  removed,  and  then  the  choice 
lies  between  allowing  the  j^atient  to  remain  content  with  his  infirmity  or 
removing  tiie  joint  by  amputation  or  excision,  according  to  the  age  of  the 
patient.  Such  cases  are  particularly  favorable  ones  for  excision  in  early 
years.  Latterly  we  have  attempted  the  cure  of  this  affection  by  destroy- 
ing the  degenerated  synovial  membrane  with  sulphuric  acid,  and  so  pro- 
curing ancidyosis,  in  tlie  same  way  as  caries  is  treated  (see  p.  433).  In 
private  practice  especially'  there  is  no  motive  for  haste  in  the  treatment 
of  such  cases.  Displacement  of  the  bones  should  be  remedied  or  cor- 
rected, properly  contrived  support  furnished,  and  the  reduction  of  the 
swelling  sought  by  pressure  and  mercurial  ointment  or  the  ung.  iodi  or 
empl.  galbani. 

Pendulous  Growths. — In  some  cases  the  synovial  membrane  is  found 
studded  over  with  a  number  of  loose  pendulous  fringes.  A  most  beauti- 
ful preparation  exists  in  the  Museum  of  St.  George's  Hospital,  which  has 
been  figured  in  various  works  on  the  joints,  and  which  shows  this  condi- 
tion in  its  highest  grade.  The  growths  are  variously  regarded  as  being 
the  products  of  simple  inflammation  or  as  one  of  tlie  phenomena  of  rheu- 
matic arthritis.  Probably  both  views  are  correct  in  different  cases.  Cer- 
tainly such  pendulous  growths  may  form,  isolated  or  in  small  numbers,  in 
simple  inflammation,  and  may  become  loose  in  the  joint  (loose  cartilages) ; 
while  Dr.  R.  Adams  has  given  good  reasons  for  believing  that  in  one  at 
least  of  Sir  B.  Brodie's  prepaiations  of  this  condition  the  disease  was 
of  the  nature  of  rheumatic  arthritis,  since  the  state  of  the  cartilages  and 
bones  and  the  history  exactly  corresponded  with  the  usual  phenomena 
of  that  affection. 

Diseases  of  the  Articular  Ends  of  Bones. — The  diseases  of  the  articular 
ends  of  the  bones  are  very  common,  and  are  the  source  from  wliich  the 
great  majority  of  the  cases  spring  which  end  in  total  disorganization  of 
the  joints.  Like  diseases  of  bone  in  other  situations,  they  may  either  be 
regarded  as  inflammations,  acute  or  chronic,  periosteal  or  endosteal,  and 

1  Nor  was  this  Brodie's  latest  opinion.  He  was  more  disposed  to  regard  it  as  gener- 
ally the  result  of  chronic  inflammation,  though  there  were  cases  in  which  he  thought 
this  explanntion  difficult. — See  Diseases  of  Joints,  chap,  iii,  Brodie's  Works,  by 
Chas.  Hawkins,  vol.  ii,  p.  1G7. 


464  DISEASES    OF    THE    JOINTS. 

tending  to  caries  or  necrosis ;  or  else  an  attempt  may  be  made  to  refer 
them  to  the  causes  from  which  the_y  are  supposed  to  originate,  and  thus 
to  classify  them  as  traumatic,  strumous,  rheumatic,  syphilitic,  etc.  Both 
classifications  have  their  practical  utility,  but  it  is  only  in  certain  well- 
marked  cases  that  eitiier  is  possible.  It  is,  for  instance,  of  the  greatest 
practical  imiiortance  to  recognize  the  undoubted  fact  that  in  many  cases 
necrosis  of  a  limited  portion  of  the  articular  end  of  a  bone  occurs,  and 
that  in  such  cases  the  limb  may  be  saved  by  the  timely  extraction  of  the 
sequestrum  (see  Fig.  18S).  It  is  only  rarely  tliat  we  can  be  certain  of 
the  existence  of  such  a  sequestrum  before  cutting  into  the  joint;  but  a 
knowledge  of  the  fact  might  in  some  instances  lead  to  an  exploratory 
incision  which  would  save  a  limb  that  would  otherwise  have  been  ampu- 
tated. 

Again,  it  would  be  very  important  were  it  possible  to  distinguish  cases 
in  which  the  disease  of  the  bones  leading  to  disintegration  of  a  joint  is  due 
to  constitutional  affection,  such  as  struma,  from  those  in  which  it  is  the 
mere  result  of  chronic  inflammation  after  injury.  But  nothing  is  more 
difficult.  I  have  given  reasons  elsewhere  ^  for  the  opinion  which  I  foi-med 
from  the  results  of  an  extensive  observation  of  joint  disease  in  childhood, 
and  which  subsequent  experience  has  strengthened,  that  the  common  ex- 
pression "strumous  disease,"  which  is  applied  as  a  matter  of  course  to 
pretty  nearly  every  chronic  joint  affection  not  owning  any  obvious  cause, 
is  erroneous  and  misleading — erroneous  in  theory,  since  such  cases  con- 
stantly occur  in  persons  who  show  no  symptoms  of  any  strumous  affection, 
and  in  whose  bodies  on  dissection  no  lesion  of  any  kind  is  detected,  to 
which  the  terra  strumous  can  be  applied  ;  and  misleading  in  practice, 
since  tiie  assumption  that  such  diseases  are  constitutional,  and  therefore 
can  only  be  eradicated  by  general  treatment,  is  contradicted  by  the  fact 
that  the  total  removal  of  the  affected  joint  is  often  followed  by  complete 
and  permanent  recovery.  I  have  sliown  ^  that  out  of  a  large  number  of 
cases  of  excision  or  amputation  of  diseased  joints — which  would  all,  I 
think,  have  been  classed  in  the  ordinary  nomenclature,  as  "  strumous  " — 
no  recurrence  of  the  disease  nor  any  other  symptom  of  struma  occurred 
during  several  years  in  the  great  majority. 

In  saying  this  I  by  no  means  deny  that  strumous  children  and  other 
strumous  persons  are  very  liable  to  such  chronic  affections  of  the  joint- 
ends  of  the  bones.  All  tliat  I  assert  is  that  a  large  proportion  (I  believe 
a  large  majority)  of  those  affections  are  independent  of  any  constitutional 
cachexia,  and  originate,  as  far  as  we  can  judge,  either  from  local  injury 
or  from  exposure  to  cold  and  wet. 

The  usual  symptoms  of  this  chronic  disease  of  the  ends  of  the  bones  is 
an  indolent  swelling,  taking  the  form  of  the  joint-ends,  occurring  gener- 
all}'  after  some  sliglit  injury  and  complicated  frequently  with  more  or  less 
synovitis.  After  a  time  inflammatory  symptoms  make  their  ap])earance, 
viz.,  deepseated  pain,  starting  of  the  limb,  al)scess  exposing  the  bone, 
which  is  found  to  be  softened  and  carious,  and  finally  dislocation  (or,  as 
it  would  perhaps  better  he  called,  displacement)  from  destruction  of  the 
ligaments.  If  the  patient  recovers,  the  joint  becomes  anchylosed,  or  else 
the  constant  discharge  breaks  down  the  health,  and  he  dies  either  from 
the  direct  effects  of  tiie  disease  or  from  some  intercurrent  malady.  The 
disease,  however,  may  be  arrested  at  any  stage.  In  its  earHest  stage, 
when  there  is  nothing  abnormal  except  some  indolent  swelling  of  the 
joint-ends,  this  swelling  is  due  partly  to  enlargement  of  the  bones  them- 

»  Surg.  Diss,  of  Childhood,  2d  ed.,  p.  424.  2  Lancet,  Feb.  24,  1866. 


DISEASES    OF    THE    ARTICULAR    ENDS.  465 

selves,  but  in  a  great  measure  to  effusion  beneatli,  in,  and  around  the 
periosteum.  Bones  in  this  condition  will  he  found  somewhat  increased 
in  bulk,  but  much  diminished  in  consistence,  their  cancelli  enlarged  and 
filled  with  intlammatory  products  in  various  stages,  and  possibly  contain- 
ing crude  tubercle,^  though  tliis  lias  been  in  my  experience  a  very  rare 
appearance  ;  and  as  a  general  rule  one  sees  only  the  ordinary  phenomena 
of  the  softening  stages  of  ostitis.  This  may  sul)side  under  the  influence 
of  prolonged  rest,  slight  counter-irritation,  and  attention  to  the  state  of 
the  general  health.  Local  rest  is  of  the  most  vital  importance,  but  it  is 
of  equal  importance  that  the  general  health  should  not  break  down  under 
prolonged  confinement,  so  that  if  the  patient's  circumstances  allow  of  it 
he  should  have  plenty  of  fresh  air.  The  patient  or  his  friends  should  be 
warned  that  permanent  benefit  can  only  be  expected  after  a  very  long 
period  of  treatment,  and  that  ultimately  the  joint  will  most  likely  be 
anchylosed,  more  or  less  entirely. 

If  the  case  goes  on  badly,  and  suppuration  ensues,  it  becomes  neces- 
sary to  examine  the  joint  carefully  and  thoroughly  under  anaesthesia. 
Nothing  can  be  worse  than  to  irritate  diseased  joints  unnecessarily  by 
repeated  examination  ;  but  a  clear  idea  of  the  actual  state  of  the  parts 
can  be  founded  only  on  a  thorough  exploration,  when  a  decided  line  of 
treatment  should  be  at  once,  adopted.  The  main  questions  in  such  cases 
are  whether  the  bones  are  exposed,  or  the  suppuration  is  external  to  the 
joint  altogether,  or  in  the  thickness  of  diseased  synovial  membrane,  and 
whether  there  is  a  sequestrum  in  the  articular  surface.  If  the  cartilages 
are  destroyed  and  the  pus  is  furnished  by  the  carious  articular  ends  there 
will  be  extensive  crepitation  in  every  passive  movement  of  the  joint.  In 
extra  articular  abscess  the  joint-ends  will  move  smoothly  and  naturally 
on  each  other.  If  a  limited  portion  of  bone  only  is  exposed  the  crepita- 
tion will  only  be  perceptible  in  certain  movements,  and  the  presence  of  a 
sequestrum,  or  loose  portion,  can  be  judged  of  partly  by  the  limitation  of 
swelling  to  that  part  of  the  joint  and  the  direction  of  the  sinuses,  but  can- 
not be  confidently  affirmed  before  incision. 

When  the  condition  of  the  joint  has  been  ascertained  the  treatment 
will  depend  on  the  extent  of  disorganization  of  the  joint,  on  the  patient's 
condition,  and  on  the  rate  of  progress  of  the  disease.  If  the  bones  are 
so  far  displaced,  as  well  as  diseased,  that  the  limb  could  be  of  no  use, 
even  if  the  disease  were  arrested,  amputation  is  of  course  indicated;  so 
also  if  the  patient  is  not  in  a  state  to  bear  the  necessarily  protracted 
treatment,  or  if  acute  traumatic  fever  has  exhausted  him  and  threatens  a 
fatal  result;  and  in  patients  at  all  advanced  in  life,  if  the  diseased  joint 
requires  removal,  it  must  be  done  by  amputation.  In  children  and  young 
persons  excision  may  be  practiced.  The  treatment  of  carious  joints  by 
the  application  of  strong  sulphuric  acid,  as  recommended  by  Mr.  Haward,^ 
may,  however,  save  many  joints  which  would  otherwise  have  been  excised, 
and  thus  preserve  the  length  and  future  growth  of  the  limb,  and  at  less 
risk  to  life.  The  operation  consists  in  making  two  long  incisions  on  either 
side  into  the  articulation,  wiping  out  from  the  joint  all  tiie  pus  and  lymph 
which  it  may  contain  with  strips  of  dry  lint,  and  then  fiUiug  its  cavity 
with  lint  soaked  in  a  mixture  of  one  part  of  strong  sulphuric  acid  and 
two  parts  of  water.  This  cauterizes  and  destroys  all  the  diseased  syno- 
vial membrane  and  the  cartilages,  which  come  away  as  sloughs.     The 

'  See  the  drawings  from  Sir  B.  Brodie's  case  of  deposit  in  the  head  of  each  femur, 
p.  406. 

2  Chir.  Soc.  Trans.,  vol.  vi,  p.  13. 

30 


466  DISEASES    OF    THE    JOINTS. 

carious  bone  is  also  disintegrated  and  comes  away,  and  then  the  exposed 
bony  snrtaccs  grannlate,  and  osseous  anchylosis  ensues.  Most  of  the 
cases  hitherto  treated  in  this  way  seem  to  have  done  well/  and  it  is  well 
worthy  of  further  trial,  though  the  present  experience  of  it  is  far  too 
scanty  to  enable  us  to  say  whether  it  will  or  will  not  to  a  great  extent 
supersede  excision  in  those  joints  in  which  osseous  anchylosis  is  desirable. 

Diseose^i  of  the  Cartilages. — The  disease  to  which  the  name  of  "ulcera- 
tion of  the  cartilages"  was  given  by  Brodie,  and  to  which  it  is  still  usu- 
all,v  applied,  is  a  A^ery  definite  and  easily  recognizalile  affection,  and  one 
to  which  the  designation  is,  doubtless,  so  far  appropriate  that  the  carti- 
lages will  always  be  found  to  be  ulcerated.  But  whether  that  ulceration 
is  the  essence  of  the  disease,  or  only  one  of  its  invariable  concomitants, 
may  very  reasonably  be  doubted.  In  my  own  opinion,  and,  I  believe,  in 
that  of  most  surgeons  of  the  present  day,  the  affection  of  the  cartilages 
plays  really  a  very  subordinate  part  in  the  disease.^ 

This  affection  is  characterized  by  the  usual  symptoms  of  inflammation 
of  the  joint,  but  especiall}',  and  besides  these  symptoms,  by  the  peculiar 
painful  starlings  of  the  limb  and  the  acute  localized  agony  which  is  pro- 
duced by  pressing  the  joint-surfaces  together,  and  in  the  worst  cases  b^'' 
the  slightest  movement  or  jar  communicated  to  the  limb.  The  sponta- 
neous startings  occur  usually  at  night,  just  as  the  patient  is  falling  asleep; 
often  they  wake  him  from  the  deepest  sleep,  and  they  leave  acute  pain, 
lasting  long  afterwards,  and  accompanied  sometimes  by  severe  sweating. 
With  these  prominent  and  agonizing  symptoms  there  is  often  very  little 
swelling  or  synovial  effusion,  though  in  other  cases  the  symptoms  of  ulcer- 
ation of  the  cartilages  follow  on  a  regular  attack  of  synovitis,  but  more 
commonly  the  preceding  symptoms  are  those  of  affection  of  the  articular 
ends  of  the  bones. 

The  after-progress  of  the  disease  is  in  one  of  three  directions  :  (1)  the 
symptoms  ma}'  subside,  leaving  a  little  loss  of  motion  at  first,  which  after- 
wards almost  entirely  disappears  in  some  cases  or  persists  in  others  ;  (2) 
the  joint  maj'  be  dislocated,  abscesses  may  form,  leaving  sinuses  through 
which  the  bone  is  exposed  and  the  case  pursues  the  usual  course  of 
chronic  disorganization  of  the  joint;  or  (3)  acute  abscess  may  form  in 
the  cavit}'  of  the  joint;  in  which  case  the  patient  usuall}'^  sinks  from 
pyaemia  or  irritative  fever,  if  the  limb  be  not  removed. 

The  pathology  of  this  disease  seems  to  be  as  follows  :  In  the  cases  in 
which  it  commences  as  synovitis  the  infiamcd  synovial  membrane  is  con- 
verted into  a  pulpy  mass,  resembling  if  not  identical  with  granulation. 
These  granulations  advance  over  the  surface  of  the  cartilage  and  propa- 
gate infiammation  to  it;  so  that  when  the  inflamed  synovial  membrane  is 
lifted  from  the  surface  of  the  cartilage  little  ulcerated  pits  are  found, 
which  have  been  worn  into  the  cartilage  by  the  granulations  of  the  syno- 
vial membrane.  The  inflammation  spreads  through  the  cartilage  to  the 
subjacent  bone.  In  the  more  ordinar}'  cases  the  course  of  the  inflamma- 
tion is  the  reverse.  From  the  inflamed  bone  it  spreads  through  the  car- 
tilage to  the  synovial  membrane. 


*  I  have  Ititely  had  a  case  which  proved  fatal  under  this  treatment.  The  child's 
parents  having  rcfiisod  amputation,  ho  sank  from  traumatic  fever. 

2  "  N<itl)iii<^  can  be  moyc.  sure  tlinn  that,  of  all  llic  joint  discuses  which  full  under 
the  surgeon's  notice,  not  one  originates  in  the  cartilage." — Barwell,  Dis.  of  the  Joints, 
p.  287.  "There  is  no  primary  disease  of  this  structure"  (sc.  Cartilage).  "All  the 
changes  that  are  to  be  found  in  it  are  secondnry  ti>  some  other  affection,  and  in  the 
generality  of  cases  to  disea.se  in  the  articular  extremities  of  the  bone." — Bryant's 
Practice  of  Surgery,  p.  823. 


ULCERATION    OF    CARTILAGE. 


4Cu 


ay 


1  TJ) 


-•'0)  ^ 


to 


Acute  inflammation  of  cartilage. — After  Redfern. 


The  appearances  of  inflamed  cartilage  to  the  naked  e3'e  consist  in  the 
formation  on  its  surface  of  ulcera- 
ted si)ots,  where  the  cartilage  is  ^'°-  -*^'''- 
removed  in  a  part  or  the  whole  of 
its  thickness,  and  in  a  degeneration 
of  its  substance,  which  becomes 
fibrous  (so  as  to  be  compared  to 
the  hairs  of  a  small  brush  or  to  the 
pile  of  velvet),  and  in  some  cases 
thickened  and  softened  in  texture. 
The  union  also  between  the  carti- 
lage and  the  bone  becomes  much 
loosened,  so  that  the  cartilages  are 
in  some  places  quite  detached, 
though  still  lying  over  the  bone  ; 
or  pieces  of  the  cartilage  may  be 
detached  and  free  in  the  joint. 

Examined  by  the  microscope  two 
kinds  of  changes  are  seen  in  such 
cases.  In  one,  which  is  more  dis- 
tinctly inflammatory,  the  nuclei  of 
the  cartilage-cells  increase  in  size 
and  divide,  so  as  to  increase  in 
number;  the  contents  of  the  cell 
become  granular ;  the  cells  enlarge 

at  the  expense  of  the  hyaline  substance,  which  is  ultimately  absorbed,  and 
then  the  cells  burst,  setting  free  their  contained  nuclei,  which  have  be- 
come transformed  into  bodies  resembling  pus-corpuscles. 

In  the  other  change,  which  partakes  more  of  the  nature  of  degenera- 
tion, the  ilitercellular  substance  is  not  destroyed,  but  is  rend'^red  granu- 
lar, and  the  cartilage-cells  are  separated  from  each  other  by  a  fibrillated 
material,  which  is  probably  developed  from  tlie  nuclei  of  the  cartilage- 
cells  by  a  process  of  pro- 
liferation. Rindfleischi  fig.  206. 
has  depicted  in  these 
more  chronic  instances  of 
inflammation  canals  ex- 
tending through  the  car- 
tilage from  the  granula- 
tions on  the  articular 
lamella  to  those  on  the 
synovial  membrane,  into 
which  vessels  shoot  which 
bring  these  two  layers  of 
granulation  into  contact. 

These  more  chronic 
changes  depend,  as  it 
seems,  partly  on  loss  of 
nutrition  from  the  loosen- 
ing of  the  connection  be- 
tween the  cartilage  and 
the  bone. 

This   sliaht    sketch   of 


-^r^ 


1(1  _Jl.. -»(«(.*- 


Vertical  section  of  inflamed  cartilage  showing  the  splitting  into 
fibres  of  its  surface.— From  Redfern. 


1  Pathological  Histology,  New  Syd.  Soc.  Trans.,  vol.  ii,  p.  260. 


468  DISEASES    OF    THE    JOINTS. 

the  morbid  anatomy  of  inflamed  cartilage,  which  ought  to  be  supplemented 
by  a  study  of  the  works  named  in  the  footnote,'  will,  it  is  hoped,  enable  the 
student  to  understand  what  has  been  said  about  the  symptoms  and  the  re- 
sults of  the  disease  called  ''  idceration  of  the  cartilages."  The  mere  erosion 
of  the  cartilages  themselves  does  not  produce  any  special  symptoms — at 
least  that  is  the  opinion  of  almost  all  surgeons  of  the  present  day'^ — and  the 
grievous  starting  pains  which  characterize  the  disease  are  produced  by 
pressure  on  the  inflamed  bony  surfaces  which  are  exposed  by  their  removal. 
Sir  13.  Brodie  himself  came  to  this  conclusion,  and  has  expressed  in  the 
latest  edition  of  his  work  the  opinion  "that  the  increased  sensibility  in 
these  cases  is  in  the  bony  plate  beneath  the  cartilage  rather  than  in  the  car- 
tilage itself;  and  that  the  presence  of  severe  pains  with  involuntary  start- 
ings  of  the  limb  is  always  to  be  regarded  as  a  sign  of  the  bone  partaking 
of  the  disease."^  If  any  further  proof  of  this  be  wanted  it  may  be  found 
in  the  fact  that  similar  pains  and  startings  often  take  place  after  excis- 
ions of  the  knee  and  elbow,  when  every  portion  of  the  cartilage  has  been 
removed,  though  they  are  not  so  severe  as  in  joint  diseases,  partly,  perhaps, 
because  in  excision  the  sensitiveness  of  the  bone  where  it  has  been  divided 
is  less  than  that  of  the  articular  lamella,  and  partly  because  the  muscular 
action  is  interfered  with  by  the  wound.  For  there  can  be  no  doubt  that 
the  spasms  which  produce  such  agony  in  ulceration  of  the  cartilages 
are  due  to  reflex  irritation  of  the  muscles,  bringing  the  inflamed  end  of 
the  bone  into  contact  either  with  cartilage  opposed  to  it,  or,  what  must 
be  far  more  painful,  with  another  inflamed  portion  of  bone. 

1.  The  various  events  which  we  have  just  noted  are  easily  understood 
from  a  consideration  of  the  anatomy  of  the  disease. 

AVhen  the  disease  subsides  after  the  cartilages  have  been  ulcerated  and 
the  bone  only  somewhat  inflamed,  no  pus,  or  no  considerable  amount  of 
pus,  having  been  eff"used  into  the  articulation,*  the  ulcerated  spot  may 
fill  up  l)y  means  of  fibrous  tissue,  and  possibly  no  anchylosis  whatever 
may  take  place  ;  or  if  a  slight  fibrous  band  or  bands  should  form  between 
the  ulcerated  spot  and  the  opposite  surface  of  the  joint  it  may  give  way. 
The  formation  of  these  fibrous  bands  is  easily  understood  from  the  ten- 
dency to  fibrillation  observed  in  the  articular  cartilage  in  inflammation 
and  the  rapid  development  of  vascular  channels  in  it. 

2.  When  the  suppuration  has  been  more  considerable  but  chronic  it 
will  make  its  way  to  the  surface,  leaving,  in  all  probability,  some  part  of 
the  bone  exposed,  and  as  the  suppuration  progresses  the  ligaments  are 

'  Redfcrn,  Anormal  Nutrition  of  Cartilage.  Barwell,  Diseases  of  the  Joints. 
Weber,  Ueber  die  Veranderunccen  der  Knorpel,  etc.  Virchow's  Archiv,  Jan.  1858. 
Kindttf'isch,  Path.  Anat.,  vol.  ii,  pp.  260,  260.  A.  Johnstone,  in  Syst  of  Surg.,  2d 
ed.,  vol.  iv. 

2  Rcdfern  says:  "  Most  extensive  disease  may  be  going  on  in  many  joints  at  the 
same  time,  and  may  proceed  to  destroy  the  whole  thicUness  of  the  cartilage  in  y)ar- 
ticular  parts,  without  the  patient's  knowledge,  and  while  he  is  engaged  in  an  active 
occupation."  I  once  saw  a  striking  ocular  demonstration  of  the  utter  painlessness  of 
ulceration  of  the  cartilage.  I  had  amputated  at  the  knee-joint  in  a  case  of  injury, 
leaving  the  whole  of  the  cartilage  cov(^ring  the  femur  intact.  Unluckily  my  ante- 
rior flap  (which  had  been  injured  in  the  accident)  sloughed,  and  the  end  of  the  femur 
covered  by  its  cartilage  lay  exposed.  We  watched  the  cartilagi!  melt  away  by  ulcer- 
ation during  many  days  till  the  whole  bone  was  denuded.  The  patient  remained 
quite  insensible  to  the  process. 

3  Works,  l)y  Charles  Hawkins,  vol.  ii,  p.  244. 

*  Sr^veral  interesting  cases  will  be  found  recorded  by  Rrodie,  in  which  anchylosis 
apparently  complete  has  ensued  on  ulceration  of  the  cartilages,  without  any  formation 
of  pus  See  especially  the  case  numbered  xliv,  on  p.  242  of  the  second  volume  of  his 
collected  works,  edited  by  Mr.  Charles  Hawkins. 


LOOSE  "cartilages."  469 

inflamed  and  softened,  so  that  the  interarticular  ligaments  are  apt  to  give 
way  and  tlie  capsule  to  yield  to  the  pressure  of  the  bone  now  displaced 
by  the  muscular  action,  and  so  dislocation  will  ensue  if  great  care  is  not 
taken. 

Finally,  the  occurrence  of  acute  suppuration  in  the  joint  needs  no 
explanation,  since  pus  is  furnished  not  merely  by  the  cartilage  but  in  far 
greater  quantit}'  by  the  granulations  on  the  inflamed  synovial  membrane 
and  bone. 

The  treatment  of  this  acute  inflammator\'  disease  is  at  the  present  time 
less  active  than  it  used  to  be;  but  still,  though  we  have,  perhaps,  been 
wise  in  giving  up  the  excessive  local  bleeding  and  counter-irritation  and 
the  free  administration  of  mercur3'  which  was  in  vogue  some  years  ago, 
we  have  abundant  opportunities  of  testing  the  value  of  more  i^ioderate 
antipidogistics  and  counter-irritants  in  the  form  of  the  free  application 
of  leeches,  blistering,  or  issues.  The  strictest  local  rest  siiould  lie  at  the 
same  time  enforced.  If  the  joint  is  too  irritable  to  bear  a  splint  it  should 
be  supported  on  all  sides  by  some  soft  substance,  such  as  a  junk  well 
padded  with  tow  or  cotton-wool  sufficiently  to  prevent  any  serious  dis- 
placement ;  or  if  such  displacement  has  taken  place  before  the  case  is 
seen  the  limb  should  be  at  once  put  into  as  good  a  position  as  possible 
nnder  chloroform.  The  free  administration  of  opium  to  such  an  extent 
as  will  relieve  the  pain  is  necessary.  In  robust  persons  with  high  inflam- 
mation I  have  often  seen  great  improvement  from  a  course  of  mercur}^ 
rapidly  administered;  and  although  conscious  of  the  evils  which  follow 
the  indiscriminate  use  of  mercury,  in  such  cases  I  venture  to  recom- 
mend it. 

The  necessity  for  amputation  arises  when  the  symptoms  of  abscess  in 
the  joint  are  plain,  and  wlien  in  the  surgeon's  judgment  the  patient  has 
not  strength  to  survive  the  opening  of  the  abscess — as  to  which  enough 
has  been  said  above  (p.  4(52). 

Excision  is  not  successful,  and  should  not  be  practiced  in  these  acute 
conditions  of  inflammation  in  the  lower  limb  ;  but  in  the  upper  limb  there 
is  no  such  ol>jection,  and  I  have  more  than  once  excised  the  elbow  with 
success  in  the  acute  stage  of  the  disease. 

There  are  other  degenerations  of  the  articular  cartilages,  as  hypertroph}', 
atrophy,  fibrous,  fatt}^,  and  calcareous  degeneration,  but  they  produce  no 
known  symptoms  during  life,  and  I  must,  therefore,  refer  the  reader  to 
works  on  pathological  anatomy  for  their  elucidation.  The  extensive 
changes  thus  found  in  the  cartilages,  with  no  symptoms  during  life, 
strengthens  the  opinion  that  in  the  destructive  disease  called  "ulceration 
of  the  cartilages"  the  condition  of  the  latter  is  really  a  subordinate 
feature. 

Loose  '■'•cartilages^''''  or,  as  some  prefer  to  call  them  "loose  bodies"  in 
the  joints,  are  sometimes  numerous.  They  are  seen  almost  but  not  quite 
exclusively  in  the  knee-joint.  Rare  cases  are  recorded  and  preserved  in 
the  elbow  and  other  joints,  but  they  are  rather  surgical  curiosities  than 
matters  of  practical  interest.  The  following  will,  therefore,  apply  to  the 
disease  as  found  in  the  knee. 

They  are  not  usually  cartilaginous,  at  least,  if  there  is  any  true  car- 
tilage in  them  it  is  often  in  such  small  quantity  as  to  escape  even  a  careful 
examination.  The  bulk  of  the  body  consists  usually  of  fibrous  tissue,  in 
which  perhaps  a  small  cartilaginous  nodule  may  be  found,  and  the  car- 
tilage is  sometimes  extensively  or  almost  entirely  calcified.  In  other 
cases,  however,  they  have  been  found  cartilaginous  throughout,  and  in 


470  DISEASES    OF    THE    JOINTS. 

some  true  bone  forms  a  part  or  tlic  whole  of  them,  and  I  have  seen  a  case 
in  which  the  supposed  loose  cartilage  turned  out  to  be  a  piece  of  semi- 
solid lyini)h. 

Tlic  causes  whicli  produce  these  loose  bodies  will  throw  some  light  on 
their  anatomy.  Hunter  believed'  that  tliey  often  arise  from  contusions 
in  wliifh  lilood  is  ett'used  into  the  joint ;  and  this  blood  becoming  organized 
and  then  being  separated  from  the  inner  surface  of  the  synovial  mem- 
brane, gives  rise  to  the  loose  body.  And  although  modern  pathologists 
may  hold  difl'erent  views  from  Hunter  about  the  frequency  of  the  process 
of  organization  of  blood-clots,  it  cannot  be  doubted  that  accident  is  a 
fi'equent  cause  of  loose  cartilage.  This  accident  may  possibly  produce 
extravasation  into  some  of  the  fringed  processes  of  synovial  membrane 
in  which  it  is  well  known  that  minute  portions  of  cartilage  may  often  be 
found.  If  such  extravasated  fringes  become  subsequently  thickened  by 
inflammation  their  attachment  to  the  main  portion  of  the  synovial  mem- 
bi'ane  may  l)ecome  gradually  looser,  until  at  length  they  drop  completely 
into  the  cavity,  and  then  would  be  found  to  present  exactly  the  structure 
generall}'  seen  in  a  loose  cartilage.  And  this  explanation  of  their  origin 
is  also  consistent  with  the  fact  that  they  are  frequentl}'  found  not  per- 
fectly loose,  but  pedunculated.  In  other  cases,  however,  there  is  no 
doubt  that  they  originate  spontaneously  from  the  detachment  of  similar 
fringed  processes,  which  in  some  persons  are  found  unusually  large  and 
numerous,-  or  they  ma}^  and  often  do  originate  from  disintegration  of  the 
cartilages  in  chronic  rheumatic  arthritis,  and  possibly  in  other  affections 
of  the  joints,  though  in  these  cases  they  are  seldom  made  the  subject  of 
any  special  treatment,  the  existence  of  the  loose  body  being  only  a  sub- 
ordinate feature  of  the  case.  Finally,  there  are  cases  (though  probably 
not  very  many)  in  which  a  piece  of  the  articular  cartilage  or  even  of  the 
articular  end  of  the  bone  may  be  knocked  off,  and  fall  as  a  loose  body 
into  the  joint.'* 

The  symptoms  which  they  produce  are  acute  pain  when  the  foreign 
bod}'  gets  between  the  ends  of  the  bones  in  the  movements  of  the  joint, 
often  followed  by  more  or  less  synovitis,  so  that  the  limits  of  the  joint 
are  somewhat  extended.  The  loose  body  is  often  plainly  to  be  felt  in  the 
sac  of  synovial  membrane  which  extends  in  front  of  the  femur,  and  then 
may  fall  into  the  back  of  the  joint  again  and  perfectly  disappear.  The 
patient  usually  is  quite  conscious  of  its  presence,  and  can  often  bring  it 
into  reach  when  the  surgeon  cannot. 

In  the  treatment  of  this  affection  it  is  necessary,  I  think,  to  bear  in 
mind  that  the  knee-joint  cannot  be  opened  without  grave  danger.  There- 
fore in  persons  whose  occupations  are  not  active,  and  who  do  not  suffer 
much  from  the  presence  of  the  foreign  body,  it  may  be  more  prudent  to 
temporize  with  the  disease  by  fixing  the  loose  cartilage  if  possible  in  the 
upper  sac  of  the  synovial  cavity,  where  its  presence  is  comparatively 
harn)less.  'IMiis  may  sometimes  be  accomplished  by  circular  strips  of 
strapping  fixed  above  and  below  it,  or  by  a  bandage  with  a  hole  to  re- 
ceive it,  and  it  is  even  possible  that  the  loose  body  may  at  length  adhere 
in  that  position.  It  will  be,  of  course,  understood  that  the  movements 
of  the  joints  are  restrained  meanwhile  by  a  firm  bandage  or  knee-cap. 

1  Hunter's  Works,  vol.  i,  p.  520,  and  vol.  ill,  p.  G25. 

*  See  tlie  fij^ure  on  p.  4,  vol.  iv,  Syst.  of  Surg. 

"  See  the  cases  of  detftchment  of  a  piece  of  cartilage,  related  by  Mr.  Teale,  Med.- 
Chir.  Trans.,  vol.  xxxix,  p.  31  ;  by  Mr.  Brodhur.^t,  St.  George'.s  Hospital  Keports, 
vol.  ii.  p.  141  ;  and  of  detaclinnMit  of  a  portion  of  the  bone  along  with  the  cartihige 
over  it,  by  Mr.  Simon,  Path.  Trans.,  vol.  xv,  p.  20G. 


CHRONIC    08TE0-ARTHRITIS.  471 

Attempts  have  been  made  to  fix  the  loose  body  by  driving  a  silvei-  suture 
through  it,  but  not,  I  believe,  witli  encouraging  results.  But  in  most 
cases  where  the  joint  is  otherwise  healthy  and  the  patient  is  ol)liged  to 
use  it,  the  removal  of  the  loose  cartilage  becomes  necessary,  and  this  is 
effected  in  one  of  two  ways.  In  both  the  body  must  be  securely  held  by 
the  surgeon's  left  forefinger  and  thumb  placed  under  it.  Then  in  the 
direct  method  of  extraction  tlie  surgeon  cuts  down  on  the  loose  sub- 
stance and  gently  squeezes  it  out  of  the  wound,  following  it  with  his 
finger  and  thumb,  so  as  if  possible  to  prevent  the  escape  of  synovia  from 
the  joint.  And  in  order  that  the  wound  into  the  joint  may  be  less  direct 
it  is  well  to  have  previously  drawn  the  skin  to  one  side  over  the  loose 
cartilage,  so  that  when  the  parts  return  to  their  proper  position  the  skin- 
wound  no  longer  corresponds  to  tlie  opening  in  the  joint.  In  the  subcu- 
taneous method  (which  is  believed  to  be  more  safe,  though  the  evidence 
on  that  point  is  not  conclusive)  a  tendon-knife  is  passed  down  to  the 
surface  of  the  loose  body  and  a  bed  or  cavity  formed  for  it  in  the  track 
of  the  knife;  an  opening  is  then  made  into  the  capsule  of  the  joint, 
tlirough  which  the  cartilage  can  be  squeezed  into  the  subcutaneous  tissue. 
There  it  is  left,  either  for  life  or,  if  it  causes  any  inconvenience,  until 
the  opening  in  the  joint  has  long  healed,  when  it  is  cut  down  upon  and 
extracted.  In  tiiese  operations  it  is  essential  to  disturb  the  parts  as  little 
as  possible,  to  unite  the  skin-wound  or  puncture  immediately  and  very 
carefully  with  strapping,  to  bandage  the  limb  evenly  from  the  toes,  and 
to  fix  it  securely  on  a  well-fitting  splint.  The  tendency  to  inflammation 
will  thus  be  best  obviated  ;  but  if  the  knee  does  inflame  cold  should  be 
at  once  applied;  and  if  the  inflammation  increases  and  becomes  violent 
suppuration  is  imminent,  and  the  case  must  be  treated  accordingly. 

Chronic  rheumatic  arthritis,  rheumatoid  arthritis,  osteo-arthritis,  rheu- 
matic gout,  or  nodosity  of  the  joints,  is  a  disease  which  has  only  lately 
been  accurately  described,  mainly  by  Irish  surgeons — Dr.  Haygarth,  Dr. 
Robert  Adams,  and  Prof.  R.  W.  Smith.  The  tissue  originally  affected 
(if,  indeed,  the  disease  begins  in  any  single  tissue)  is  difficult  to  deter- 
mine, since  we  hardly  ever  see  the  disease  dissected  except  in  an  ad- 
vanced stage,  but  it  is  commonly  believed  to  commence  with  injection  of 
the  synovial  membrane,  which  becomes  distended  with  fluid,  its  vascular 
fringelike  processes  overdeveloped,  the  joint  somewhat  filled  with  fluid, 
the  ligaments  distended  and  inflamed  ;  the  bursas  near  the  joint  often 
share  in  the  distension  ;  bony  deposits  form  in  the  ligamentous  capsule 
giving  rise  to  the  formation  of  tlie  '' additamentary  bones"  so  character- 
istic of  this  alfection;  the  cartilages  become  degenerated  and  gradually 
disappear,  sometimes  portions  of  them  drop  into  the  joint,  forming  one 
kind  of  loose  cartilage.  As  the  cartilage  disappears  the  articular  surface 
of  the  bone  becomes  polished  and  eburnated,  the  shape  also  of  the  bony 
surface  becomes  greatly  changed,  the  cavities  being  much  enlarged,  and 
the  articulating  ends  flattened  out  as  if  they  had  been  partly  melted  and 
then  squeezed  out  into  a  kind  of  mushroom  sha|)e. 

There  is  little  or  no  tendency  to  suppuration,  nor  does  anchylosis  ensue, 
thougli  the  limb  may  be  stiffened  from  the  unnatural  shape  of  the  bones. 
In  the  more  favorable  cases,  however,  just  the  opposite  issue  follows  ;  for 
as  the  joint  surfaces  become  polished  on  each  other  the  movement  be- 
comes again  free  and  painless. 

Tlie  chief  symptoms  of  chronic  rheumatic  arthritis  are  wearing  pain  in 
the  part,  alteration  of  its  shape,  and  crackling  on  motion.  This  crack- 
ling is  sometimes  so  loud  as  to  be  distinctly  heard  all  over  the  room.     It 


472  DISEASES    OF    THE    JOINTS. 

is  due  partly  to  tlie  rubbing  of  the  joint-surfaces  on  each  other  and  partly 
to  that  of  the  additanientary  bones. 

The  treatment  of  this  complaint  when  it  is  fully  established — i.e.^ 
when  the  shape  of  the  joint  surfaces  is  much  altered  and  they  are  ex- 
posed and  crackle  on  each  other — is  never  very  satisfactory'.  All  that 
can  then  be  done  is  to  palliate  the  pain  by  opium  if  necessar}-,  hot  douches, 
regulated  pressure,  and  support  to  the  joint.  But  in  the  early  stage  the 
general  treatment  of  rheumatism  carefully  carried  out,  and  particularly'^ 
residence  in  genial  climates,  and  the  persevering  use  of  hot  springs,  may 
do  much  to  avert  the  occurrence  of  the  more  profound  and  incurable 
changes  in  the  bones  and  ligaments. 

In  a  very  few  cases  excision  of  the  affected  joint  has  been  practiced. 
Thus  Dr.  Humphry  excised  the  condyle  of  the  jaw,^  and  the  head  of  the 
femur  has  been  excised  on  account  of  chronic  rheumatic  arthritis  at  an 
unusually  advanced  age,  and  with  alleged  success.  Such  operations, 
however,  can  be  seldom  advisable,  since  the  disease  is  a  constitutional  one, 
and  therefore  liable  to  present  itself  anew  in  another  joint ;  nor  is  the 
suflering  which  it  occasions  sufficient,  as  a  rule,  to  justify  so  dangerous 
an  operation. 

It  is  now  universally  admitted  that  most  of  the  cases  which  have  been 
published  as  "partial  dislocations,"  especially  of  the  shoulder,  and  as 
"fractures  with  ligamentous  union,"  of  processes  in  the  neighborhood  of 
joints,  such  as  the  acromion,  were  really  instances  of  chronic  rheumatic 
arthritis  accompanied  by  changes  in  the  shape  and  position  of  the  joint 
surfaces,  by  erosion  and  unnatural  adhesion  of  the  tendons  near  the 
heads  of  the  bones,  and  by  the  formation  of  the  additamentary  bones, 
which  are  characteristic  of  this  affection.  (See  Dr.  R.  Adams's  work  on 
Rheumatic  Gout,  2d  ed.,  pp.  118  and  seq. ;  and  his  plate  iii.  Figs.  1,  2.) 

Anchylosis,  or  stiffening  of  joints,  is  of  three  kinds.  In  the  first,  which 
is  denominated  the  exb'a-articular,  it  depends  on  fibrous  adhesions  in 
the  soft  parts  external  to  the  bones,  such  as  take  place  in  limbs  which 
have  been  long  kept  in  constrained  positions,  as  in  the  treatment  of  frac- 
ture. In  the  second,  or  fibi^ous  (false)  anchylosis,  the  joint  surfaces  are 
united  by  bands  which  pass  from  one  articular  cartilage  to  the  other, 
such  as  have  been  above  described  as  forming  after  ulceration  of  the 
cartilages  or  after  synovitis.  In  the  third,  or  hony  (true)  anchylosis  the 
articular  cartilages  having  been  removed,  the  bones,  exposed  and  ulcer- 
ated, unite,  as  in  compound  fracture,  by  granulations,  in  which  ossifica- 
tion occurs,  until  at  length  the  whole  becomes  one  solid  mass  of  bone. 

The  diagnosis  between  bony  and  fibrous  anchylosis  can  usually  be  made 
under  chloroform,  for  in  the  fibrous  anchylosis  some  amount  of  passive 
motion  is  alwa3's  possil)le,  while  in  the  bony  there  is  none.  And  again, 
in  bony  anchylosis  the  muscles  around  the  joint  waste  to  an  extent  which 
is  never  seen  in  the  fibrous.  The  diagnosis  between  the  fil)rous  and  the 
extra-articnlar  anchylosis  can  be  made  in  part  by  the  history  and  in  part 
b}'  the  result  of  examination  under  chloroform.  In  fibrous  anchylosis 
movement  is  fettered  by  a  definite  band  or  bands.  It  is,  therefore,  per- 
fectly unopposed  until  those  bands  are  put  on  the  stretch,  when  it  is  ab- 
ruptly checked.  In  the  extra-articular  it  is  a  generally  stiffened  condi- 
tion of  all  the  parts  around  which  opposes  motion. 

The  treatment  must  be  determined  parti}'  by  the  nature  of  the  anchy- 
losis, and  partly  by  the  amount  of  inconvenience  which  it  causes.     Extra- 


1  On  the  Human  Skeleton,  p  306. 


ANCHYLOSIS.  473 

articular  adliesions  can  usuall}'  be  got  rid  of  by  constant  passive  motion, 
oiling  the  part,  gradually  or  abruptly  stretching  it,  or  applying  various 
extending  apparatus.  Many  sudden  cures  are  effected  in  this  and  in 
fibrous  anch^'losis  b}' sudden  wrenches,  which  break  down  the  bands  and 
restore  motion  at  once.  Such  cures  are  often  worked  haphazard  (and 
sometimes,  also,  it  must  be  owned,  with  a  definite  purpose  and  knowledge) 
by  quacks  in  cases  neglected  or  given  up  by  regular  practitioners,  much 
to  the  shame  of  the  latter.  Remembering  the  frequency  of  these  cases, 
we  should  be  cautious  of  insisting  too  long  on  confined  positions  of 
joints  in  the  treatment  of  accident  or  disease  ;  and  when  stiffening  has 
taken  place,  and  all  inflammatory  symptoms  have  subsided,  a  cai'eful  ex- 
amination under  chloroform  will  often  detect  one  or  more  definite  bands, 
which  can  be  ruptured  and  the  part  at  once  restored  to  its  function, 
gradually  increasing  passive  and  active  motion  being  afterwards  care- 
fully insisted  on. 

In  more  extensive  fibrous  anchylosis  there  will  be  much  more  difficulty 
in  restoring  moliility.  Long  patience  is  required  on  the  surgeon's  part, 
and  unusual  conttdence  on  that  of  the  patient,  before  the  desired  end  can 
be  reached,  and  often  the  adhesions  will  reform  time  after  time.  Still 
even  if  ultimately  a  stiff  joint  is  left,  at  least  its  position  may  be  im- 
proved and  the  limb  be  left  useful  instead  of  useless.  Some  caution  is 
necessary  in  making  forcible  extension  in  sucii  cases  to  avoid  doing  in- 
jury to  neighboring  parts,  or  fracturing  the  bones  in  childhood,  or  in 
adults  when  the  bone  is  weakened  by  atrophy.  A  useful  precaution  is 
to  hold  the  bones  as  near  the  joint  as  may  be,  and  to  rupture  the  adhe- 
sions by  short  movements  in  the  way  of  flexion  before  attempting  to  put 
the  limb  straight  by  extension  movements.  Again,  the  tendons,  in  case 
of  old  dislocation  or  anchylosis  in  false  positions,  are  often  so  contracted 
as  to  require  division  before  the  case  can  be  successfulh'  treated,  and 
this  must  always  be  done  some  days  before  the  attempt  at  extension. 

Bony  anchylosis  is  one  of  tlie  methods  of  cure  in  joint  disease,  and  it 
should  not,  therefore,  be  interfered  with,  unless  the  position  in  which  it 
has  occurred  renders  the  limb  useless.  In  such  cases  the  simplest  plan 
(and  it  is  also  the  least  dangerous)  is  to  fracture  the  bone  below  the  joint 
and  put  the  limb  straight;  but  this  is  seldom  possible  or  safe  except  in 
childhood.  When  there  is  little  change  in  tlie  shape  of  the  bones,  and 
the  uniting  medium  is  not  very  extensive,  the  operation  introduced  in  the 
case  of  the  knee-joint  by  Langenbeck  and  Gross, ^  and  since  practiced 
more  frequently  b}'^  Mr.  W.  Adams'-  in  the  hip-joint,  of  dividing  the  unit- 
ing medium,  or  the  bone  in  its  neighborhood,  b}'  means  of  a  fine  saw 
introduced  as  much  as  possible  subcutaneously,  like  a  tenotome,  is  easy 
and  successful.  But  in  cases  whi(;h  really  require  any  such  opei'ation — 
i.  (\,  where  the  change  in  the  relative  position  of  the  bones  is  considerable 
— there  is  often  a  very  large  deposit  of  bone  around  the  old  joint,  and  the 
shape  and  size  of  the  anchylosed  articular  ends  has  been  much  altered. 
It  m;iy,  therefore,  be  impossible  in  such  cases  to  execute  any  section 
really  deserving  of  the  title  subcutaneous,  and  the  operation  approaches 
in  gravity  and  in  extent  to  that  of  excision,  and  is  liable,  like  excision, 

1  Langenbeck 's  and  Gross's  operations  on  the  knee  are  referred  to  in  the  New  Syd. 
Soc.'s  Biennial  Retrospect,  1867-8,  p.  256;  and  in  the  Syst.  of  Surg  ,  2d  ed.,  vol.  iii, 
p.  722. 

^  Laiigcnbeck's,  Gu^rin's,  and  other  surgeons'  labors  in  this  operation  will  be  found 
summarized  in  Mr.  Adams's  pamphlet  on  Subcutaneous  Division  of  the  Neck  of  the 
Thigh-bone,  1871. 


474  DISEASES    OF    THE    JOINTS. 

to  be  followed  by  renewed  disease  in  the  divided  surfaces,  1)3'  exhausting 
supi)urjvtion,  or  by  pyn?mia. 

Neuralgia  and  hysterical  affections  of  joints,  though  they  are  not  iden- 
tical, yet  are  hard  to  separate  from  each  other  in  practice.  They  are 
both  characterized  by  pain  which  is  out  of  all  proportion  to  the  evidence 
of  actual  change  of  structure,  though  there  is  in  some  cases  some  amount 
of  swelling  or  puffiness  around  the  joint,  testifying  to  the  presence  of  a 
certain  degree  of  increased  vascular  action,  which,  however,  is  rather  the 
consequence  than  the  cause  of  the  pain.  In  many  cases  this  neuralgic 
affection  is  only  one  of  the  symptoms  of  general  hysteria,  as  testified  by 
the  other  ordinary  phenomena  of  that  state,  but  in  other  cases  there  is 
no  such  general  affection.  True  neuralgia  is  periodic,  and  is  usually  con- 
nected with  some  disturbance  of  general  health  or  digestion.  It  must 
be  treated,  as  in  other  parts,  by  anti-periodics,  as  quinine,  arsenic,  or 
hydrochlorate  of  ammonia  in  full  doses,  and  especially  by  attention  to 
the  general  health  and  the  condition  of  the  bowels,  and  by  free  exercise 
of  the  part. 

The  distinction  between  hysterical  aff"ection  of  a  joint  and  organic  dis- 
ease is  made  chiefly  by  noticing  the  disproportion  between  the  pain  and 
the  evidence  of  local  lesions,*  l)y  the  varying  and  inconsistent  nature  of 
the  symptoms,  and  by  examination  under  chloroform,  which  is  often  per- 
fectly decisive,  as  it  is  also  in  voluntar3^  imposition.  It  is  strange  in 
these  cases  to  see  how  motion,  which  has  seemed  almost  impossible  while 
the  patient  was  conscious,  becomes  at  once  completelj'  natural  when 
annesthesia  is  obtained,  and  the  perfectly  smooth  and  natural  condition 
of  the  articular  surfaces  testifies  to  the  absence  of  all  serious  disease. 

The  diagnosis  is,  however,  most  difficult  in  practice,  though  its  prin- 
ciples when  stated  in  the  above  summary  manner  appear  to  be  easy.  A 
careful  perusal  of  Sir  J.  Paget's  lectures  on  this  topic  will  show  that  there 
is  no  symptom  of  organic  disease  of  a  joint  which  may  not  be  imitated 
by  "nervous  mimicry,"  as  he  calls  it — the  lameness,  the  permanent  loss 
of  use,  complete  stiffness,  wearing  pain,  even  wasting  of  the  muscles 
around  the  joint;  and  the  matter  becomes  still  further  complicated 
when  we  reflect  that  on  tlie  one  hand  a  patient  most  obviousl3'  hyster- 
ical may,  nevertheless,  have  articular  disease,  and  that  on  the  other  a 
patient  may  be  suffering  from  nervous  disease  who  displays  no  trace 
whatever  of  hysteria,  llencc  Sir  J.  Paget  dwells  forcibly  on  the  neces- 
sit3- of  commencing  the  investigation  of  the  case  with  the  local  symptoms 
and  appearances,  and  giving  to  the  latter  far  greater  weight  in  diagnosis 
than  to  the  general  aspect  and  history  of  the  patient.  But  it  is  wise  not 
to  be  in  a  iuirry,  and  only  to  form  and  announce  a  positive  opinion,  after 
careful  an<l  rei)eatcd  examination  and  observation. 

The  treatment  of  these  affections  is  si)oken  of  on  page  380. 

The  above  observati(jns  on  the  general  pathology  of  joint  diseases  are 
intended  to  be  applicaltle  to  all  the  joints  in  the  body,  though  they  are 
chiefly  drawn  from  tlie  phenomena  of  the  diseases  of  the  knee.  We  must 
now  speak  more  particularly,  though  very  shortl3',  of  the  diseases  of 
some  of  the  other  joints. 

1  Sir  J.  Piij^et  dwells  fsjx'eially  on  the  importance  of  the  local  temperature.  In 
inflammatory  affections,  a.i  .>.ynoviti>,  the  heat  of  the  joint  is  perceptibly  increased, 
as  felt  by  the  hand  laid  over  it,  and  this  i.s  not  the  case  in  nervous  disorders.  This 
test,  however,  is  only  apj)licable  to  the  superficial  joints. — Paget's  Clinical  Lectures, 
p.  215. 


MORBUS    COXARIUS.  475 

Disease  of  the  Hij). — The  disease  of  the  hip  {Morbus  Coxarius)  which 
is  so  common  in  the  poor  weakly  children  of  our  large  cities,  and  which 
is  seen  occasionally  also  in  children  who  are  more  fortunatel}-  circum- 
stanced, is  often  denominated  slrumoiis  disease.  But  1  should  like  (in 
accordance  with  the  observations  made  above,  page  4G4),  to  commence 
its  description  by  protesting  against  the  use  of  a  term  which  includes  a 
theory  that  is  not  only  unproved,  but,  as  I  contend,  disproved  by  the 
result  of  numerous  cases.  It  would  indeed  be  absurd  to  den}'  that 
strumous  children  often  suffer  by  hip  disease,  that  hip  disease  is  often 
associated  with  pulmonary  consumption  in  the  family  or  in  the  person 
affected,  or  that  it  is  sometimes,  though  more  rarely,  accompanied  by 
other  strumous  or  scrofulous  aff^ections.  But  I  think  it  would  be  an 
equally  gross  error  to  deny  that  it  often  occurs,  just  as  disease  of  any 
other  joint  does,  from  local  injury  or  exposure  to  cold  ;  that  it  is  suscep- 
tible of  complete  cure,  without  any  constitutional  aff"ection  left  behind  it, 
or  any  tendency  to  disease  in  any  other  part  of  the  body ;  and  that  at 
even  the  most  advanced  stage  it  may  in  appropriate  cases  be  extirpated 
by  surgical  operation  with  just  the  same  prospect  of  definite  cure  as  after 
excision  of  any  other  joint.  In  fact,  each  case  must  be  judged  on  its 
own  merits — there  are  strumous  cases  of  morbus  coxarius  and  cases  not 
strumous,  and  their  successful  treatment  depends  in  a  great  measure  on 
their  diagnosis.  The  symptoms  of  disease  of  the  hip  are  generally 
divided  into  three  stages: 

1.  Stage  of  Inflammation. — The  first,  or  inflammatory  stage,  is  charac- 
terized by  starting  pain  at  night,  by  pain  in  the  knee,  limping,  and 
wasting  of  the  muscles.  Sometimes  one  of  these  symptoms,  sometimes 
another,  is  the  first  which  is  noticed.  Perhaps  of  all  other  symptoms  the 
loss  of  motion  of  the  joint  is  that  which  is  most  convincing.  On  laying 
the  child  down  and  rotating  or  flexing  first  the  sound  and  then  the  af- 
fected limb,  the  contrast  between  the  easy  and  even  movement  of  the 
former  and  the  stiff",  painful,  imperfect  motion  of  the  latter  is  very 
striking.  There  is  occasionally,  but  not  often,  some  fulness  of  the  hip 
as  if  from  effusion  into  the  capsule  of  the  joint,  and  some  heat  of  the 
parts.  The  limb  very  commonly  appears  to  be  lengthened,  but  this  is 
found  on  measurement  to  be  only  apparent,  and  dependent  on  the  posi- 
tion of  the  pelvis,  which  is  adducted — that  is,  drawn  down  on  the  affected 
side — so  that  the  spine  of  the  ilium  is  lower  on  that  than  on  the  sound 
side.  The  opposite  side  of  the  pelvis,  however,  is  often  dropped  and  the 
affected  limb  is  apparently  shortened,  though  no  real  change  in  its  length 
has  taken  place.^ 

^  What  the  cause  of  the  various  phenomena  of  hip  disease  may  be  is  not  easy  to 
determine.  The  wasting  of  the  muscles  is  a  most  striking  phenomenon,  and  is  present 
often  to  a  considerable  extent  before  the  diagnosis  of  hip  disease  has  been  formed ; 
though  not,  therefore,  before  the  disease  has  commenced  (see  Nunn,  in  Path.  Trans., 
vol.  xviii,  p.  217)  ;  and  it  aflf'ects,  as  Mr.  Nunn  has  pointed  out,  notthe  muscles  of  the 
hip  only — though  chiefly  these — but  also  the  whole  limb.  Sir  J.  Paget  (Clin.  Lec- 
tures, p.  208)  has  called  attention  to  the  great  extent  of  wasting  which  goes  on  in 
these  and  other  acute  diseases  of  the  joints,  and  has  shown  that  it  is  too  rapid  to  be 
accounted  for  entirely  by  disuse;  though  disuse,  of  course,  pla3's  a  part  in  it.  The 
causes  also  of  the  apparent  lengthening  and  shortening  of  the  limb  are  the  subjects  of 
much  difl'erence  of  opinion.  It  is  clear  that  the  lengthening  depends  on  position 
only.  The  two  main  theories  which  are  now  adduced  as  reasons  for  this  position  are 
that  of  MM.  Martin  and  CoUineau,  which  refers  it  to  the  disposition  of  the  Kbres  of 
the  capsule,  and  that  of  Mr.  Barwell,  which  attributes  it  solely  to  a  contracted  con- 
dition of  the  abductor  muscles  of  the  thigh.  In  the  view  of  the  French  authors 
there  are  different  kinds  of  hip  disease,  and  that  kind  which  commences  in  inflam- 
mation of  the  articular  capsule  ("  capsular  coxalgia,"  as  they  style  it)  is  accompanied 


476  DISEASES    OF    THE    JOINTS. 

The  pathological  anatomy  of  the  earl}'  stage  of  hip  disease  is  not  easy 
to  determine,  and  it  appears  to  me  probable  that  the  disease  commences 
at  one  time  in  the  ends  of  the  bones,  at  anotlier  in  the  synovial  mem- 
brane or  in  the  ligaments.  On  this  head  I  would  refer  to  the  observa- 
tions which  I  have  made  in  a  work  on  tlie  Surgical  Treatment  of  Children's 
Diseases.  2d  edition,  pp.435  et  seq.,  in  which  I  endeavor  to  prove  that  in 
most  cases  the  visible  results  of  inflammation  are  first  seen  in  or  about  the 
ligamentous  capsule  and  the  ligamentum  teres,  though  some  cases  prob- 
abh'  commence  as  common  synovitis,  and  others  with  low  inflammation 
of  the  bones. 

2.  Stage  of  Abscess. — The  second  stage  is  that  of  abscess.,  which  is  not, 
however,  necessarily  connected  with  disease  of  the  bones,  nor  always 
situated  in  the  cavity  of  the  joint.  Very  frequently  it  is  external  to  the 
articulation  and  the  bones  are  unaffected.  Examination  under  chloro- 
form will  settle  this  point  by  revealing  true  crepitus  when  the  bones  are 
diseased,  or  the  grating  sensation  of  roughened  cartilage  when  the  mis- 
chief is  less  deepseated. 

3.  Stage  of  Beat  Shortening. — The  third  stage  is  that  of  real  shortening. 
This  shortening  is  produced  by  caries  and  absorption  of  the  head  and 
neck  of  the  femur  and  of  the  acetabulum.  The  upper  end  of  the  femur 
is  in  some  cases  so  disintegrated  that  only  a  small  irregular  projection 
may  remain  above  the  trochanter,  and  in  most  cases  the  head  is  found  to 
be  diminished  in  size,  and  nearer  the  trochanter  than  natural.  The 
acetabulum  is  often  greatly  enlarged,  and  not  unfrequently  perforated  by 
ulceration.  There  is  abscess,  which  has  generall}'  burst  externall}',  either 
in  the  thigh,  the  pelvis,  or  both.  In  consequence  of  this  change  of  sliape 
of  the  bones  there  is  a  displacement,  commonly  called  dislocation,  but 
which  differs  from  dislocation  in  the  very  important  particular  that  the 

at  first  by  a  relaxed  condition  of  the  capsular  ligament,  which  produces  abduction 
and  rotiition  outwards,  or  rather  necessarily  involves  that  poi*ition,  in  consequence  of 
the  anatomical  disposition  of  the  fibres  of  the  capsule,  and  the  muscles  accordingly 
place  the  limb  in  abduction.  This  position  of  the  femur  induces,  secondarily,  an 
adducted  position, or  dropping,  of  the  pelvis,  in  order  to  maintain  equilibrium  in  the 
erect  jiosition.  After  a  lime  tlie  inflammatory  elongation  of  the  capsule  is  succeeded 
by  induration  and  contraction,  involving  a  change  from  the  elongated  to  tlie  appar- 
ently shortened  condition  of  the  limb.  Thus  are  explained  the  many  cases  in  which 
elongation  is  the  primary,  and  shortening  the  secondary  symptcjm.  Shortening, 
adduction,  and  rotation  inwards  of  the  femur  are  also  produced,  according  to  these 
authors,  by  an  inflamed  condition  of  the  acetabulum  and  liead  of  the  femur,  and  by 
the  mu.-rcular  contractions  provoked  by  sucii  inflammation.  This  species  of  hip  dis- 
ease ("coxalgic  osteitis  ")  may  occur  either  primarily  (and  thus  are  explained  those 
cases  in  which  shortening  occurs  without  previous  elongation),  or  it  may  follow  on 
the  "capsular  coxalgia,"  which  produces  elongation.  Th(!  real  shortening  everybody 
allows  to  be  produced  by  changes  in  the  size  and  relation  of  the  acetabulum  and  up- 
per end  of  the  femur.  Mr.  Barwcli  attributes  the  lengthening  to  a  spasmodic  condi- 
tion of  the  abductor  muscles,  which  he  says  always  accompanies  the  distension  of  the 
capsule;  and  he  ap])ears  to  believe  that  such  distension  is  always  relieved  by  the 
bursting  of  tiie  ca])sule  before  the  second  stage — that  of  adduction  or  shortening — 
comes  on.  If  I  have  rightly  understood  Mr.  Harwell's  theory,  it  hardly  explains 
those  cases  in  which  shortening  is  not  preceded  by  elongation,  nor  those  more 
numerous  cases  in  which  there  is  dccitledly  no  trace  of  any  such  perforation  of  the 
capsule  as  Mr.  Barwell  speaks  of.  But  bulb  theories  agree  in  this,  that  they  refer 
both  jiosilions  to  the  preponderating  and  spasmodic  action  of  cci'lain  sets  of  muscles; 
and  without  professing  myself  satisfied  as  to  the  correctness  of  the  details  of  either 
theory,  I  fully  agree  in  tin;  main  practical  inference  to  which  they  point,  viz.,  that 
the  early  symptoms  of  hip  disease  aris  in  a  great  measure  muscular,  and  can  only  be 
treated  successfully  by  measures  directed  to  the  rcilief  of  muscular  contraction, 
i.  c,  by  mechanical  extension. — Holmes's  Surgical  Treatment  of  Children's  Diseases, 
p.  443. 


MORBUS    COXARIUS. 


477 


Dislocation  of  the  hip  from  disease.  A  preparation,  Ser.  iii, 
No.  86,  in  the  Museum  of  St.  George's  Hospital. — System  of 
Surg.,  2d  edition,  vol.  iv,  p.  83. 


ulcerated  articular  surfaces  are  not  separated  from  each  other,  but  re- 
main   in    mutual    contact, 

and  therefore  irritate  each  ^^'^-  2*'^- 

other.  To  this  rule  there 
are,  of  course,  exceptions, 
in  which  the  head  of  the 
femur  has  entirely  quitted 
the  acetabulum  ;  but,  as  far 
as  I  have  seen,  they  are 
very  rare.  In  some  still 
rarer  cases  the  capsule  is 
so  stretched  and  the  liga- 
ments have  so  far  yielded 
that  the  head  of  the  bone 
will  quit  the  acetabulum 
and  return  again  into  it 
on  manipulation  with  per- 
fect ease.  I  have  referred 
to  such  a  case  in  the  work 
above  quoted  (p.  438),  in 
which  the  patient  had  not 
suffered  from  any  congeni- 
tal affection,  where  there 
had  been  no  formation  of 
matter,  and  there  was  no 
grating  of  the  bones  on 
each  other.  But  by  very 
slight  manipulation  the  head  of  the  femur  could  be  dislocated  on  to  the 
dorsum  ilii,  as  proved  by  the  sensation  of  the  head  slipping  out  of  the 
socket,  which  could  be  plainl}'  perceived  ;  and  the  characteristic  shorten- 
ing of  the  limb  was  then  immediately  produced,  and  the  bone  could  be 
felt  on  the  dorsum  ilii.  It  was  equally  easy  to  reduce  the  bone  into  its 
natural  position.  Dislocation  from  disease  can  always  be  diagnosed  by 
measuring  tlie  length  of  the  limb  and  observing  the  position  of  the 
trochanter,  which  is  elevated  above  the  natural  level.  The  readiest  way 
of  ascertaining  this  is  by  what  is  called  "  Neiaton's  test."  If  a  string  is 
stretched  from  the  anterior  superior  spinous  process  to  the  tuberosity  of 
the  ischium  on  the  sound  side  it  will  be  seen  that  the  trochanter  is  entirely 
below  it,  or  possibly  the  upper  border  of  the  trochanter  just  touches  the 
string.  On  the  affected  side  the  trochanter  rises  above  this  line  to  an  ex- 
tent proportioned  to  the  destruction  of  the  neck  of  the  femur.  Or,  if  the 
surgeon  prefers  it,  he  may  use  Mr.  Bryant's  method  of  measuring  by  the 
vertical  distance  of  the  top  of  the  trochanter  from  a  horizontal  line  car- 
ried through  the  anterior  superior  spine  (see  page  291). 

Diagnosis. — The  diagnosis  of  hip-joint  disease  is  not  always  easy,  at 
least  many  mistakes  are  committed.  Excluding  hysterical  or  neuralgic 
affection,  the  diagnosis  of  which  from  organic  disease  must  rest  on  the 
same  principles  in  this  as  in  other  joints,  congenital  dislocation,  disease 
of  the  knee,  psoas  abscess,  caries  of  the  pelvis,  disease  of  the  bursa  beneath 
the  psoas  muscle,  and  infantile  paralysis  affecting  the  muscles  of  the  but- 
tock, are  the  aflections  usually  confounded  with  morbus  coxarius.  The 
best  test  is  the  loss  of  motion  in  the  affected  limb.  For  in  every  one  of 
the  affections  above  enumerated  the  suspected  limb  can  be  moved  easily 
and  painlessly.  This  is  the  case  even  in  those  which  are  accompanied  by 
inflammation,  if  care  be  taken  to  relax  and  steady  the  parts  which  ai'e  in- 


478 


DISEASES    OF    THE    JOINTS. 


flamed.  But  some  special  diagnostic  s.ymptoms  must  be  added.  In  con- 
genital dislocation  there  is  limjnno;,  possibly  wasting  of  the  muscles,  and 
when  the  child  stands  on  the  limb  there  is  shortening.     But  he  moves 

quite  readily  and  actively, 
Fio.  208.  though  with  an  awkward 

waddle;  the  length  of  the 
limb  can  generally  be  re- 
stored by  traction,  and 
there  is  no  pain  on  pas- 
sive motion.  In  disease 
of  the  knee  there  is  pain 
in  the  knee,  as  there 
is  also  in  disease  of  the 
hip  ;  but  careful  examina- 
tion will  show  the  thick- 
ening and  increased  heat 
of  the  parts  forming  the 
knee-joint,  the  stiffness  on 
attempts  at  passive  mo- 
tion, and  the  other  symp- 
toms of  disease  of  the 
knee.  I  may  just  remark 
in  passing  that  disease  of 
the  knee  and  hip  may  co- 
exist, so  that  the  proof  of 
disease  of  the  knee  is  no 
actual  disproof  of  hip  dis- 
ease. In  psoas  abscess, 
or  in  abscess  in  tiie  iliac 
fossa  or  buttock  from  dis- 
ease of  the  pelvis,  there  are 
the  characteristic  symp- 
toms of  disease  of  the 
spine  or  pelvis  superadd- 
ed to  the  freedom  of  mo- 
tion of  the  hip.  Disease 
of  the  bursa  of  the  psoas 
is  a  rare  affection.  It  may 
be  known  l)y  the  pain 
which  is  produced  in  the 
tumor  on  extending  the 
muscle,  and  the  relief  of 
symptoms  and  freedom  of 
movement  on  its  relaxa- 
tion, and  by  the  presence 
of  a  resisting  and  elastic, 
if  not  lluctuating,  tumor, 
of  perfectly  defined  shape 
and  size,  in  the  immediate  neighborhood  of  the  hip.  Passive  motion  of  the 
joint  is  free  and  painless,  except  when  it  causes  pressure  on  this  tumor. 
Infantile  paralysis,  wlicn  confined  to  the  muscles  around  tlie  hip  (which 
is  rare),  sometimes  gives  rise  to  mistake  on  a  careless  examination,  but 
the  painful  symptoms  of  hip  disease  are  absent,  and  there  is  no  obstacle 
to  passive  motion,  while  active  motion,  if  any  power  is  left,  though  limited, 
is  painless. 


Congenital  dislocation  of  the  hip.  From  a  typifal  case  iu 
which  both  hips  were  dislocated,  .showing  the  symptoms  char- 
acteristic of  this  allection,  viz.,  obliquity  of  the  pelvis,  causing 
lordosis,  disproportionate  length  of  the  lower  limbs,  the 
shoulders  thrown  back,  the  legs  weak  and  flaccid,  the  feet  flat. 
The  trochanters  are  promint'nt  and  nearer  the  spine  of  the 
ilium  than  natural,  and  the  head  of  the  thigh-bone,  if  of  the 
natural  size  and  shape,  can  be  felt  on  the  dorsum  ilii.— From 
Syst.  of  Surg.,  2d  edition,  vol.  v,  p.  831. 


MORBUS    COXARIUS.  479 

Treatment. — The  treatment  in  the  earlier  stages  of  hip  disease  consists 
mainly  in  rest  and  attention  to  the  general  health.  If  the  limb  has  been 
drawn  into  an  nnnatnral  i)osition  it  must  be  put  straight  under  chloro- 
form, which  is  always  perfectly  easy  in  the  early  stages,  and  extension 
must  be  applied  eitlier  by  a  long  splint  or  b}^  a  weight  suspended  from  a 
pulley  at  the  foot  of  the  bed,'  which  is  far  better  in  children,  since  the  long 
splint  irritates  them  and  is  constantly  displaced.  The  weight  must  be 
proportioned  to  the  age  of  the  child — 3-4  lbs.  for  a  young  child  and  7-10 
lbs.  for  one  approaching  puberty  may  be  taken  as  a  rough  average,  but 
this  must  be  ascertained  by  experiment.^  Its  traction  seems  to  prevent 
the  mutual  contact  of  the  inflamed  surfaces,  and  the  consequent  muscular 
spasms  which  are  so  painful  a  feature  of  the  disease.  In  cases  where  the 
inflammatory  symptoms  are  unusuall}'  severe  leeches  may  be  applied  in 
the  groin,  and  where  there  is  much  pain  blisters  or  the  light  application 
of  the  actual  cautery  in  the  neighborhood  of  the  joint  are  often  of  service. 
But  prolonged  rest  in  bed  is  the  main  agent  in  the  cure  of  the  disease, 
and  this  confinement  to  bed,  far  from  being  deleterious,  is  generally 
attended  with  considerable  improvement  in  the  general  health.  In  sum- 
mer weather,  if  the  {patient's  circumstances  admit  of  it,  his  bed  should  be 
placed  on  a  wheeled  couch  without  disturbing  him,  and  he  should  enjoy 
the  fresh  air;  but  so  long  as  there  is  any  tenderness  of  the  parts  on  mo- 
tion no  disturbance  of  tiie  hip  should  be  permitted.  How  long  that  may 
be  it  is  very  hard  to  say.  I  have  known  cases  treated  earl}'  recover  after 
less  than  half  a  year's  rest,  while  more  obstinate  cases  will  require  several 
years;  but  when  taken  in  the  earliest  stage  of  the  complaint  hip  disease 
is  often  curable  most  completely,  with  no  loss  of  motion,  no  change  of 
shape  of  the  parts,  and  no  defect  of  health ;  and  this  forms  a  powerful 
motive  for  recognizing  the  earliest  symptoms  of  the  affection.  Those 
symptoms  are  often  verj'  insidious;  there  is  little  or  no  tangible  pain,  the 
child  is  often  believed  to  suffer  only  from  "growing  pains,"  and  the  limp- 
ing may  not  be  constantly  noticed  ;  but  the  stiff"ness  of  the  joints  on  pas- 
sive motion,  and  the  pain  which  is  produced  by  attempts  to  move  the 
thigh,  especially  in  the  sense  of  abduction,^  are  symptoms  which  careful 
examination  can  hardlj^  fail  to  verify  at  any  period  at  which  the  disease 
can  be  diagnosed. 

It  is  not  advisable,  I  think,  to  open  abscesses  connected  with  diseased 
hip  unless  there  is  some  special  reason  fordoing  so.  I  have  seen  unmis- 
takal)le  abscesses  disappear;  and  even  if  they  are  to  burst  it  is  better  to 
allow  the  deep  parts  as  long  a  time  as  possible  to  consolidate  before  the 
opening  forms.  If  the  abscess  seems  to  be  increasing,  its  evacuation  by 
means  of  the  aspirator  is  very  desirable. 

In  the  third  stage,  when  the  bones  are  obviously  diseased,  the  question 
of  excision  becomes  a  practical  one.  The  answer  to  this  question  will 
depend  mainly  on  the  prospect  that  we  believe  the  patient  to  have  of 
spontaneous  cure ;  and  this  again  depends  on  the  means  he  has  for  pro- 
curing long-continued  rest,  with  careful  nursing.  If  this  can  be  had, 
more  patients  I  believe  will  get  well  than  after  excision,  and  with  better 

1  A  diagram  of  extension  by  means  of  the  weight  will  be  found  on  page  300 
*  I  do  not  see  any  object  in  using  more  force  than  is  necessary  to  prevent  pain  and 
insure  the  complete  repose  of  tlie  parts.  American  surgeons  use  very  much  greater 
extension  than  tliat  suggested  in  the  text.  In  a  case  recently  published  by  Dr.  Tay- 
lor, of  New  York,  in  a  child  aged  thirteen,  besides  an  extending  apparatus  calculated 
to  exercise  a  traction  equal  to  100  lbs.,  a  weight  of  50  lbs.  was  applied  to  the  foot. — 
See  London  Med.  Record,  July,  1875. 

3  Holmes's  Surg.  Dis.  of  Childhood,  2d  ed.,  p.  441. 


480  DISEASES    OF    THE    JOINTS. 

limbs ;  but  in  the  poor  children  whom  we  are  often  called  upon  to  treat, 
it  ma}'  be  more  judicious  to  remove  the  parts,  and  if  this  is  to  be  done 
with  an}'  prospect  of  success  it  should  not  be  delayed  too  long.  The 
operation  is  not  a  ver}'  severe  one,  and  it  leaves  a  very  useful  limb  ; 
though  I  think  generally  the  shortening  is  greater  and  the  union  not  so 
firm  and  strong  as  after  natural  anchylosis.  For  the  details  of  the  opera- 
tion I  must  refer  the  reader  to  the  chapter  on  Operative  Surgery. 

Other  Affections. — The  hip  is  also  the  seat  of  many  other  diseases.  The 
ordinary  so-called  "  strumous  "  disease  is  one  of  the  common  affections 
of  childhood,  yet  an  identical  affection  is  not  by  any  means  unknown  in 
later  life  ;  and  it  is  curious,  but  I  believe  true,  that  the  disease  in  the 
adult  is  less  severe  and  dangerous  to  life  than  in  the  child.  I  have  often 
noticed  this  with  surprise,  and  recently  saw  the  observation  confirmed  in 
a  paper  by  Dr.  Taylor,  of  New  York.  Then  we  meet  comparatively  often 
with  affections  of  the  great  trochanter  or  its  neighborhood,  sometimes 
with,  sometimes  without,  suppuration,  which  it  is  difficult  to  separate 
from  hip  disease,  and  which  may,  in  fact,  spread  to  the  hip.  These  are 
usually  the  consequences  of  falls  or  blows,  and  they  demand  careful  but 
decisive  treatment,  in  order,  if  possible,  to  avert  the  implication  of  the 
joint.  Rest  and  counter-irritation  before  suppuration  sets  in,  and  free 
incision,  exposure  of  the  carious  or  necrosed  bone,  the  removal  of  seques- 
tra and  the  application  of  sulphuric  acid  to  the  softened  bone  are  the 
chief  indications. 

Chronic  rheumatic  arthritis  has  its  favorite  seat  in  the  hip,  so  much  so 
that  the  disease  was  for  a  long  time  only  known  in  that  joint,  and  called 
malum  coxoe  senile.  The  change  of  shape  in  the  parts,  producing  short- 
ening of  the  limb,  the  wearing  pain,  the  slow  course  of  the  disease,  the 
crackling  on  passive  motion,  plainly  mark  the  nature  of  the  affection. 
The  treatment  is  usually  unsatisfactory  (see  p.  473). 

Sacro-iliac  Disease. — Closely  connected  with  disease  of  the  hip  is  dis- 
ease of  the  pelvis.  In  fact,  we  have  seen  that  some  amount  of  disease  of 
the  pelvis  almost  always  accompanies  the  last  stages  of  hip  disease.  But 
the  most  characteristic  affection  of  the  pelvis  is  that  which  occurs  at  or 
near  its  junction  with  the  spinal  column.  In  many  cases  which  are  diag- 
nosed as  sacro-iliac  disease  it  is  probable  that  the  disease  aflfects  the 
bones  of  the  pelvis  or  spine  as  much  or  more  than  the  sacro-iliac  joint 
itself;  but  when  the  disease  is  localized  in  the  articulation  its  character- 
istic sign  will  be  pain  in  sitting,  standing,  or  walking ;  in  fact,  in  any 
action  which  brings  the  weight  of  the  body  to  bear  on  the  pelvis.  On 
examination  it  will  be  found  that  there  is  no  pain  when  the  hip  is  moved, 
or  when  the  spine  is  flexed  or  extended,  provided  the  pelvis  is  kept  steady, 
but  there  is  pain  when  the  pelvis  is  moved  on  the  spine.  There  is  also 
swelling  or  some  pnffiness  about  the  part,  with  increased  heat  to  the  hand 
or  to  the  thermometer,  pain  rnnning  along  the  course  of  the  lumbar 
nerves,  and  sometimes,  flexion  of  the  hip  from  irritation  of  the  psoas 
muscle.  These  latter  symptoms  may  cause  a  suspicion  of  disease  of  the 
hip  or  spine,  but  carelnl  examination  will  show  that  the  movements  of 
these  parts  are  free  and  their  temperature  is  not  elevated,  while  the  heat 
and  pain  about  the  sacro-iliac  joint  will  point  to  the  real  seat  of  the  mis- 
chief. The  prognosis  depends  on  the  age  of  the  patient,  and  on  the  stage 
which  the  disease  has  attained  when  the  treatment  has  commenced.  When 
the  patient  is  an  adult,  and  the  disease  has  proceeded  to  suppuration,  the 
prognosis  is  generally  unfavorable,  though  instances  of  recovery  are  not 


DISEASE    OF    THE    TARSUS.  481 

wanting.  It  mnst  be  treated,  like  disease  of  the  spine,  by  complete  rest, 
with  proper  attention  to  diet  and  regimen,  so  that  the  patient  may  be 
supported  through  the  stage  of  exhaustion  or  hectic  which  may  possibly 
supervene  until  anchylosis  is  obtained.  As  in  disease  of  the  spine  and 
hip,  it  seems  better  to  allow  abscesses  to  open  spontaneously,  unless  they 
are  causing  irritation. 

The  diseases  of  the  knee  having  been  taken  as  typical  of  those  of  the 
joints  generall^^,  no  further  remarks  need  be  made  on  them  here, 

AnJde  and  Tarsus The  ankle  is,  perhaps,  next  to  the  knee  and  hip, 

the  most  frequent  seat  of  disease,  and  it  is  also  very  commonly  impli- 
cated in  inflammation  of  the  tarsus.  It  is,  therefore,  very  impoitant  to 
stud^'  carefully  the  diagnostic  signs  between  disease  limited  to  the  ankle- 
joint,  disease  limited  to  the  astragalus,  the  os  calcis,  or  the  joints  between 
these  two  bones,  general  disease  of  the  tarsus,  and  disease  implicating 
the  ankle  and  tarsus  simultaneously.  Disease  when  limited  to  the  ankle- 
joint  is  marked  by  effusion  into  that  cavity,  which  raises  up  the  extensor 
tendons  and  produces  fluctuation  on  either  side  of  them,  and  as  it  in- 
creases presents  at  one  or  other  or  both  borders  of  the  tendo  Achillis. 
The  movements  of  the  foot  on  the  leg  are  painful,  and  if  the  disease  has 
proceeded  to  denudation  of  the  bones  crepitus  may  be  felt  under  chloro- 
form, or  there  may  be  sinuses  from  which  the  probe  can  feel  bare  bone  in 
the  joint.  At  the  same  time  there  is  no  increase  of  heat,  no  swelling  or 
tenderness  over  any  part  of  the  os  calcis,  except  possibly  just  the  upper 
part  where  it  is  overlapped  by  the  articular  effusion  ;  nor  over  the  front 
of  the  astragalus.  Disease  which  is  limited  to  the  astragalus  produces 
swelling,  heat,  and  tenderness  corresponding  to  the  position  of  the  inflamed 
bone,  and,  therefore,  very  close  to  the  ankfe-joint,  but  unaccompanied  by 
the  effusion  beneath  the  extensor  tendons,  or  the  pain  on  passive  motion. 
Still  it  must  be  allowed  that  the  diagnosis  is  a  difficult  one,  and  that  the 
cases  in  which  the  disease  commencing  in  the  astragalus  does  not  impli- 
cate the  ankle  are  exceptional.  Such  cases  are,  however,  met  with,  and 
it  has  occurred  to  me  several  times  to  remove  the  whole  astragalus  for 
extensive  disease  of  the  bone,  leaving  a  healthy  ankle-joint,  and  with  com- 
plete success.  Disease  of  the  tarsus  has  very  commonly  its  starting-point 
in  the  joints  between  the  astragalus  and  os  calcis,  as  Sir  B.  Brodie  long 
ago  pointed  out,  though  it  ordinarily  begins  in  the  structure  of  the  bone. 
When  the  astragalo-calcanean  joint  is  the  seat  of  the  affection  there  will 
be  pain,  tenderness,  swelling,  and  heat  about  the  upper  part  of  the  os 
calcis,  and  the  movement  of  the  calcaneum  on  the  astragalus  will  be  pain- 
ful, though  that  of  the  foot  on  the  leg  is  not.  Careful  manipulation  is, 
however,  necessary  to  discriminate  this.  Rest  and  counter-irritation 
before  the  formation  of  matter,  and  early  incision  with  continued  rest 
afterwards,  are  the  essentials  of  treatment.  The  patient  need  not,  how- 
ever, be  confined  to  bed  after  the  abscess  is  opened.  The  foot  should  i)e 
put  up  in  a  plaster  of  Paris  splint,  with  a  hole  cut  for  the  opening,  and 
he  should  go  about,  resting  the  knee  on  a  wooden  leg.  In  inveterate 
cases,  where  the  bone  is  exposed,  and  the  disease  threatens  to  spread,  the 
foot  may  often  be  preserved  by  excising  the  os  calcis  and  removing  any 
part  of  the  astragalus  which  is  diseased.  Disease  of  the  calcaneum  is 
easily  known  by  the  presence  of  swelling  limited  to  the  bcme,  or  of 
sinuses,  all  of  which  lead  towards  or  to  it,  and  by  the  al)sence  of  all  the 
special  symptoms  above  enumerated  as  chai-acteristic  of  disease  of  the 
ankle,  astragalus,  and  astragalo-calcanean  joints. 

The  presence  of  general  disease  of  the  tarsus  is  usually  indicated  by 

31 


482  DISEASES    OF    THE    JOINTS. 

extensive  swelling  of  the  whole  of  the  foot  and  by  pain  in  all  its  move- 
ments;  indeed,  all  use  of  the  foot  is  soon  lost.  And  in  all  cases  of  dis- 
ease of  these  parts  the  foot  should  be  carefully  examined  under  anaisthesia 
before  any  serious  operation  is  contemplated,  in  order  to  ascertain  whether 
or  not  these  various  affections  are  combined,  as  thej'  so  commonly  are. 
It  would,  of  course,  be  a  serious  error  to  excise  the  ankle-joint  or  resect 
the  OS  calcis  if  the  tarsal  bones  left  behind  be  in  a  state  of  chronic  soften- 
ing in  the  one  case,  or  the  ankle  joint  diseased  in  the  other.  This  is  an 
error  which  is,  perhaps,  not  often  committed,  but  it  is,  on  the  other  hand, 
exceedingly  common  to  see  a  foot  amputated  for  supposed  "strumous 
disease  of  the  tarsus,''  when  on  examination  the  affection  turns  out  to  be 
limited  to  one  of  the  tarsal  bones,  and  the  patient  might  have  been  cured 
b3'  a  less  extensive  mutilation. 

Diseases  of  the  joints  of  the  upper  extremity  are  as  a  general  rule  more 
curable  than  those  of  the  lower.  Besides  the  generally  less  serious  char- 
acter of  all  affections  of  tlie  upper  limb  as  compared  with  those  of  the 
lower  there  is  the  powerful  consideration  that  the  joints  of  the  upper  limb 
have  not  to  bear  the  weight  of  the  body,  and  can  be  easily  kept  at  rest 
while  the  patient  is  moving  about  and  getting  air  and  exercise. 

Diseases  of  the  sternoclavicular  joint  are  rare,  and  as  far  I  have  seen 
occur  generally  in  persons  of  bad  constitution,  and  are  to  that  extent  to 
be  looked  on  with  suspicion,  though  recovery-  not  unfrequently  takes 
place,  even  after  extensive  abscess  and  destruction  of  the  joint.  Rest, 
tlie  prompt  removal  of  sequestra,  and  the  sulphuric  acid  treatment  to  any 
exposed  bony  surfaces  are  the  general  indications. 

Tlie  shoulder  is  far  less  frequentl_Y  diseased  than  any  of  the  other  large 
joints,  iiotwitlistanding  its  constant  movement,  and  its  exposure  to  all 
sorts  of  injury;  and  when  inflammatory  disease  does  occur  the  prospect 
of  recovery  with  a  useful  liml)  is  tolerably  good,  provided  treatment  be 
early,  patient,  and  judicious.  Osteo-arthritis,  however,  is  rather  common 
in  later  life,  and  will  in  all  probability  impair  the  use  of  the  joint,  and 
prove  a  source  of  pain  and  trouble  during  the  jDatient's  life.  I  have 
ali'eady  pointed  out  (p.  279)  how  the  change  in  shape  of  the  head  of  the 
bone,  the  new  cavity  which  is  often  worn  in  the  capsule,  the  erosion  of 
the  biceps  tendon,  and  the  loss  of  the  mobility  of  the  joint,  occui'ring  in 
this  disease,  liave  been  confounded  after  death  with  the  effects  of  partial 
dislocation.  The  disease  is  easily  recognized  during  life  b^^  the  crackling 
in  the  joint  and  the  change  in  shape  of  the  parts,  togetlier  with  the  wear- 
ing pain.  Tlie  treatment  is,  unfortunately,  a  less  eas}'  problem  (see  p. 
473). 

Inflammation  of  the  shoulder-joint  may  long  exist  without  suppuration, 
and  its  diagnosis  from  nervous  aftection  demands  much  care,  patience, 
and  attentive  examination,  u}Hler  chloroform  if  necessary.  Kest  and 
counter-irritation  shouhl  be  persevci'ed  in  so  long  as  much  pain  is  pro- 
duced by  motion,  but  no  longer.  Too  long  confinement  is  apt  to  produce 
rigidity  of  the  lower  part  of  tlie  capsule,  depriving  the  patient  of  tlie 
power  of  raising  the  arm.  Suppuration,  when  it  occurs,  is  often  directed 
by  one  of  the  tendons  around  the  joint  to  a  considerable  distance,  so 
that  the  real  origin  of  tlie  discharge  is  occasionally  overlooked  for  a  time. 
Another  source  of  ambiguity  is  the  occasional  occurrence  of  disease  in 
tile  l)ursa  which  lies  between  the  deltoid  muscle  and  the  head  of  the  bone, 
and  which  does  not  communicate  with  the  joint.'     I  once  treated  a  case 


'  The  synoviiil  fold  which  (.'xi.sts  boiu-iUh  the;  subscnuiilaris,  and  is  spoken  of  as  its 
bursa,  is  really  a  part  of  the  synovial  iiienihrano;  and  when  the  infraspinatus  has  a 
bursa  below  its  tendon  this  also  forms  a  part  of  the  joint. 


DISEASE    OF    THE    WRIST.  483 

in  which  the  swelling  beneath  the  deltoid,  the  pain  on  motion,  and  the 
crepitation  which  was  perceived  on  rotating  the  head  of  the  bone,  led  to 
the  diagnosis  of  disease  of  the  joint.  On  cutting  down  through  the  fibres 
of  the  deltoid  the  bursa  was  laid  open,  filled  with  a  mass  of  lymi)h  and 
pus;  the  joint  was  found  healthy,  and  all  tiie  symptoms  subsided. 

The  excision  of  this  joint  is  so  successful,  that,  if  the  symptoms  demand 
it,  no  hesitation  need  be  experienced  in  recommending  it.  At  the  same 
time  the  surgeon  must  remember  that  the  natural  cure,  by  anchylosis,  if 
it  can  be  obtained,  usually  leaves  at  least  as  useful  a  limb  as  that  after 
excision,  and  he  should  therefore  only  recommend  operation  when  he 
thinks  the  patient  is  losing  ground,  or  when  it  seems  necessary  to  hasten: 
the  cure. 

The  elbow  is  a  very  frequent  seat  of  carious  disease,  and  in  some  rarer 
cases  of  necrosis.  Dislocation  very  rarely  occurs,  except  of  the  head  of 
the  radius,  which  is  comparatively  often  found  on  the  back  of  the  outer 
condyle,  a  displacement  attributed  to  the  hand  having  been  kept  in  the 
pronated  position.  This  position  should  therefore  be  avoided  in  disease 
of  this  joint,  the  forearm  being  placed  at  an  acute  (not  a  right)  angle 
with  the  arm,  and  in  the  position  midway  between  pronation  and  supina- 
tion. When  aljscess  has  formed  and  the  bone  is  exposed  I  am  in  the 
habit  of  recommending  excision,  provided  the  patient  is  in  good  health. 
It  is  true  that  the  disease  is  limited  in  many  of  these  cases  ;  in  some  after 
the  removal  of  a  sequestrum,  or  after  cutting  off  a  portion  of  the  articu- 
lating surface  a  cure  has  been  obtained  with  a  moderately  useful  limb, 
and  in  many  a  natural  cure  by  anchylosis  would  ultimately  result ;  but 
on  the  whole  it  seems  that  the  free  excision  of  the  joint  is  both  more 
certain  in  its  prospects  of  prompt  recovery,  and  more  promising  as  far 
as  the  utility  of  the  liml)  goes,  than  either  of  these  other  operations. 

Chronic  rheumatic  arthritis  of  the  elbow  is  generally  accompanied  with 
a  similar  affection  of  other  joints,  otliervvise  it  would  be  a  question  whether 
excision  might  not  be  recommended  in  some  of  these  cases.  It  is  probably 
this  affection  which  generally  is  the  cause  of  the  occurrence  of  loose  car- 
tilage in  this  joint.  Next  to  the  knee  loose  cartilage  is  perhajjs  more 
common  in  the  elbow  than  elsewhere  ;  but  I  never  saw  a  case  operated  on. 

The  writit  and  carpus  are  often  diseased,  and  that  to  a  very  great 
extent,  and  especially  at  late  periods  of  life,  in  the  class  of  patients  who 
are  met  with  at  hos|)itals,  though  far  more  rarely  in  persons  who  are 
exempt  from  manual  labor.  Chronic  rheumatic  arthritis  also  attacks 
this  joint,  and  sometimes  produces  a  pseudo-dislocation,  or  so  changes 
the  relations  of  the  parts  that  dislocation  occurs  on  some  slight  injury. 
The  effects  of  disease  of  the  wrist  on  the  tendons  whose  action  is  neces- 
sary to  the  use  of  the  hand  are  perhaps  as  formidable  as  the  direct  injury 
to  the  joints,  and  when  the  disease  has  proceeded  far  the  results  of  all 
methods  of  treatment  are  imperfect.  The  early  treatment,  therefore,  of 
such  cases  is  very  important;  but  from  the  circumstances  of  the  patients 
it  is  but  seldom  that  an  opportunity  is  obtained  for  it.  When  suppura- 
tion has  occurred  the  abscesses  should  be  earl^'^  and  freely  opened,  the 
parts  should  be  kept  at  rest  on  a  splint,  and  passive  motion  carefully 
given  to  every  joint  which  admits  of  it,  the  patient  being  also  encouraged 
to  use  as  much  voluntary  motion  as  he  can  without  much  pain. 

It  is  only  in  the  last  resort,  and  as  a  substitute  for  amputation,  that 
excision  ought  to  be  proposed. 


484 


DISEASES    OF    THE    SPINE. 


CHAPTER   XXIV. 


DISEASES  OF  THE  SPINE. 


Fig.  209. 


Caries  of  the  spine,  or,  as  it  is  sometimes  called  simply,  "  disease  " 
of  the  spine,  is  very  frequent  among  strumous  and  other  weakly  children 

and  young  persons,  often  fol- 
lowing on  slight  accidents, 
but  as  often  occurring  spon- 
taneously —  insidious,  and 
marked  by  few  or  no  symp- 
toms in  its  commencement, 
but  leading  to  the  greatest 
lesions  in  its  progress,  and 
very  frequently  fatal. 

It  affects  any  part  of  the 
spine,  from  the  highest  cer- 
vical to  the  lowest  lumbar 
vertebrte,  and  cseteris  pari- 
bui<  is  more  dangerous  the 
higher  in  the  column  the 
affected  part  is.  It  has  its 
origin  always  in  the  spinal 
column  itself,  i.  e.,  in  the 
body  of  the  vertebra,  or  the 
intervertebral  substance, ' 
rapidly  spreading  from  one 
to  the  other.  In  the  can- 
cellous tissue  of  the  verte- 
bra it  seems  to  originate 
either  in  a  deposit  of  tuber- 
cle, which  softens,  or  in  low 
inflammation,  leading  to  sup- 
puration, which  spreads 
through  the  bone.  In  the 
intervertebral  substance  its 
pathology  is  the  same  as 
...       ■       m  f     ■     ■    cA    that  of  other  ulcerations  of 

Angular  curvature  of  the  spine.   The  preparation  is  viewed 

from  the  right  side.   Therein  no  difference  whatever  between  Cartilage      (seC     DlSCaSCS    Ot 

the  size  of  the  two  pleural  cavities.    The  smooth  surface  a,  Joints).      The  inflamed  1)0116 

is  a  buttress  of  new  hone,  the  result  of  inflammation,  which  fm'nislies     PUS      wllicll     is    at 

has  replaced  or  has  soldered   together  the  remains  of  the  /.      .  i-      •,      i,      '.i         ,  . 

bodiesof  seven  dorsal  vertebrae    At  the  side  of  this  is  seen  first  limited  by  the  Structures 

a  mass  of  rough,  irregular  bone  by  which  the  heads  of  the  arouild  the  Sl)ine,  COndcilSCd 

corresponding  ribs  arc  anchylosed  together.   The  projecting  j,^^q  ^^  kind  of  SaC  for  it  (Fig. 

spinous  processt-sareal-so  firmly  united  by  bone -l^om  a  .^IQ)      j,nd    the    absCCSS    ma'y 
preparation  111  the  Museum  of  !5t.  George's  Hospital,  ber.  V,  ^'.  .  .  •' 

^,^27  remain     quiescent     in     this 

state  for  an  unlimited  time, 
then  dry  up  and  be  absorbed,  leaving  little  trace  of  its  former  presence; 


'  Th<f  disoasH  almost  always  arises  in  the  bone,  but  jircparations  arc  not  wanting 
showing  its  occasional  commencement  in  the  intervertebral  disk. 


ANGULAR    CURVATURE.  485 

or  it  may  spread  to  a  considerable  distance,  verj' commonly  passing  along 
the  sheath  of  the  psoas  muscle  into  the  thigh  (psoas  abscess)  or  between 
the  trans vei'se  processes  into  the  loins  (lumbar  abscess),  or  presenting 
behind  the  pharynx  (post-i)haryngeal),  or  making  its  way  into  some  of 
the  neighboring  cavities  or  viscera,  so  that  spinal  abscesses  may  burst 
into  the  pleura,  the  lungs,  the  peritoneum,  intestines,  kidneys,  urethra, 
bladder,  etc.  The  affected  vertelirjie  and  intervertebral  disks  are  thus 
gradual!}'  removed — the  latter  often  resisting  their  destruction  longer 
than  the  bones  do  ;  and  then  the  column  gradually  sinks  together,  the 
arches  and  spines  of  the  destroyed  vertebra?  being  thrust  backwards 
along  with  the  spinal  cord,  forming  an  angular  projection  in  the  back 
(angular  curvature),  while  the  vertebrae  or  the  remains  of  vertebrre,  now 
brought  into  unnatural  contact,  become  anchylosed  or  soldered  together 
(if  the  patient  is  to  recover),  and  thus  the  humpback  is  produced  with 
which  we  are  so  familiar.  The  enormous  loss  of  stature  which  many 
of  those  persons  present  shows  how  extensive  may  be  the  destruction 
from  which  a  patient  may  recover  without  loss  either  of  life  or  of  spinal 
power.  At  the  same  time  the  disease  is  very  often  fatal  by  itself,  the 
patient  d^'ing  either  from  exhaustion  or  from  the  inflammation  of  the 
sac  of  the  abscess,  or  from  inflammation  of  or  pressure  on  the  cord,  or 
from  some  complication,  such  as  the  bursting  of  the  abscess  into  the  peri- 
toneal cavity;  and  a  good  many  such  patients  die  of  concomitant  internal 
disease,  chiefly  phthisis. 

The  immunity  which  the  cord  so  commonly  enjoys  in  disease  of  the 
spinal  column,  even  when  the  latter  is  of  very  great  extent,  is  so  remark- 
able a  phenomenon  that  we  must  endeavor  to  give  a  distinct  explanation 
of  it,  as  well  as  of  the  nature  of  the  affection  of  the  cord  when  it  does 
occur.  The  reasons  why  the  cord  commonly  escapes  disorganization 
from  pressure  or  inflammation  are  threefold:  (1)  the  very  gradual  prog- 
ress of  the  change  of  form  in  the  column  allows  the  spinal  cord  to  accom- 
modate itself  to  its  new  position.  Also  we  must  not  forget  that  the 
vertebral  canal  is  much  larger  than  the  cord  ;  (2)  the  gradual  falling  for- 
ward of  the  upper  part  of  the  column  pushes  the  abscess  forward,  as 
shown  in  Fig.  210,  and  prevents  it  from  making  its  way  towards  the 
spinal  canal  and  propagating  inflammation  into  its  interior;  and  (3)  the 
theca  vertebralis  protects  the  medulla  from  implication  in  the  affection 
of  the  column.  For  these  reasons  the  spinal  marrow  generally  escapes 
either  pressure  or  inflammatory  softening;  but  it  does  not  always  do  so. 
In  rare  cases,  as  the  result  of  sudden  giving  way  of  the  column,  either 
spontaneously  or  from  violence  (as  in  the  well-known  case  in  which  a 
quack  undertook  to  straighten  the  column  in  a  case  of  caries),  the  cord 
may  be  crushed,  just  as  in  any  other  case  of  fracture  of  the  spine,  with 
the  same  result  of  instantaneous  and  total  paralysis  of  motion  and  sen- 
sation, which  will  in  all  probability  be  permanent.  More  commonly  the 
spinal  cord  is  affected  only  by  inflammatory  changes  in  its  anterior  por- 
tion, or  possibly  by  partial  pressure,  either  from  abscess  pressing  on  it  in 
front  or  from  bending  at  the  angle,  and  in  such  cases  only  the  motor 
roots  of  the  nerves  are  implicated,  and  sensation  is  perfect.  It  is  much 
rarer  for  sensation  to  be  affected  as  well  as  motion,  and  for  sensation  to 
be  alone  affected  seems  to  be  unknown. 

Many  such  cases  of  paraplegia  end  in  recovery,  but  in  some  the  lower 
limbs  remain  withered  and  paralj'zed.  The  paralysis  of  the  sphincters  is 
almost  always  temporary. 

The  diagnosis  of  caries  of  the  spine  is  by  no  means  easy  in  all  cases. 
When  there  is  no  abscess  perceptible,  and  no  curvature,  the  symptoms 


486 


DISEASES    OF    THE    SPINE. 


are  pain  in  the  back  in  a  fixed  spot,  increased  by  movement,  and  particu- 
larly by  percussion  of  the  att'ected  part  of  the  spine,  sometimes  to  an 
exquisite  degree;  tenderness,  confined  to  the  spinal  cohinm,  and  possibly 
some  amount  of  thickening  or  even  of  increased  temperature  around  the 
diseased  bones.  The  affected  part  of  the  spine  is  kept  rigid,  producing  a 
very  characteristic  attitude  when  the  disease  is  situated  in  the  upper  part 

Fig.  210  Fig  211. 


Fig.  210. — Angular  curvature  of  the  spine  in  the  lower  part  of  the  dorsal  region.  The  bodies  of  the 
lower  dorsal  vertebra  and  the  first  lumbar  have  been  extensively  destroyed  by  caries.  In  the  neigh- 
borhood of  the  disease  are  the  remains  of  the  parietes  of  a  thick  cyst,  at  the  bottom  of  which  may 
be  seen  the  thickened  theca  vertebralis. — St.  George's  Hosp.  Museum,  Ser.  v,  No.  18. 

Fig.  211. — Coniprts.sion  of  the  cord  by  a  displaced  fragment,  in  caries  of  the  spine.  The  seventh  and 
ninth  dorsal  vertcbrse  have  been  partially  destroyed,  while  the  body  of  the  eighth  is  represented  only 
by  an  angular  fragment  between  theiu,  which  has  been  thrust  backwards  so  as  to  compress  the  cord. 
Paralysis,  however,  was  not  total. — From  a  drawing  (Ser.  xxi,  No.  40)  presented  by  Sir  B.  Brodie  to  the 
Museum  of  St.  George's  Hospital. 

of  the  neck.  H3'stcrical  or  neuralgic  pain  often  closely  simulates  caries, 
but  is  not  so  constant  and  equable;  is  usuall}'  accompanied  by  tender- 
ness, not  of  the  spine  only,  but  diffused  over  the  back,  and  frequently 
joined  with  other  symi)toms  of  liysteria  or  with  uterine  disturbances. 
The  growtii  of  a  tumor  from  tlie  vertebrae  may  at  fii'st  be  indistinguish- 
able from  caries,  V)ut  tlie  progress  of  the  case  will  soon  clear  up  all  doubt. 
Frequently  the  early  stages  of  caries  are  not  accompanied  by  any  decided 
symptoms,  and  I  liave  seen  even  large  abscesses  connected  with  extensive 
caries  of  tiie  spine  discovered  in  tlie  post-mortem  examination  of  persons 
who  never  made  any  complaint  leading  to  the  suspicion  of  such  disease. 
When  curvature  exists  there  is  no  longer  room  for  doubt;  in  some  few 
cases,  indeed,  lateral  curvature  does  to  a  certain  extent  simulate  angular, 
but  an  attentive  examination  will  usually  clear  up  the  case. 

In  man}-  cases  of  caries  of  the  spine  recovery  takes  place  without  visi- 


ANGULAR    CURVATURE.  487 

ble  abscess,  even  when  the  deformity  testifies  to  considerable  loss  of  sub- 
stance. In  some  of  these  cases,  on  dissection,  the  inspissated  remains  of 
a  definite  collection  of  pus  will  he  found  ;  but  there  is  no  proof  that  this 
is  always  the  case.  As  softened  bone  is  removed  without  suppuration 
when  the  spine  is  eroded  by  the  pressure  of  an  aneurism,  so  it  seems  tliat 
the  bone  when  softened  by  inflammation  may  be  removed  without  the  for- 
mation of  pus,  though  this  is  of  course  more  rare.  It  is  in  the  remains 
of  old,  dried-up  spinal  abscesses  that  the  re>iidual  abscesses,  spoken  of 
on  p.  57,  have  one  of  their  most  common  seats. 

Spwal  abscess  is  generally  psoas  or  lumbar.  Little  more  need  be  said 
about  lumbar  abscess.  It  presents  at  the  outer  edge  of  the  erector  spina; 
muscle,  between  the  ilium  and  ribs,  and  the  only  questions  which  occur 
in  its  diagnosis  are  usually  whether  it  is  a  simple  abscess  or  one  caused 
by  diseased  l)one,  and  in  the  latter  case  whether  the  disease  is  in  the  spine 
or  pelvis.  These  questions  will  be  settled  by  the  symptoms  and  by  exam- 
ination of  the  parts.  When  the  pelvis  is  diseased  it  can  often  be  felt  with 
the  probe  ;  but  the  spinal  disease,  being  situated  on  the  front  of  the  col- 
umn, is  out  of  reach. 

Psoas  abscess,  however,  constitutes  a  distinct  surgical  disease,  the  diag- 
nosis of  which,  as  well  as  its  treatment,  requires  special  rules.  The  dis- 
ease in  the  spinal  column  which  gives  rise  to  it  is  often  seated  above  the 
origin  of  the  psoas  muscle,  the  pus  travelling  down  the  front  of  tlie  col- 
umn in  the  posterior  mediastinum  till  it  makes  its  way  beneath  the  liga- 
mentum  arcuatum  internum,  and  so  gains  the  sheath  of  the  psoas — some- 
times on  both  sides.  It  then  travels  down  the  loins,  forming  a  fulness 
which  can  often  be  distinctly  recognized  at  the  side  of  the  lumbar  spine, 
and  sometimes  irrritating  the  muscle  so  as  to  produce  flexion  of  the  thigh 
and  pain  on  attempts  to  extend  it.'  It  then  fills  the  iliac  fossa,  passes  be- 
neath Poupart's  ligament  on  the  outer  side  of  the  vessels,  crosses  beneath 
the  femoral  sheath  to  the  inside  of  the  thigh,  where  it  usually  stops,  pre- 
senting and  burstingjust  below  the  groin  ;  but  in  rarer  cases  it  may  travel 
a  long  distance  down  the  thigh  before  it  bursts.  The  diseases  with  which 
psoas  abscess  is  likely  to  be  confounded  are  femoral  hernia,  simple  ab- 
scess, cystic  tumor,  cancer,  and  aneurism.  Like  femoral  hernia,  it  often 
has  a  distinct  impulse.  Its  orifice  of  communication  with  the  iliac  fossa 
and  the  portion  of  the  abscess  external  to  the  vessels  is  often  so  small  as 
not  to  be  readily  discovered.  But  tlie  fulness  in  the  iliac  fossa  is  usually 
quite  sufficient  to  distinguish  it  from  hernia,  even  if  the  pain  in  the  spine 
and  deformity  be  absent.  And  although  a  psoas  abscess  may  be  to  a 
certain  extent  reducible  on  pressure  in  the  recumbent  position,  this  is 
merely  a  diminution  of  size,  quite  different  from  the  sudden  and  complete 
disappearance  of  hernia.  From  simple  abscess  and  from  cystic  or  bursal 
tumor  the  spinal  .symptoms  and  the  fulness  in  the  iliac  fossa  are  sufficient 
marks  of  distinction.  Cancer  may  simulate  abscess  in  this  as  in  other 
regions,  but  the  diagnostic  marks  are  numerous.  Singularly  enough  the 
disease  which  most  closely  resembles  psoas  ai)scess  is  that  which  would 
at  first  sight  appear  to  be  farthest  removed  from  it,  viz.,  aneurism,  at 
least  that  form  of  disease  of  arteries  to  which  the  somewhat  unmeaning 
name  of  diffused  aneurism  is  given,  i.  e.,  a  collection  of  V)lood  communi- 
cating with  a  diseased  artery,  and  which  is  often  caused  by  the  rupture 
of  a  small  pre-existing  aneurism  ;  at  other  times  by  the  giving  way  of  a 
diseased  portion  of  the  artery.     The  growth  of  an  abdominal  aneurism 

1  Similar  flexion  and  pain  may,  liowever,  exist  in  sacro-iliac  disease  (see  p.  480) 
and  in  disease  of  the  pelvis. 


488 


DISEASES    OF    THE    SPINE. 


against  the  spine  often  gives  rise  to  weaving  pain  in  tlie  back  from  ab- 
sorption of  the  vertebrffi;  tlie  tumor  in  some  cases  does  not  pulsate,  and 
it  grows  down  the  loins  just  as  a  psoas  abscess  would  do.  So  close  is  the 
resemblance  that  the  mistake  has  been  committed  by  some  of  the  best 
surgeons.'  Doubtless,  in  most  of  these  cases  auscultation  would  reveal 
a  bruit ;  and  this,  though  it  might  not  be  decisive  of  the  nature  of 
the  disease,  would  at  least  induce  caution  in  opening  the  tumor,  and  a 
preliminary  exi)loration  with  the  grooved  needle,  if  the  surgeon  should 
still  desire  to  make  the  opening. 

When  the  diagnosis  of  psoas  abscess  has  been  established  the  question 
of  treatment  occurs.  The  patient  must  be  confined  to  bed  and  kept  in 
the  strictest  repose  for  a  very  long  period.  It  is  better  not  even  to  allow 
him  to  rise  from  his  back,  but  merel3^  to  turn  from  side  to  side,  but  it  is 
not  always  easy  to  enforce  such  complete  repose.  At  the  same  time  his 
strength  must  be  supported  by  nourishing  diet,  without  stimulants,  and 
cod-liver  oil  or  iodide  of  iron  may  be  administered  internally  if  they 
agree  with  the  digestion.  In  fact,  the  general  treatment  must  be  regu- 
lated by  the  constitutional  condition.  But  the  main  question  is 
whether  to  open  the  abscess  or  not.  As  a  general  rule  it  is  better  to  allow 
it  to  burst;  but  if  there  is  much  pain  or  inflammation,  or  if  it  is  increas- 
ing to  a  very  large  size,  it  will  be  proper  to  open  it.  I  have  no  doubt 
that  this  is  best  done  in  the  manner  described  by  Mr.  Lister,  i.e.,  by 
allowing  the  pus  to  ooze  gradually  through  a  veil  made  of  lint  or  muslin 
saturated  with  carbolic  acid  lotion,  which  is  to  be  replaced  by  the  usual 
carbolized  dressings  after  the  oozing  has  almost  ceased  (see  p.  5fi).  If 
inflammation  nevertheless  occurs  (which,  however,  has  not  taken  place  in 
several  cases  I  have  treated  in  this  way)  the  sac  should  be  well  washed 
out  by  injection  of  carbolic  lotion  (I  to  40)  and  a  drainage  tube  intro- 
duced. Other  plans  are  to  tap  the  abscess  with  the  aspirator  (p.  229)  or 
with  an  exhausting  syringe  attached  to  a  trocar,  or  to  tap  it  with  a  trocar 
the  tube  of  which  passes  into  a  basin  of  w^ater,  so  as  to  avoid  the  entrance 
of  air.  After  a  considerable  quantity  of  pus  has  been  evacuated  the  punc- 
ture is  closed,  and  after  a  few  days  the  operation  is  repeated;  or  a  small 

valvular  puncture  may  be  made,  and 
a  poultice  applied.  The  risk  in  open- 
ing these  abscesses  is  the  probability 
of  inflammation  supervening,  marked 
by  shivering,  fever,  swelling,  redness, 
and  oedema  around  the  puncture,  and 
foulness  of  the  discharge.  This  is  a 
dangerous  occurrence,  likely  to  lead 
to  death  directly  from  fever  or  septi- 
caemia, or  indirectly  from  exacerba- 
tion of  the  disease  in  the  bones.  Free 
incision,  washing  out  the  cavity  with 
antiseptics,  vigorous  stimulation,  and 
support  are  the  measures  which  should 
be  adopted.  When  the  abscess  has 
healed,  or  remains  in  the  state  of  a 
mere  inactive  sinus,  the  treatment 
resolves  itself  into  that  of  the  spinal 
disease  only.  And  the  treatment  of 
spinal  disease    really  resolves  itself 


Fig.  212. 


Apparatu.s  for  supporting  tlio  spini'  and  re- 
ceiving the  projecting  vertebra;,  in  a  case  of  angu- 
lar curvature. 


'  See  a  paper  On  the  Diagnosis  of  Aneurism. — St.  George's  Hosp.  Keports,  vol.  vii, 
p.  192. 


CARIES    OF    CERVICAL    VERTEBRA. 


489 


into  mere  rest,  that  is  to  say,  the  bones  themselves  should  be  kept  at  rest, 
and  all  the  muscles  which  act  upon  them  as  far  as  is  possible.  So  long 
as  the  patient  can  be  kept  in  bed,  without  detriment  to  his  health,  he  is 
better  there  than  moving  about;  or  the  bed  can  be  placed  on  a  carriage, 
and  he  can  be  wheeled  into  another  room  or  into  the  fresh  air.  When  it 
seems  expedient,  on  account  of  his  suffering  from  confinement,  and  the 
bones  appearing  to  be  sulficiently  soldered,  an  apparatus  may  be  con- 
structed by  which  the  weight  of  the  upper  part  of  the  body  is  taken  off 
the  spine  and  transmitted  through  crutches  supported  on  rigid  rods  to  a 
girdle  I'esting  on  the  pelvis.  This  should  be  worn  even  for  a  considera- 
ble time  after  it  is  believed  that  the  bones  have  become  anchylosed.  The 
symptoms  of  such  ar.chylosis  are  the  disaj)pearance  of  pain  on  motion,  the 
wasting  of  the  muscles  in  the  intervertebral  gutters,  and  the  fact  that 
the  vertebrae  move  altogether  when  the  back  is  bent.  It  need  hardly  be 
added  that  no  attempt  should  be  made  to  rectify  the  curvature,  which, 
in  fact,  is  a  necessary  part  of  the  cure,  and  which  often  becomes  more 
marked  as  consolidation  becomes  perfect,  and  the  soft  parts  waste  around 
the  anchylosed  bones. 

Disease  of  Cervical  Vertebrae. — Disease  of  the  cervical  portion  of  the 
spine  deserves  special  notice.  It  is  much  more  fatal  than  the  similar 
affection  of  the  lumbar  or  dorsal  regions,  and  it  has  both  special  charac- 

FiG.  213.  Fig.  214. 


Fig.  213. — Caries  of  the  cervical  vertebrie  and  ulceration  of  the  intervertebral  disks,  communicating 
with  the  pharynx  by  an  ulcerated  opening.  The  membranes  of  the  cord  were  found  united  to  each 
other  and  to  the  posterior  surfaces  of  the  vertebrae,  and  the  upper  part  of  the  cord  was  softened,  a, 
section  of  the  basilar  process ;  6,  the  opening  in  the  pharynx  communicating  with  the  diseased  spine  ; 
c,  the  epiglottis,  with  a  portion  of  the  tongue  below  it. 

The  symptoms  were  so  slight  that  the  ulcer  in  the  pharynx  was  not  known  to  have  any  connection 
with  diseased  spine  till  the  post-mortem  examination.  The  patient  died  suddenly,  after  being  in  the 
hospital  for  a  few  days. 

Fig.  214. — The  back  view  of  the  same  preparation,  showing:  n,  the  base  of  the  skull;  6,  the  opening 
of  the  pharyngeal  abscess;  c,  the  posterior  common  ligament  and  theca  vertebral  is,  thickened  and 
turned  down,  in  order  to  show  the  diseased  bone  and  the  opening  of  the  abscess;  d,  carious  and  ex- 
posed surface  of  some  of  the  lower  vertebrae. — From  a  preparation  in  the  Museum  of  St.  George's  Hos- 
pital, Ser.  V,  No.  13. 


ters  and  special  dangers  of  its  own.  The  disease  is,  I  think,  even  more 
common  in  childhood,  relatively  to  adult  life,  than  that  of  the  other  re- 
gions of  the  spine,  and  it  usually  at  first  simulates  mere  "  stiff  neck,"  the 


490 


DISEASES    OF    THE    SPIXE. 


})ain  on  motion  causing  the  child  to  hold  its  neck  stiff.  When  the  dis- 
ease atttvcks  quite  the  upi^er  end  of  the  column,  so  that  the  movements 
of  the  head  produce  an  immediate  effect  on  the  carious  bones,  the  child 
gets  a  hahit  of  keeping  the  head  instinctively  but  very  carefully  fixed  in 
a  certain  i)Osition  which  is  very  characteristic,  and  in  turning  often  turns 
the  whole  body,  and  steadies  the  head  with  both  hands.  Often  a  slight 
tap  on  the  top  of  the  head  will  produce  pain.  There  is  usually  thickening 
around  the  affected  vertebrae,  very  rarely  any  curvature,  the  small  size  and 
deep  position  of  the  spines  preventing  it;  often  sinuses  ai>out  the  neck, 
and  frequently  postpharyngeal  abscess,  which  causes  a  swelling  or  opening 
at  the  back  of  the  pharynx  (Figs.  213,  214).  The  chief  danger  in  this 
disease  is  that  of  softening  of  the  upper  part  of  the  cord,  leading  to  dysp- 
na?a  and  speedy  death.  But  another  and  still  more  sudden  mode  of 
death  is  that  which  results  from  displacement  of  the  odontoid  process  in 
disease  of  the  two  upper  vertebrae,  and  which  is  illustrated  by  the  two 
annexed  figures.     The  former  (Fig.  215)  shows  all  the  ligamentous  appa- 


FlG.  215. 


Fig.  216. 


Fig.  21.'5.— Dispase  of  the  skull  and  upper  part  of  tlie  spine,  in  which  the  transverse  lijj;ament  has 
been  almost  entirely  destroyed.  There  is  a  large  opening  through  the  base  of  the  skull  (occipital  and 
sphenoid  bones)  communicating  with  the  pharynx,  through  which  a  rod  is  passed.  Below  this  the 
odontoid  process  is  seen  exposed  by  the  ulceration  of  the  transverse  ligament  and  its  vertical  append- 
age. Only  a  thin  string  remains,  under  which  two  black  bristles  are  passed.  The  odontoid  process, 
however,  is  still  retained  in  position  by  some  remains  of  tlie  cheek  ligaments.  The  connections  be- 
tween the  second  and  third  vertebra;  are  almost  destroyed.  The  flap  turned  up  at  the  top  of  the  prep- 
aration consisted  of  the  dura  mater,  covered  externally  by  a  quantity  of  tliick  scrofulous  matter, 
which  had  produced  pressure  on  the  spinal  marrow.— From  the  Museum  of  St.  George's  Hospital,  Ser. 
V,  No.  14. 

Fk;.  210. — A  preparation  showing  displacement  of  the  odontoid  process  backwards  from  ulceration 
of  the  transverse  and  cheek  ligaments  in  disease  of  the  upper  part  of  the  spinal  column.  Death  was 
instantaneous.— St.  George's  Hospital  Museum,  iSer.  v,  No.  15. 

ratuK  connected  with  the  odontoid  process  destroyed,  with  the  single  ex- 
ception of  a  small  string  of  the  transverse  ligament  which  has  escaped 
destruction,  the  patient  having  died  from  the  extensive  affection  of  other 


LATERAL    CURVATURE.  491 

parts  of  the  vertebral  column.  Had  this  not  been  the  case  the  slight  re- 
mains of  the  transverse  and  cheek  ligaments  would  liave  given  way,  and 
the  same  result  would  have  followed  as  that  which  is  shown  by  the  other 
fignre  (Fig.  216).  This  was  taken  from  the  body  of  a  girl  aged  nine,  who 
had  been  for  some  time  in  St.  George's  Hospital,  with  disease  of  the 
upper  i)art  of  the  spinal  column.  One  day  tlie  nurse  was  raising  her 
head  to  wash  her,  when  she  fell  back  dead.  The  figure  shows  that  the 
whole  ligamentous  apparatus  which  confines  the  odontoid  process  has 
been  destroyed  ;  and  that  process  being  suddenly  displaced  backwards 
and  upwards  has  impinged  on  the  medulla  and  produced  instant  death. 
The  same  accident  has  happened  in  cases  where  (as  in  that  which  fur- 
nished Figs.  213,  214)  there  had  been  no  previous  suspicion  of  disease 
of  the  spine.  Thus,  a  lady  was  sitting  in  her  chair,  and  turning  her 
head  to  greet  a  person  entering  the  room  fell  dead.  Another  was  playing 
with  her  child,  who  pulled  her  head  back,  and  she  died  on  the  spot.  In 
both  cases  this  displacement  of  the  odontoid  process  was  found. 

In  order,  then,  to  guard  against  the  risk,  not  merely  of  this  fatal  dis- 
placement of  the  odontoid  process,  but  also  of  the  irritation  of  the  spinal 
cord  and  of  the  extension  of  the  disease  of  the  bones  by  movements  of 
the  affected  vertebrre,  the  most  rigid  rest  must  be  insisted  on.  It  is  not 
enough  merely  to  put  the  patient  to  bed.  The  head  and  neck  ought  to 
be  confined  in  a  case  of  gutta-percha,  in  the  moulding  and  applying  of 
which  all  imaginable  gentleness  should  be  used;^  and  the  patient  must 
never  be  allowed  to  rise  from  the  horizontal  posture,  the  sheets  being  so 
arranged  that  they  can  be  changed  without  raising  him.  This  rigid  rest 
must  be  continued  until  the  pain  on  motion  of  the  head  has  ceased  for 
some  time.  In  other  respects  the  treatment  is  the  same  as  in  disease  of 
other  portions  of  the  spine. 

Lateral  Curvature. — Next  in  frequency  to  angular  curvature,  if  not 
even  more  common,  is  what  is  usually  called  lateral  curvature  of  the 
spine,  though,  as  the  curvature  is  not  in  ordinaiy  cases  merely  to  one 
side,  but  each  vertebra  is  also  somewhat  rotated  on  the  next  to  it,  the 
distortion  is  sometimes  called  "  rotation  curvature."  The  annexed  illus- 
tration (Fig.  217)  shows  the  spine  in  a  very  extreme  example  of  this 
deformity,  so  extreme  that  the  atlas  in  the  erect  position  is  only  a  few 
inches  above  the  sacro-vertebral  prominence  ;  and  it  will  l)e  observed  that 
the  spine  is  so  rotated  that  there  are  vertebrae  wliich  look  towards  each 
side  and  some  which  are  directed  almost  backwards.  This  rotation  of 
the  vertebra;  is  obviously  caused  by  some  active  force  which  can  only  be 
exercised  by  the  muscles  inserted  into  them.  The  original  cause  of  the 
distortion,  however,  appears  to  be  merely  passive.  The  deformity  com- 
mences in  almost  all  cases  about  the  period  of  puberty,  and  in  girls  far 
oftener  than  in  boys,  the  patient  being  weakly  and  sickly  from  confine- 
ment, and  possibly  over-study,  or  from  menstrual  irregularity.  In  such 
persons  anything  which  produces  habitual  inclination  of  the  spine  to  one 
side,  as  the  habit  of  standing  on  one  leg,  acting  on  the  lumbar  spine,  or 
the  habit  of  carrying  a  burden  (such  as  a  nurse-child)  on  one  arm,  acting 
on  the  dorsal  region,  may  prove  the  starting-point  of  more  extensive  de- 
formity. The  muscles  are  now  thrown  into  irregular  action  ;  and  as  the 
attachments  of  the  muscles  on  the  convex  side  of  the  curve  are  approxi- 

1  This  is  better  on  the  whole  than  putting  the  head  and  neck  into  a  kind  of  sand- 
bath,  as  is  sometimes  recommended,  or  fixing  anything  on  the  coueh  to  contain  the 
head,  since  these  will  not  move  along  with  the  patient  when  it  becomes  necessary  to 
move  him  ;  but,  of  course,  the  making  of  the  splint  involves  some  risk. 


492 


DISEASES    OF    THE    SPINE. 


mated  their  fibres  become  indurated  and  thrown  into  chronic  action, 
while  the  stretched  muscles  on  the  other  side  are  proportionally  weak- 
ened and  inactive.  The  displaced  vertebne  are  also  changed  in  shape 
by  pressure,  so  that  when  tlie  deformity  has  lasted  long  the  body  of  the 
vertebra?  is  much  thicker  on  the  convex  than  on  the  concave  side  of  the 
curve,  and  the  transverse  processes  almost  locked  together,  and  the  de- 
formity is,  at  that  stage  at  least,  incurable.  When  the  spine  in  either 
the  lumbar  or  dorsal  region  is  thus  primarily  curved  a  somewhat  similar 
secondary  incurvation  commences  in  the  dorsal  or  lumbar  region,  pro- 
duced by  the  elforts  necessary  to  maintain  the  balance  of  the  bod\'.  This 
secondary  curve  is,  however,  always  less  marked  than  the  primary  one. 
A  third  compensatory  curve  in  the  cervical  region  may  sometimes  be 
traced  in  cases  of  extreme  lateral  curvature,  as  in  Fig.  217.     Lateral 


A  preparation  of  extreme  lateral  curvature  (or  "  rotation  curvature  ")  of  the  spine. — From  the  Museum 

of  St.  George's  Hospital. 

curvature  in  the  dorsal  region  produces,  in  the  first  place,  a  displacement 
of  the  ribs  and  scapula  upwards  on  the  convex  side  of  the  curve,  so  that 
that  shoulder  is  raised  higher  than  the  other.  This  is  commonly  on  the 
right  side,  and  the  first  thing  which  attracts  attention  is  the  "growing 
out"  of  that  .shoulder,  as  it  is  termed.  When  the  deformity  is  extensive 
and  confirmed  the  thorax  will  be  greatl3^  altered  in  shape,  so  that  the  ribs 
are  flattened  down,  the  intercostal  spaces  nearly  obliterated,  and  the 
cavity  for  the  lung  greatly  narrowed,  while  on  the  other  side  it  is  the 
reverse.  In  the  lumbar  curve  the  distance  between  the  last  rib  and  the 
ilium  (i.e.,  the  flank)  is  much  increased  on  the  convex  side  of  the  curve, 
while  on  the  concavity  it  is  so  much  diminished  that  the  patient  is  some- 
times annoyed  by  the  rib  impinging  on  the  ilium ;  this  produces  consid- 
erable falling  in  of  that  flank.  The  hip  also  is  raised  and  prominent  on 
the  convex  side  of  the  curve. 

The  diagnosis  is  generally  simple.  The  patient  being  stripped,  the  line 
of  the  spinous  process  should  be  dotted  with  ink  as  she  stands  with  both 
feet  flat  on  the  ground  and  planted  together.  She  should  then  i)e  made 
to  stoop;  the  position  of  the  shoulders  should  be  compared,  the  distance 
between  the  ilium  and  last  rib  on  either  side  ascertained,  and  the  extent 
of  the  thoracic  and  lumbar  curvatures  compared.  The  only  affections  of 
the  spine  which  it  is  possible  to  confound  with  lateral  curvature  are  :  a, 
curvature  from  caries;  6,  curvature  from  rickets  ;  and,  c,  curvature  from 


SPINAL    CURVATURES. 


493 


empyema.  In  some  very  rare  cases  of  caries  of  the  spine  the  sides  of 
the  bodies  are  either  entirely  or  chiefly  affected  and  tlie  spine  falls  to  one 
side  instead  of  directly  backwards  ;  but  on  attentively  investigating  the 
history  of  such  a  case  there  is  never  any  ditticulty  in  discovering  its  na- 
ture ;  the  curve  is  always  limited  to  a  few  only  of  the  vertebne  instead  of 
being  diffused  over  the  whole  regiou,  and  is  always  accompanied  by  more 
or  less  of  angular  deformity.  The  curvature  from  rickets  is  usually  also 
of  an  irregular  kind,  the  softened  vertebrae  projecting  backwards  as  well 
as  to  one  side.  It  commences  at  quite  a  different  period  of  life  frou)  the 
ordinary  lateral  curvature,  and  is  generally,  if  not  always,  accompanied 
by  deformity  of  other  bones,  as  the  legs  or  forearms.  The  curvature 
which  follows  on  empyema  is  a  truly  lateral  curvature,  accompanied  by 
no  rotation,  and  is  always  easily  distinguished  from  lateral  curvature  by 
the  history  and  by  the  sinuses.^ 

Having  fixed  the  diagnosis,  the  next  thing  which  is  to  be  done  is  to 
ascertain  the  cause  and  how  the  disease  has  commenced.  If  it  has  com- 
menced in  the  lumbar  region  as  a  consequence  of  inclination  of  the  pelvis 
depending  on  unequal  length  of  the  limbs  (as  in  diseased  hip),  the  first 
step  in  the  treatment  is  obviously  to  restore  the  length  of  the  limb  by  a 
proper  boot,  and  thus  to  act  on  the  pelvis.  If  it  seems  to  depend  on  a 
habit  of  standing  on  one  leg  or  of  dropping  one  shoulder,  that  habit  must 
be  corrected  and  the  patient  carefully  drilled.  Any  habitual  exertion 
that  tends  to  distort  the  spine  (as  carry- 
ing a  weight,  working  at  a  one-armed  fig_  218. 
trade,  etc.)  must  be  given  up.  Gym- 
nastic exercises  wdiich  call  the  muscles 
of  the  two  sides  of  the  body  into  equa- 
ble action  are  extremely  useful,  under 
careful  supervision,  in  the  early  stage 
of  the  disease.  A  long  rest  in  the  re- 
cumbent position,  and  with  the  body 
in  a  perfect  state  of  extension,  in  the 
middle  of  the  day,  after  dinner,  is  also 
very  desirable,  as  avoiding  over-fa- 
tigue. The  general  health  must  be 
cared  for,  and  steel  is  generally  indi- 
cated. An  apparatus  may  also  be  ap- 
plied to  press  gently  on  the  convex 
side  of  the  curve  in  the  back  and  to 
separate  the  ribs  from  the  ilium  on  the 
concavity  of  the  loins.  When  the  curve 
is  pronounced  and  the  disease  invet- 
erate nothing  can  be  done  to  correct 
the  existing  deformity,  though  the  ap- 
plication of  an  instrument  may  be  still  advisable,  in  order  to  prevent  it 
from  increasing. 

Other  Spinal  Curvatures. — The  other  curvatures  of  the  spinal  column 
are  kyi)hosis,  or  the  general  antero-posterior  curve  which  is  common  in 
weakly  children  and  in  old  men  ;  and  lordosis,  or  the  incurvation  of  the 
bodies  of  the  lumbar  vertebrte  forwards.  The  term  kyphosis  is  sometimes 
applied  to  all  antero-posterior  displacement,  including  angular  curvature  ; 
but  it  seems  to  me  better  to  speak  of  the  latter  by  itself.     Kyphosis  oc- 

1  Un  the  diflerence  between  the  ordinary  lateral  curvature  and  that  from  empyema, 
see  a  treatise  by  Dr.  Little,  On  Spinal  Weakness  and  Spinal  Curvatures,  1868,  p.  73. 


Apparatus  for  supporting  the  spine  and  press- 
ing the  projecting  part  of  tlie  thorax  and  spine 
towards  the  middle  line  in  a  ease  of  lateral  cur- 
vature. 


494  DISEASES    OF    THE    SPINE. 

curs  in  early  infnnc_y  from  mere  relaxation.  In  fact,  the  spine  has  no 
pronounced  curves  in  early  life,  and  when  the  baby  is  made  to  sit  up  for 
a  time  the  back  will  always  be  found  to  be  bowed  ;  but  this  bend  is  only 
temporary,  and  is  effaced  by  suspending  the  body  from  the  shoulders. 
Weakly  children  suffer  in  the  same  way  from  what  is  called  in  schools 
'•cat's-back  " — the  chin  poking  forward  and  the  spine  projecting  often  to 
such  an  extent  that  the  case  is  mistaken  for  one  of  incipient  angular  cur- 
vature. But  attentive  examination  shows  that  the  curve  is  uniformly 
distributed,  unaccompanied  by  pain  or  inflammation,  and  capable  to  a 
great  extent,  if  not  entirely,  of  obliteration  by  gentle  extension  or  sus- 
pension. It  will  disappear  with  rest,  strengthening,  and  correction  of 
any  lazy  habit  of  stooping;  and  if  extreme  some  bandage  to  the  back 
may  be  necessary.  The  kyphosis  of  old  age  can  hardly  be  mistaken.  It 
is  not  susceptible  of  more  than  partial  relief  from  rest  and  snpport. 

Lordosis,  or  saddleback,  is  caused  chiefly  by  disease  or  congenital  dis- 
location of  the  liip  (Fig-  208,  p.  478).  It  is,  therefore,  a  secondary  change, 
the  treatment  of  which  must  consist  mainly  in  the  correction  of  the  pri- 
mary disi)laceraent.  The  forward  inclination  of  the  pelvis  which  produces 
the  lordosis  is  necessitated  by  the  backward  displacement  of  the  centre 
of  gravity  of  the  body,  caused  by  tlie  dislocation  of  the  hip,  hence  the  first 
step  is,  if  possible,  to  remedy  this  displacement.  This  may  be  sometimes 
effected,  in  congenital  dislocation,  l)y  fixing  the  head  of  the  bone,  if  mova- 
ble, in  or  near  its  natural  position,  or  in  anchylosis  b}'  dividing  the  neck 
of  the  bone  and  putting  the  limb  straiglit.  When  this  has  been  done 
extension  by  an  appro|)riate  instrument  will  diminish  the  lumbar  cnrve, 
though  it  is  not  probable  tliat  it  will  succeed  in  wholly  rectifying  it. 

Anchylosis  of  the  spine  is  another  condition  not  very  uncommon  in  old 
age,  and  is  one  of  the  causes  of  the  rigidity  of  the  spine  in  advanced  life, 
though  by  no  means  the  only  or,  perhaps,  the  most  common.  It  is  proba- 
bly' allied  to,  or  associated  with,  chronic  rheumatic  artiiritis.  The  anterior 
common  ligament  is  often  in  these  cases  found  converted  into  a  mass  of 
bone,  and  tlie  ossification  seems  to  have  invaded  also  the  intervertebral 
disks.     It  is,  of  course,  incurable. 

Cancer  of  Ihe  Spine. — Tumors  of  all  kinds  may  be  found  in  the  spinal 
canal,  but  I  cannot  spare  the  space  necessary  for  their  detailed  descrip- 
tion, nor  do  I  consider  it  necessary.  The  symptoms  are  those  of  irrita- 
tion or  of  pressure  on  the  cord,  together  with  absence  of  prool"  of  any 
disease  in  the  bones;  but  the  diagnosis  is  seldom  made  quite  confidently 
till  a  post-mortem  examination  sliovvs  the  nature  of  tlie  tumor.  The  only 
other  affection  I  sliall  speak  of  is  tlie  carcinomatous  deposit  which  is 
found  in  the  bones  of  the  spinal  column,  sometimes  as  a  primary  disease, 
sometimes  as  secondary  to  cancer  in  other  parts,  and  especially  to  scirrhus 
of  the  breast.'  The  disease  is  seen  at  all  periods  of  life  (Mr.  Hawkins 
relates  the  case  of  a  child  five  years  of  age),  but  is  more  common  after 
middle  a'ge.  The  form  of  cancer  is  usually  encephaloid,  though  scirrhus 
is  not  unknown.  The  symptoms  are  often  very  severe — great  pain,  severe 
muscular  spasms  from  irritation  of  the  nerves  emerging  from  the  affected 
portion  of  the  siiine,  i)aral3sis  more  or  less  extended,  rapid  emaciation, 
and  death.  When  the  disease  occurs  primarily  the  diagnosis  can  only 
be  confidently  made  when  the  tumor  can  be  felt,  though  the  severe 
localized  pain  and  the  rapid  wasting  may  cause  a  susiiicioii  of  the  nature 
of  the  malady.     In  cases  where  cancer  in  other  parts  has  preceded,  or  is 

'  See  Ca;.«ar  Hawkins's  Contributions  to  I'atli.  iind  Surijj.,  vol.  i,  p.  380;  Med.-Chir. 
Trans.,  vol.  xxiv,  p.  45. 


SPINA     BIFIDA. 


495 


Fl(i.  219. 


still  present,  less  hesitsition  will  he  felt,'  All  that  can  be  done  is  to 
soothe  the  patient's  sutierings  by  the  free  use  of  narcotics,  and  to  insist 
on  total  rest. 

Spina  bifida  is  a  tnmor  formed  by  a  congenital  hernia  of  the  spinal 
membranes  (dura  mater  and  arachnoid  j,  through  a  cleft  left  in  the  arches 
of  the  vertebrjB  by  incomplete  coalescence  of  their  laminie.  The  disease 
is  more  common  in  the  lumbar  than  in  any  other  region  (though  it  may 
occur  in  either  the  cervical  or  the  dorsal),  and  this  is  consistent  with  the 
fact  that  the  closure  of  the  arches  takes  place  gradually  from  above  down- 
wards. As  in  the  analogous  tumors  in  the  brain  (meningocele),  there  is 
not  only  want  of  closure  of  the  bones  but  also  dropsical  effusion  in  the 
sac  of  the  membranes.  The  sac  of  the  tumor  is  formed  by  the  skin  and 
the  dura  mater  and  arachnoid,  and  it  always  contains  the  cerebro-spinal 
fluid.  Sometimes  also  the  i)ia  mater  and  the  cord,  or  in  the  lumbar  region 
the  nerves  of  the  cauda  equina,  are  carried  into  the  sac,  and  united  to  it 
in  the  middle  line  (Fig.  219).  In  some  cases  the  skin  is  more  or  less 
delicient  over  the  tumor,  exposing  the  membranes  through  which  the 
fluid  shines  as  through  a  thin  bladder.  On  the  other  hand  the  skin  has 
been  found  much  thicker  than  natural.  There  are  often  other  deformi- 
ties, such  as  clubfoot,  harelip,  hydro- 
cephalus, or  meningocele  ;  and  if  the 
child  survives,  permanent  paralysis 
of  the  sphincters  or  paraplegia  may 
result.  But  as  a  general  rule  such 
children  do  not  long  survive.  The 
tumor  often  bursts,  and  fatal  convul- 
sions come  on,  or  the  child  is  too  weakly 
to  resist  some  of  the  ordinary  ailments 
of  infancy.  Still  there  are  cases  on 
record  in  which  a  person  with  spina 
bifida  has  been  known  to  survive  to 
and  beyond  middle  life'''  without  any 
apparent  drawback  from  the  disease; 
and  at  least  one  remarkable  instance 
is  recorded  in  which  a  tumor  which 
was  believeil  to  have  been  a  spina 
bifida  (though  it  was  more  prol)al)ly  a 
meningocele)  gradually  lost  its  com- 
munication with  the  cerebro  spinal 
canal,  and  was  removed  from  the 
back  of  the  neck  as  a  simple  cyst;' 
and  other  instances  of  spontaneous 
cure  are  recorded.  Viewing,  then, 
the  great  danger  of  any  effectual  sur- 
gical treatment,  it  seems  better  to  the  sac,  whilst  others  intersect  lis  cavity.-St. 
watch    the    case    CarefuU}',  and    not   to       George's  Hospital  Museum,  Ser.  v,  No.  54. 

interfere  unless  the  tumor  is  growing. 

In  that  case  the  tumor  should  be  tapped  with  a  fine  trocar  on  one  side, 


Spina  bifida,  taken  from  a  child  who  died  a 
fortnight  after  birth,  the  immediate  cause  of 
death  being  sloughing  of  the  parietes  of  the  sac. 
The  arches  of  the  three  lower  vertebrie  and 
part  of  the  sacrum  are  deficient.  The  cauda 
equina  passes  into  the  tumor,  and  some  of  the 
nerves  are  spread  out  upon  the  inner  wall  of 


1  I  saw  a  singular  case  of  cancer  the  other  day,  in  which,  after  severe  pain  in  the 
spine,  but  without  paraplegia,  one  of  the  verte'brie  was  found  to  crepitate  distinctly 
on  the  other.  After  a  few  days  this  symptom  disappeared,  the  soft  mass  having 
grown  in  between  the  two  vertebrae 

2  In  u  published  case  the  patient  survived  to  the  age  of  fifty,  and  I  have  heard  of 
older  cases  in  private.     See  Jaohnes's  Surg.  Dis.  of  Childhood,  p.  83. 

3  Solly,  Med.-Chir.  Trans.,  vol.  xl,  p.  19. 


496  DISEASES    OF    MUSCLES    AND    BURSiE. 

since  when  the  nerves  are  in  the  sac  they  always  adhere  in  the  middle 
line,  and  as  much  of  the  fluid  should  be  drawn  off  as  will  decidedly  relieve 
the  tension.  A  shield  or  compress  of  gutta-percha,  well  padded,  should 
then  be  a|iplied.  Under  this  treatment,  b}'  repeated  tappings,  some  cures 
have  been  effected.'  In  other  cases  tiiere  seems  no  doubt  that  a  radical 
cure  lias  been  produced  by  the  injection  of  tincture  of  iodine.  Perhaps 
the  best  plan  is  to  draw  off  a  good  part  of  the  Huid  through  a  fine  trocar, 
and  then  inject  a  drop  or  two  drops  of  the  pure  tincture  of  iodine  into 
the  remaining  lluid.-  Attempts  liave  been  made  in  tumors  wliicli  are 
pedunculated — and  which,  tiierefore,  are  less  likely  to  contain  the  cord 
or  nerves — to  obliterate  the  neck  by  the  gradual  pressure  of  a  clamp,  and 
such  tumors  have  even  been  successfully  removed.^  It  must  be  left  to 
the  surgeon's  own  judgment  wlietlier  he  thinks  it  justifiable  to  risk  this 
last  resource.  The  pedunculated  condition  of  the  tumor  and  its  high 
position  are  doubtless  favorable  circumstances  for  the  success  of  the 
attempt.  Yet  it  might  be  argued  that  such  tumors  would  very  probably 
remain  inactive.  1  have  never  but  once  performed  the  operation  myself, 
and  tlien  on  a  tumor  in  tiie  loins,  in  the  case  of  a  girl  eet.  8,  whose  life 
was  rendered  intolerable  from  permanent  paralysis  of  the  sphincters,  but 
spinal  meningitis  soon  set  in,  and  proved  fatal  by  opisthotonos. 

I  ought  to  add  that  there  are  tumors  which  may  be  mistaken  for  spina 
bifida.  I  have  seen  a  fatty  tumor  allowed  to  grow  to  an  enormous  size, 
under  the  idea  tliat,  being  situated  in  the  middle  line  of  the  spine,  it  was 
a  spina  bifida  ;  but  this  was  onl}^  for  want  of  careful  examination.  But 
congenital  subcutaneous  tumors,  when  situated  exactly  in  the  middle  line, 
ma}'  lead  to  greater  difficulties.*  In  almost  all  spina  bifida  tumors,  how- 
ever, the  sac  swells  up  when  tlie  child  cries,  and  the  edges  of  its  aperture 
can  be  felt  when  it  is  flaccid.  Some  malformations  are  classed  with  spina 
bifida  in  wiiich  tlie  whole  spinal  laminse  are  deficient,  and  others  in  which 
the  ventricles  and  tlie  central  spinal  canal  are  distended,  and  the  sub- 
stance of  the  cord  spread  over  the  sac,  but  they  are  of  little  practical 
interest,  being  incomjjatible  with  life. 


CHAPTER   XXV. 

DISEASES  OF  MUSCLES  AND  BURSiE. 

Muscles  are  liable  to  rupture  from  injury  such  as  occurs  not  unfre- 
quently  in  the  pectoral  muscle  when  a  man  in  falling  grasps  at  a  bar  and 
suddenly  brings  the  whole  momentum  of  his  body  to  bear  on  the  flaps  of 

'  Sir  A   Cooper,  Mod.-Chir.  Trans.,  vol.  ii. 

^  TJriiinard  injects  t^ss.  of  a  solution  of  5  j^rs.  of  iodinn  and  15  of  iod.  of  pot.  to  the 
r>7..  <<{'  WiitfT,  washini;  tlu;  sae  out  afterwards  witli  wati'r,  and  rciinjecting  some  of  the 
orif^inal  ccrcjhro-spinal  fluid.  Vclpeau  injects  a  .spina  bifida,  lil<o  a  common  hydrocele, 
with  a  diluted  solution  of  iodim;. 

•■»  Wil.-on,  in  Path.  Trans.,  vol.  xiv,  p.  214.  Several  other  cases  have  been  since 
recorded. 

*  See  T.  Smith,  in  St.  Bartholomew's  Hospital  Keports,  vol.  ii,  p.  25. 


WHITLOW.  497 

the  axilla;  or  from  overexertion,  as  is  cominoii  in  the  gastrocnemius;^ 
or  from  spasm,  as  occurs  sometimes  in  the  rectus  abdominis  in  cases  of 
tetanus  (see  page  8G).  The  usual  seat  of  I'upture  is  at  the  junction  of 
the  muscle  and  tendon,  but  it  very  commonly  also  takes  place  in  the 
centre  of  the  muscular  belly,  as  is  seen  in  the  pectoralis  major  and  the 
biceps  flexor  cubiti."  The  diagnosis  is  easy  when  the  accident  is  recent, 
from  the  hollow  which  replaces  the  natural  outline  of  the  muscle;  but 
when  the  injury  is  of  some  standing,  and  the  seat  of  rupture  has  been 
filled  up  with  the  products  of  inflammation,  it  is  very  ditiicult  to  distin- 
guish it  from  some  form  of  innocent  tumor. 

The  treatment  consists  in  relaxing  the  muscle  by  some  apparatus  which 
will  bring  its  two  ends  nearer  together,  and  b}^  careful  and  even  bandag- 
ing, in  order  to  push  the  muscular  fibres  downwards  and  diminish  the 
gap.  The  prospects  of  ultimate  recovery  in  the  case  of  the  gastrocne- 
mius, which  is  the  muscle  most  commonly  the  seat  of  this  injury,  are 
good.  Hunter,  we  are  told,  "did  not  confine  himself  to  bed  for  this  ac- 
cident, but  continued  to  walk  about  during  the  cure.  His  mode  of  treat- 
ment was  to  keep  the  heel  raised,  and  to  compress  the  muscle  gently  with 
a  roller,  ])y  which  any  fresh  separation  of  the  ends  of  the  tendon  by 
spasmodic  or  involuntary  contraction  was  prevented,  for  he  found  that 
by  no  voluntary  impulse  could  he  excite  them  to  contract  after  the  rup- 
ture of  their  tendon.  ...  It  was  ascertained  at  Mr.  Hunter's  death  that 
the  union  of  the  ruptured  tendon  was  b}'  ossific  de[)osition," 

Injiammation  of  inuacles,  as  far  as  it  can  be  distinguished  from  that 
of  other  parts,  occurs  usually  in  the  course  of  rheumatism  oi-  syphilis. 
The  "gummatous"  tumors  which  form  in  the  later  secondary  or  tertiary 
stages  of  constitutional  syphilis  may  often  be  recognized  in  large  muscu- 
lar masses,  such  as  the  gastrocnemius  or  the  scapular  muscles,  forming 
rounded,  hard,  movable  tumors,  which  are  painful,  especially  at  night, 
and  are  very  slow  in  their  progress.  They  show  very  little  tendency  to 
suppurate.  They  are  usually  quickly  removed  by  a  course  of  iodide  of 
potassium,  perhaps  assisted  by  iodine  externally. 

Injiaynmotion  of  Tendons. — The  sheaths  of  the  long  tendons  of  the 
forearm  are  often  found  inflamed  after  excessive  exercise — as  after  a 
hard  day's  rowing — forming  a  long  sausage-shaped  swelling,  inflamed 
and  tender,  and  giving  a  peculiar  creaking  sensation  to  the  finger  when 
the  muscle  acts  and  sets  in  motion  the  lymph  contained  in  its  sheath 
("tenosinite  crepitante  "  of  French  authors).  This  inflammation  usually 
subsides  rapidly  by  rest  and  the  application  of  iodine. 

Whitlow  is  a  popular  name  given  to  inflammation  in  or  in  the  neigh- 
borhood of  the  slieath  of  one  of  the  flexor  tendons  of  the  fingers. 
Surgically  speaking,  however,  there  are  various  forms  of  this  disease. 
The  common  whitlow,  or  paronychia,  consists  usually  of  a  collection  of 
purulent  fluid  between  the  skin  and  epidermis  ("phlj^zacious  pustule," 
as  it  is  sometimes  called),  and  requires  nothing  but  the  division  of  the 
epidermis  and  a  little  common  dressing.  In  other  cases  abscess  forms 
below  the  skin,  and  should  be  early  opened.     This,  however,  involves  no 

1  John  Hunter  ruptured  the  tendo  Achillis  in  dancing  at  the  age  of  furty. — Hunter's 
Works,  vol.  1,  p.  34. 

^  In  some  cases  it  is  probable  that  only  the  fascia  covering  the  muscle  may  have 
been  torn,  allowing  the  fibres  to  protrude  through  the  rent  when  the  muscle  acts,  but 
not  involving  any  actual  lesion  of  the  muscle  itself. 

32 


498  DISEASES    OF    MUSCULAR    SYSTEM, 

danger  to  the  finger.  But  the  a,cute  inflammation  inside  the  sheath  of 
the  tendon  (paronychia  tendinosa,  or  periosteal  whitlow)  is  a  very  serious 
disease,  and  is  too  often,  tlirough  the  mismanagement  of  ignorant  per- 
sons, permitted  to  go  on  to  the  destruction  of  the  finger  or  even  of  the 
hand.  It  arises  usually  after  punctured  or  poisoned  wound,  sometimes 
■without  known  cause,  as  a  deepseated  and  ver^-  painful  swelling,  gen- 
erally in  the  middle  phalanx  of  the  finger,  with  very  little  redness,  and 
with  a  ver}^  slight  amount  of  swelling  compared  to  the  pain,  which 
is  often  so  violent  as  to  prevent  the  patient  from  sleeping.  The  part  is 
exquisitely  tender;  it  is  too  tense  for  fluctuation  to  be  felt,  but  matter 
will  generuU}'  form,  and  an  incision  is  ui-gently  needed,  whether  suppu- 
ration has  or  has  not  taken  place.  The  relief  to  the  pain  and  tension 
atibrded  bj'  a  free  and  deep  incision  in  the  middle  line  of  the  finger  is 
decisive  and  immediate;  and  if  the  incision  be  made  before  abscess  has 
formed,  so  much  the  better  for  the  integrity  of  the  part.  If,  on  the  other 
hand,  it  is  dela3'ed,  the  inflammatory  effusion  will  separate  the  tendon 
from  the  vessels  which  supply  it,  and  cause  sloughing  of  the  tendon  ;  or 
suppuration  will  penetrate  the  periosteum,  pi'oducing  necrosis  of  the 
phalanx;  or  may  even  burrow  backwards  into  the  palm  of  the  hand  and 
destroy  the  whole  function  of  the  member.^ 

The  incision  is  vei-y  painful,  although  the  pain  is  only  momentary,  and 
therefore  chloroform  may  be  given,  especiall}'  as  it  renders  it  easier  to 
incise  the  parts  with  the  requisite  freedom.  The  bleeding  should  be  en- 
couraged by  putting  the  hand  into  warm  water.  Then  tiie  hand  should 
be  elevated  on  to  the  opposite  shoulder,  and  a  large  poultice  applied. 

Housemaid'a  Knee. — The  most  common  of  all  the  diseases  of  bursae  is 
that  enlargement  of  the  bursa  patellae,  which  is  popularly  called  "house- 
maid's knee,"  inasmuch  as  women  of  this  class  are  most  lial)le  to  it,  from 
the  irritation  of  constant  kneeling  in  their  work.  It  is,  however,  by  no 
means  confined  to  housemaids  nor  entirely  to  the  female  sex,  though  • 
men  are  rarely  the  subjects  of  it.  The  disease  is  also  sometimes  referred 
to  injury  with  extravasation  of  blood  into  the  bursa.  In  either  case  the 
effusion  must  be  referred  to  inflammation,  though  frequently  of  so  low  a 
type  that  no  inflammator}^  appearances  are  perceptible.  It  forms  a  prom- 
inent rounded  tumor,  covering  the  lower  part  of  the  patella,  and  in 
contact  below  with  the  capsule  of  the  joint,  usually  too  tense  to  allow  of 
the  feeling  of  fluctuation,  though  in  other  cases  this  may  be  perceptible. 
There  is  generally  no  pain  or  inconvenience  at  first,  except  the  obstruc- 
tion which  the  swelling  causes  to  kneeling;  but  afterwards  from  persist- 
ence in  following  the  occupation,  acute  inflammation  often  comes  on, 
with  great  swelling,  a'dema  and  redness  extending  around  the  joint, 
much  pain,  I'igors,  and  other  feverish  symptoms.  Such  cases  are  occa- 
sionally mistaken  for  abscess  in  the  joint;  but  the  buried  condition  of 
the  patella  siiows  that  ihe  greater  part,  at  least,  of  the  abscess  is  exter- 
nal to  the  articulation;  and  thougii  it  is  no  doubt  possible  for  a  bursal 
abscess  to  make  its  way  into  the  joint,  yet  it  very  rarely  happens.  Such 
abscesses  should  be  early  and  pi'etty  freely  opened.  It  is  a  good  plan  to 
make  an  incision  in  front,  then  pass  in  a  director  and  cut  down  on  its 
point  on  either  side  of  the  cavity,  so  as  to  insure  a  depending  opening 
on  either  side.  Bursal  abscesses,  as  far  as  I  have  seen,  almost  always 
do  well. 

The  ordinary  chronic  enlargement  consists  at  first  merely  of  the  bursa, 


1  Si-n  two  (!Hses  recorded  by  Mr.  Tntum  in  Syst.  of  Surg.,  2d  ed.,  vol.  iii,  p.  648,  in 
both  of  which  amputation  of  the  forearm  beciime  necessary. 


ENLARGED    BURS^..  499 

filled  with  a  fluid  much  resembling  synovia,  and  containing  small  por- 
tions of  fibrin  ;  at  other  times  more  or  less  blood  is  mixed  with  the 
fluid.  As  disease  progresses  the  walls  of  the  bursa  thicken,  the  portions 
of  fibrin  in  the  fluid  increase,  forming  a  number  of  "  millet-seed  "  liodies, 
which  can  sometimes  he  felt  creaking  in  the  sac  when  it  is  handled.  As 
the  thickness  of  the  walls  increases,  the  cavity  becomes  encroached  upon 
— though  the  tumor  may  increase  in  size  also — and  sometimes  the  cyst 
is  converted  into  a  solid,  fibrous  tumor.  Far  more  commonly,  however,  a 
small  cavity  containing  small  lumps  of  fibrin  or  altered  blood  will  be 
found  at  a  very  advanced  period  of  the  disease  ;  and  even  when  the 
tumor  is  solid  throughout,  its  centre  will  be  observed  to  be  much  softer 
and  more  succulent  than  its  circumference  (see  Fig.  151,  p.  347). 

At  its  commencement  the  disease  is  very  amenable  to  treatment.  Per- 
fect rest,  with  slight  counter-irritation,  as  by  tincture  of  iodine  or  a  blister, 
repeated  from  time  to  time  as  may  seem  necessary,  will  remove  the  swell- 
ing; in  fact,  I  have  seen  many  of  these  bursiB  subside  altogether  by 
simple  confinement  to  bed.  If  the  cyst  is  large,  but  not  thick,  there  is 
no  objection  to  drawing  off  the  fluid  with  the  aspirator,  and  then  strap- 
ping the  part;  or  if  the  fluid  recollect  applying  a  blister.  When  the  sac 
is  very  thick  these  means  will  not  succeed.  A  seton  kept  in  till  it  causes 
suppui'ation  will  produce  the  obliteration  of  the  cavity,  and  the  thicken- 
ing will  to  a  great  extent  subside,  but  not  entirel_y.  After  the  seton  an 
irregular  cicatrized  mass  will  be  left,  disagreeal>le  to  kneel  upon.  Be- 
sides, the  treatment  is  painful  and  not  free  from  danger.  Incision  is 
necessary  when  suppuration  is  cleai'ly  present,  and  is  quite  justifiable 
when  it  is  onl}'  suspected.  If  no  pus  is  found  the  sac  is  evacuated,  and 
will  probably  fill  up  by  granulation.  Incision  and  pressure  is  a  vei'y 
valuable  plan  of  treatment  in  many  cases,  much  less  dangerous  and 
painful  than  the  seton,  and  often  likely  to  obviate  the  necessity'  of  re- 
moval when  the  walls  are  even  of  considerable  solidity.  It  is  warmly 
advocated  b}^  Mr.  Savorj-,'  who,  indeed,  says,  "it  may  be  adopted  in 
almost  ever}'  case."  It  consists  merely  in  puncturing  the  enlarged  bursa 
with  a  lancet  or  small  knife  at  its  most  prominent  part,  evacuating  its 
contents,  and  liringing  the  walls  together  as  accurately  as  possible  with 
strapping.  The  [)atient  need  not  be  confined  to  bed,  though  this  is  in  my 
opinion  desirable.  Sometimes  the  cyst  does  not  refill.  If  it  docs,  it 
must  he  again  punctured,  and  will  then  usually  suppurate,  when  a  poul- 
tice is  advisable.  The  thickened  walls  melt  down  in  the  suppuration,  and 
when  the  wound  closes  only  an  ill-defined  hardness  is  left.  The  pressure 
of  the  strapping  should  be  kept  up  in  cases  which  do  not  suppurate  for 
a  week  or  fortnight  after  the  cure  appears  complete.  But  when  the  walls 
are  much  thickened  the  total  removal  of  the  tumor  is  the  most  advisable 
course.  It  can  hardly  be  denied  that  the  operation  involves  some  risk, 
but  this  cannot  be  great,  for  I  have  removed  many  such  tumors,  and 
seen  many  others  removed,  and  never  heard  of  any  bad  consequences.'^ 
The  surgeon  will  remember  that  the  lower  [tart  of  the  tumor  is  in  contact 
with  the  capsule  of  the  joint.  A  free  incision  is  to  be  made  from  top  to 
bottom  over  the  middle  line  of  the  tumor  and  the  skin  fully  dissected 
back  on  both  sides.     Then  the  upper  portion  of  the  tumor  is  separated 


'  St.  Bartholomew's  Hospital  Reports,   vol    ii,  p.  79. 

^  Mr  Erichsen  speaks  ot  the  occasional  occuri'cnce  of  abscess  spreatling  into  the 
ham,  whicli  he  attributes  to  the  layer  of  deep  fascia  having  been  divided,  which,  after 
surrounding  the  knee,  is  fixed  to  the  borders  of  the  patella.  Science  and  Art  of  Surg., 
5th  edition,  vol.  ii,  p.  '250.  I  have  never  seen  this  complication,  but  it  furnishes  an- 
other motive  for  carefully  keeping  the  edge  of  the  knife  on  the  tumor  during  the 
dissection. 


500  DISEASES    OF    MUSCULAK    SYSTEM. 

from  the  periosteum  of  the  patella,  and  in  removino;  the  lower  part  from 
the  contiguity  of  the  joint  care  is  taken  to  put  the  cellular  adhesions 
which  fix  it  on  the  stretch  and  divide  them  with  the  edge  of  the  knife 
turned  towards  the  tumor.  In  this  way  it  is  impossible  to  wound  the 
joiut.  The  wound  is  to  be  strapped  up  carefully,  and  the  limb  put  on  a 
splint  and  carefull}'  bandaged  from  the  foot  upwards. 

Affections  of    Various  Bursse Numerous  other  bursoe  exist  in  the 

normal  condition  or  are  developed  from  constant  friction  between  the 
skin  and  an  underlying  bone.  There  is  one  on  the  anterior  aspect  of  the 
upper  end  of  the  tibia,  between  the  tubercle  of  the  tibia  and  the  liga- 
mentum  patelhie,  which  is  occasionally  though  rarely  found  enlarged  ;  one 
over  the  olecranon,  which  is  peculiarly  apt  to  enlarge  in  miners,  from  the 
attitude  in  which  they  constantly  work,  and  is  then  denominated  "miner's 
elbow  ;"  and  several  in  the  popliteal  space, ^  one  of  which,  that  beneath  the 
tendon  of  the  semi-membranosus  muscle,  is  comparatively  often  enlarged, 
and  when  it  shares  the  pulsation  of  the  popliteal  artery  lias  been  mistaken 
for  aneurism,  though  such  a  mistake  can  onl}'  be  accounted  for  by  care- 
lessness. The  bursa  under  the  tendon  of  the  psoas  is  anotlier  instance 
in  which  a  natural  bursa  is  occasionally  enlarged.  The  subject  has  been 
treated  of  in  reference  to  the  diagnosis  of  hip-disease  on  p.  477.  None 
of  these  bursal  enlargements  (if  we  except  the  last)  are  difficult  of  diag- 
nosis to  one  who  remembers  their  position  and  the  fact  of  their  occasional 
diseased  condition.  But  if  any  hesitation  is  felt  as  to  the  nature  of  the 
tumor  the  grooved  needle  will  solve  the  difficulty  at  once.  They  must  be 
treated  in  the  same  way  as  housemaid's  knee,  by  blisters,  iodine  injection, 
or  incision.  And  if  tliey  suppurate,  as  some  are  very  prone  to  do,  es- 
l)ecially  that  over  the  olecranon,  they  should  be  laid  prett}'  freely  open. 
Su[)puration  in  this  bursa  often  produces  a  diffused  inflammation  extend- 
ing down  the  forearm,  which  is  sometimes  mistaken  for  phlegmonous 
erysipelas,  but  which  really  requires  no  treatment  beyond  the  free  evacua- 
tion of  the  bursal  abscess. 

In  treating  the  bursas  which  are  comparatively  often  found  in  the  pop- 
liteal space  the  surgeon  must  remember  that  those  at  the  outer  side  of  the 
ham  almost  always  communicate  with  the  joint,  and  that  beneath  the 
tendon  of  the  semi-membranosus  not  unfrequently  does  so.  Great  care, 
therefore,  is  necessary  to  examine  the  limb  in  various  positions,  in  order 
to  ascertain  whether  this  is  tiie  case  before  any  active  treatment  is  under- 
taken. The  communication,  if  it  exists,  can  generally  be  opened  by  flex- 
ing the  knee,  and  then  some  or  all  of  the  fluid  in  the  bursa  can  be  pressed 
baik  into  tlie  joint.  When  this  is  the  case  no  o[)eration  is  admissible. 
Wlien  the  bursa  does  not  appear  to  communicate  with  the  joint,  if  the 
patient  suffers  mucii  inconvenience  from  the  jiresence  of  the  tumor,  and 
external  appUcations  with  rest  have  failed  to  ciire  it,  it  will  be  justifiable 
to  inject  it  with  iodine,  or  to  put  a  line  seton  through  it.  But  such  bursse 
often  exist  and  attain  a  large  size  withovit  giving  tlie  patient  any  trouble. 
I  saw  a  man  the  other  day  who  had  been  for  more  than  ten  years  an  al)le 
seaman  in  her  Majesty's  navy,  and  who  had  never  suffered  in  the  least 
from  the  presence  of  the  bursa,  though  it  was  unusually  large. 

Bursas  of  new  formation  are  found  over  the  displaced  bones  in  clubfoot, 
over  the  end  of  the  lii)ula  in  tailors,  and  in  many  parts  of  the  body  subject 
to  pressure ;  and  accidental  or  irregular  bursa;  are  met  with  in  various 

'  For  an  account  of  tlic  noiinul  anatomy  of  tiiosu  bun'^a;  see  Gray's  Anatomy,  7th 
ed.,  p.  415. 


GANGLION.  501 

parts — e.  f/.,  over  the  113'oicl  bone  or  larynx — but  they  seldom  grow  to  a 
size  requiring  any  serious  treatment. 

Bunion. — A  bunion  is  a  bursa  formed  over  the  half-dislocated  phalanx 
of  the  great  toe  from  the  i)ressure  of  the  boot.  It  is  often  followed  by 
destructive  disease  of  the  joint.  But  it  does  not  always  (at  least  at  first) 
communicate  with  it.  Wlien  the  atfection  is  confined  to  mere  inflamma- 
tion of  the  bursa  rest  and  sootliing  api)lications  will  probably  subdue  it, 
and  its  recurrence  must  be  obviated  by  some  change  in  the  shape  of  the 
boot.  If  it  suppurates  it  is  better  to  allow  it  to  burst  without  interference ; 
but  if  the  matter  will  not  come  to  the  surface  it  must  be  incised,  and  then 
if  it  does  not  seem  to  communicate  with  the  joint  its  interior  may  be 
rubbed  with  lunar  caustic  or  the  strong  nitric  acid,  in  order  to  procure 
its  ol)literation.  If  the  joint  is  involved  the  shortest  and,  on  the  whole, 
the  best  course  for  the  patient  is  to  amputate  the  toe,  though  if  the  patient 
wishes  it  there  is  no  objection  to  the  resection  of  the  diseased  joint.  It 
is  doubtful,  however,  whether  this  operation,  even  if  successful,  will  leave 
the  foot  more  useful  than  after  amputation  of  the  toe. 

Ganglion  is  the  name  given  to  an  enlarged  bursa  which  is  developed 
in  connection  with  one  of  the  tendons.  Such  bursae  are  most  common 
on  the  back  of  the  wrist,  on  or  near  the  extensor  secundi  internodii 
pollicis,  though  thej'^  are  not  rarely  developed  in  other  tendons.  The 
exact  connection  of  the  sac  with  the  tendon  does  not  seem  to  be  quite 
clearl}'  ascertained.  It  forms  a  small,  hard,  round  swelling  at  the  back 
of  the  joint,  and  the  main  symptom  which  it  causes  is  weakness  of  the 
wrist  and  hand,  sometimes  to  an  extent  which  is  hard  to  reconcile  with 
the  apparent  triviality  of  the  affection.  It  has  been  clearly-  proved  that, 
in  some  cases,  at  any  rate,  a  ganglion  owes  its  origin  to  a  protrusion  of 
the  synovial  membrane  of  the  wrist  or  carpal  joints,^  and  this  is  proljably 
often,  if  not  always,  tlie  nature  of  those  ganglia  which  present  deep  in 
the  wrist  under  or  close  to  the  radial  artery  ;  but  that  the  more  superficial 
and  movable  ones  are  formed  in  the  same  way  is  at  any  rate  unproved. 
Nor  is  it  proved  or  probable  that  as  a  rule  they  have  any  open  com- 
munication with  the  sheaths  of  the  tendons,  though  they  are  believed  to 
be  often  developed  by  an  outgrowth  from  them  originally,  the  communica- 
tion between  which  and  the  sheath  of  the  tendons  has  become  obliterated. 

A  ganglion  almost  always  contains  a  clear  gelatinous  fluid  exactly  re- 
sembling thin  jelly. 

The  treatment  consists  in  freel}^  dividing  the  ganglion  subcutaneously, 
squeezing  out  the  contents,  and  applying  pressure.  The  old  rough  method 
of  bursting  tlie  sac  by  a  blow  of  a  book  or  by  forcible  pressure  was  essen- 
tially the  same,  but  it  is  far  less  certain,  more  painful,  and  is  besides 
excessively  rough  and  unsurgical.  It  is  far  better  to  pass  in  a  tendon- 
knife  at  a  little  distance  from  the  small  round  lump,  apply  its  edge  fairly 
to  the  side  of  the  tumor,  and  cut  the  sac  across  as  freely  as  possible. 
Then  all  the  contents  of  tlie  sac  are  to  be  squeezed  out — whether  through 
the  puncture  or  into  the  cellular  tissue  does  not  matter — and  pressure  is 
to  be  applied  bj'  means  of  a  piece  of  sheet  lead  or  other  firm  substance 
carefully  strapped  on  to  the  remains  of  the  sac.  This  method  succeeds 
in  the  great  majority  of  cases,  but  in  some  the  tumor  refills  even  after  it 
has  been  subcutaneously  divided  with  all  possible  care  many  times.  Such 
cases  may  usually  be  cured  by  a  seton  of  two  or  three  threads  run  through 
the  sac,  and  kept  in  till  suppuration  is  set  up,  when  it  can  be  withdrawn. 

1  There  is  a  preparation  in  the  Museum  of  St.  George's  Hospital  showing  such  a 
communication  in  a  case  of  ganglion.     See  also  Nelaton,  Path.  Chir.,  vol.  v,  p.  905. 


502  DISEASES    OF    MUSCULAR    SYSTEM. 

If  tin?  tilso  fails  the  choice  is  between  laying  tlie  ganglion  open  and  dress- 
ing in  the  cavity  till  it  fills  up,  or  dissecting  it  out. 

The  com  poll  ml  palmar  ganglion,  is  a  tumor  or  cyst  developed  in  the 
sheath  of  the  common  flexor  tendons  passing  under  the  annular  ligament 
of  the  wrist.  It  forms  a  tumor  which  presents  in  the  forearm  and  in  the 
palm,  extending  on  both  sides  of  the  annular  ligament  which  binds  down 
its  central  part;  and  often,  on  making  the  patient  move  his  fingers,  a 
creaking  sensation  is  perceived,  caused  by  the  "millet-seed"  bodies 
whi(;h  are  found  in  it.  These  are  small  masses  of  lymph,  often  very  nu- 
merous, wiiich  are  almost  always  contained  in  these  compound  ganglions. 
The  wrist  is  very  much  limited  in  its  movements  in  these  cases,  and  some 
of  the  fingers  also  are  sometimes  entirely  deprived  of  motion,  flexed  into 
the  palm,  and  utterly  useless.  The  main  obstacle  to  the  cure  of  the  dis- 
ease is  the  presence  of  the  millet-seed  bodies  ;  when  these  are  evacuated 
the  case  generall}^  does  well.  I  have  never  hitherto  seen  a  case  of  this 
disease  in  which  any  progress  to  cure  was  made  until  these  bodies  had 
been  evacuated,  and  I  have  now  given  up  as  useless  any  attempts  to  cure 
it  by  blisters  or  injections.  The  best  plan  is  to  make  a  limited  incision 
into  one  part  of  the  tumor  (that  in  the  forearm  is  usually  selected)  and 
press  out  all  the  millet-seed  bodies,  emptying  the  sac  as  completely  as 
possible.  Strapping  should  be  applied  methodically  from  below  upwards, 
so  as  to  keep  the  parietes  of  the  sac  as  closely  as  possible  in  contact,  in 
the  hope  that  they  will  close,  and  that  no  further  inflammation  will  occur. 
In  all  the  cases,  however,  that  I  have  seen  suppuration  has  taken  place; 
but  this  has  not  interfered  with  the  success  of  the  treatment.  Unless  the 
suppuration  is  unusually  violent  or  some  complication  should  occur,  the 
prognosis  is  good,  and  the  patient  generally  recovers  the  entire  use  of  the 
hand  and  fingers. 

Simple  and  Progressive  Atrophy. — Muscles  are  subject  to  various  de- 
generations, some  of  which  constitute  definite  and  important  surgical 
affections;  others  are  rather  the  consequences  or  accompaniments  of  dis- 
ease, or  are  mere  pathological  curiosities.  The  atrophy  which  follows  on 
disuse  requires  no  further  notice — the  muscle  is  merely  smaller,  but  with- 
out any  change  in  the  anatomical  structure  of  its  fibres.  Clearly  con- 
trasted with  this  is  the  "progressive  muscular  atrophy  "  of  Cruveilhier, 
in  which,  from  some  general  cause  which  is  not  at  present  completely 
understood,  the  muscular  tissue  in  one  or  more  regions  becomes,  without 
any  known  injury  or  other  reason,  wasted — the  wasting  extends  during 
an  indefinite  period,  involves  fresh  groups  of  muscles,  and  may  go  on  till 
the  patient's  death.  The  disease  is  often  hereditary,  and  it  affects  usually 
the  male  members  of  the  family.  In  other  cases  it  has  been  thought  to  be 
excited  by  cold  and  damp,  or  by  syphilis.  Cruveilhier  believed  that  the 
disease  depended  on  degeneration  of  the  anterior  or. motor  roots  of  the 
spinal  nerves  ;  but  this  seems  contradicted  by  the  result  of  post-mortem 
examination  in  many  cases  where  no  such  lesion  existed.  Dr.  Lockhart 
Clarke  believes  tiiat  the  essence  of  the  disease  consists  in  "lesions  of  the 
gra^'  substance  of  tiie  cord,  consisting  chiefly  of  areas  of  what  he  calls 
granular  and  fluid  disintegration,"  and  other  pathologists  have  supported 
this  statement,  wiiich  is  rendered  still  more  probable  by  the  fact  that 
symptoms  identical  with  the  hereditary  aifection  have  been  noted  in  cases 
of  ol)vious  disease  of  the  spinal  cord.  It  is  probable,  therefore,  that  the 
disease  should  be  classed  with  those  of  the  nervous  centres  ;  yet,  as  this 
is  not  yet  al)Solutely  proved,  it  is  generally  still  assigned  to  those  of  the 
muscles.     It  commences  most   commonly  in  the  u[)per  extremity,  and 


INFANTILE    PARALYSIS.  503 

usually  with  wasting  of  the  muscles  of  the  palm,  spreading  upwards  to 
those  of  the  arm,  chest,  al)domen,  and  lastly  to  those  of  respiration  and 
deglutition.  More  rarely  it  begins  in  the  thorax,  and  still  more  rarely 
in  the  lower  limbs.  The  weakness  is  accompanied  by  a  loss  of  co-ordi- 
nation, producing  uncertainty  in  the  movements,  vvith  (U'amps  and  twitches 
in  the  i)art.  Sensation  is  usually  unaftected.  Occasionally  there  is  some 
numbness,  and  pain  is  complained  of  in  the  affected  muscles  in  about  half 
the  cases.  The  wasting  does  not  involve  the  vvhole  muscle.  On  micro- 
scopic examination  side  by  side  with  the  wasted  fibres  are  seen  others 
which  are  perfectly  natural,  and  the  same  is  the  case  to  the  naked  eye. 
The  atrophy  is  accompanied  by  granular  or  fatty  degeneration  of  the 
muscular  tissue,  the  sarcous  elements  being  replaced  by  granules  or  fat- 
cells,  while  the  strife  have  become  more  or  less  indistinct.  In  other  cases 
a  rarer  degeneration  is  found — the  waxy  or  vitreous — in  which  the  fibres 
are  changed  into  a  transparent  homogeneous  substance,  in  which  no 
strife  can  be  seen,  and  the  muscle  resembles  a  piece  of  tendon  or  apo- 
neurosis. 

The  treatment  of  this  disease  is  rarely  satisfactory.  Strict  attention  to 
the  general  health,  the  treatment  of  any  syphilitic  taint  which  may  be 
present  or  lie  suspected,  the  prolonged  use  of  galvanism  in  its  various 
forms,  and  the  use  of  the  warm  sulphurous  water  of  Aix-la-Chapelle,  ap- 
pear to  be  of  admitted  value.  Medical  treatment  may  succeed  in  some 
cases,  and  if  so  the  drugs  which  are  most  likely  to  be  of  value  are  arsenic, 
phosphorus,  and  the  mineral  tonics,  as  zinc  or  iron.  But  to  be  erticacious 
these  remedies  must  be  long-continued,  in  small  doses.  Dr.  Lockhart 
Clarke  suggests  the  trial  of  counter-irritation  to  the  spine. 

Besides  these  two  well-marked  forms  of  atrophy  there  are  others  in 
which  the  atrophy  of  disuse  is  variously  combined  with  fatty  or  granular 
degeneration,  ''  in  acute  diseases,  alcoholism,  lead-poisoning,  rheuma- 
tism," etc.;  but  as  this  is  merely  a  subordinate  feature  of  the  general 
disease,  nothing  further  need  be  said  about  it.' 

Two  forms  of  degeneration  of  muscles  in  childhood  claim  notice  here. 
1.  Infantile  paralysis,  or  "essential"  paralysis,  so  called,  because  it  is 
not  supposed  to  be  connected  with  any  morbid  state  of  the  nervous  cen- 
tres. We  may  fairly  reserve  our  opinion  on  the  latter  point.  No  proof 
has,  it  is  true,  been  obtained  hitherto  that  the  spinal  cord  is  alfected  in 
infantile  paralysis  ;  yet  the  symptoms  point  strongly  to  disease  either  of 
the  cord  or  nerves  as  the  cause  of  the  paralysis  which  so  speedily  occurs 
in  a  muscle  or  group  of  muscles.  The  disease  begins  usually  after  a 
feverish  attack,  or  sometimes  during  teething,  after  convulsions,  in  some 
cases  without  any  noticeable  derangement  of  the  general  health.  The 
muscular  affection,  whether  preceded  by  general  ill-health  or  not,  is  in 
itself  sudden.  It  usually  affects  the  lower  extremities,  and  either  the 
whole  limb  or  groups  of  its  muscles,  or  a  solitary  muscle  may  be  affected. 
Less  commonly  it  is  noticed  in  the  upper  extremity.  The  muscle  which 
is  most  commonly  affected  alone  is,  I  think,  the  deltoid.  The  sternomas- 
toid  is  also  sometimes  alone  affected.  When  special  groups  of  muscles  of 
the  leg  are  paralyzed  the  corresponding  form  of  clubfoot  follows  from  the 
unbalanced  action  of  their  antagonists.  Paralysis  affecting  the  muscles 
or  one  buttock  sometimes  leads  to  a  suspicion  of  hip  disease,  but  is  easily 
distinguished  from  it  on  attentive  examination  b}^  the  perfect  freedom 
and  painlessness  of  passive  motion. 

1  I  do  not  speak  hereof  "locomotor   ataxy,"  regarding  it  as  lying  more  in  the 
province  of  a  treatise  on  medicine  ;  and  I  apply  the  same  observations  to  trichiniasis. 


4 


504  ORTHOPAEDIC    SURGERY. 

When  the  disease  is  inveterate  nothing  can  be  done  except  to  restore 
the  limbs  by  tenotoni_y  and  mechanical  appliances  to  such  a  position  as 
may  be  most  useful  to  the  patient,  if  he  has  the  power  of  using  them  in 
any  degree.  But  in  early  cases  a  cure  may  fairly  be  hoped  for  from  the 
persistent  use  of  galvanism,  from  exciting  the  muscles  to  voluntary  action 
as  far  as  is  possible,^  from  tonics,  such  as  strychnia,  and  from  shampoo- 
ing or  rubbing  the  limbs. 

2.  The  other  form  of  paralysis  in  childhood  is  that  curious  disease 
called  "  pseudo-hypertrophic  paralysis,"  or  "  Dnchenne's  disease."  The 
subjects  are  more  or  less  idiotic.  After  a  stage  of  partial  paralysis,  or 
weakness  of  the  lower  limbs,  which  may  last  several  months,  the  patient 
being  quite  unable  to  stand  or  walk,  the  stage  of  hypertrophy  commences, 
in  which  the  gastrocnemii,  the  gluteal  muscles,  and  those  of  the  loins 
become  very  much  swollen.  Tiie  swelling,  however,  or  apparent  hyper- 
trophy, is  found  to  be  due  not  to  any  real  hypertrophy  of  the  muscle,  but 
to  an  abundant  formation  of  connective  tissue  or  fat,  or  both,  amongst 
its  fibres,  which  are  themselves  at  least  at  first  health}^  and  present  the 
normal  response  to  galvanism.  In  the  third  stage  (which  may  be  de- 
ferred for  3^ears  after  the  commencement  of  the  second)  the  limbs  begin 
to  waste,  complete  paralysis  ensues,  and  the  patient  dies  sooner  or  later, 
unless  some  accidental  malady  carries  him  off. 

"During  its  first  stage  the  disease  is  sometimes  curable.  Duchenne 
has  recorded  two  such  cases. ^  But  in  the  second  stage  scarcely  any  hope 
of  recover}'  can  be  entertained.  The  treatment  consists  chiefly  of  local 
faradization  and  shampooing." — Lockhart  Clarke. 

Tumors  of  Muscle. — Muscles  are  subject  to  all  the  forms  of  tumor  de- 
scribed in  chap,  xvii,  but  I  do  not  know  that  their  occurrence  in  muscles 
is  a  fact  of  any  special  significance.  I  have  spoken  on  p.  .358  of  the  sin- 
gular cases  in  which  muscles  ossify,  or  where  loose  bony  tumors  are  found 
to  be  developed  in  them.  The  gummatous  tumors  due  to  syphilis  some- 
times attain  an  enormous  size,  and  in  one  well-known  case'*  the  scapula 
was  removed  for  such  a  growth.  The}'  are,  however,  almost  always 
amenable  to  internal  remedies. 


CHAPTER   XXVI. 

CLUBFOOT  AND  OTHER  DEFORMITIES.— ORTHOPAEDIC  SURGERY. 

The  various  deformities  which  are  treated  of  in  this  chapter,  and  of 
which  clubfoot  may  be  taken  as  the  type,  as  it  is  also  by  far  the  most  fre- 
quent example,  are  due  to  permanent  contraction  of  the  muscles,  the  re- 

1  Much  good  often  results  from  putting  the  child  in  a  "go-cart,"  where,  in  order 
to  move  about,  the  affected  musch;s  must  be  called  u])on  to  act. 

^  De  la  Paralysie  musculaire  p.seudo-hyperiroplnque.     Paris,  1868. 
3  South,  in  Path.  Trans.,  vol.  vii,  p.  346. 


TENOTOMY.  505 

suit  either  of  the  relaxation  of  their  antagonists  from  paralysis,  of  a  tonic 
spasm  in  their  own  substance,  or  of  some  change  in  the  structure  of  tiie 
muscular  filires  leading  to  their  permanent  contraction.^  It  is  very  diffi- 
cult, indeed,  to  determine  the  share  which  paralysis  or  spasm  respectively 
may  have  in  producing  the  congenital  forms  of  the  malady,  but  in  many 
of  the  non-congenital  cases  the  deformity  clearly  depends  on  infantile 
paralysis.  Congenital  cases,  on  the  other  hand,  seem  more  of  a  spas- 
modic nature,  though  the  spasm  relaxes  to  a  great  extent  in  sleep  or  in 
A'awning.'and  they  are  accordingly  generally  believed  to  depend  on  some 
abnormal  state  of  the  nervous  centres,  though  what  that  state  is  remains 
unknown.  The  cases  in  which  deformity  is  produced  by  disease  of  the 
muscles  themselves  irrespective  of  spasmodic  or  paralytic  deformity  are 
purel}'  exceptional.  The  main  point  to  determine  in  the  treatment  of 
deformities  is  their  curability  by  or  without  surgical  operation.  The 
milder  cases  of  deformity,  whether  spastic  or  paralytic,  may  be  remedied 
by  gradual  extension  by  means  of  appropriate  apparatus,  and  some  even 
by  the  manipulations  of  the  nurse  or  mother;  Init  for  cases  of  ordinary 
severity  tenotomy  is  required  before  the  application  of  the  instrument 
intended  to  place  the  parts  in  the  natural  position. 

Tenotomy,  or  the  subcutaneous  division  of  tendons,  is  an  operation 
now  very  extensively  practiced,  but  for  which  the  surgical  profession  is 
indebted  to  the  genius  of  a  surgeon  still  living — the  illustrious  Stromeyer.^ 
It  consists  in  passing  a  small  thin  knife  through  a  minute  puncture  close 
to  the  contracted  tendon,  dividing  it,  if  possible,  without  injuring  any 
part  in  its  vicinity;  then  withdrawing  the  knife,  closing  the  wound  care- 
fully and  allowing  it  to  heal,  which  in  almost  all  cases  it  does  by  the  pro- 
cess of  first  intention.  The  upper  end  of  the  divided  tendon  retracts  in 
its  sheath,  and  the  latter  becomes  filled  with  lymph,  in  which  fibrous 
tissue  is  developed,  very  much  as  a  simple  fracture  is  united.  This 
fibrous  tissue  is  at  first  soft,  and  easily  yields  to  an  extending  force  (Fig. 
220)  ;  and  the  subsequent  treatment  consists  in  gently  drawing  it  out  to 
the  required  length.  When  tiiis  process  is  completed  the  uniting  mate- 
rial is  thinner  than  the  natural  tendon,  and  the  muscle  comparatively 
weak ;  but  it  gradually  acquires  strength  and  breadth,  and  when  exam- 
ined some  time  afterwards  so  closely  resembles  the  original  tendon,*  that 
the  difference  is  only  visible  on  a  fresh  section,  and  after  very  close  ex- 
amination.    Sometimes  after  division  one  or  both  ends  of  the  divided 


'  This  change  is  called  by  American  surgeons  "  contracture,"  and  is  chiefly  ex- 
emplitied  by  the  state  of  the  muscles  on  the  flexed  side  of  a  permanently  contracted 
joint,  as  the  hi[)  or  knee. 

^  See  Dr.  Little's  observations  on  this  head  in  Syst   of  Surg.,  vol.  iii,  p.  660  et  seq. 

3  Mr.  Adams  says:  -'On  February  28th,  1831,  Stromeyer  first  divided  the  tendo 
Achillis  by  subcutaneous  puncture  in  a  case  of  non-congenital  equino-varus  in  a  boy 
aged  nineteen.  No  inflammation  followed.  By  gradual  extension  the  deformity 
was  cured  in  two  months,  and  the  boy  allowed  to  walk  with  a  steel  support  to  the 
boot." — Rust's  Magazine,  1833,  vol.  xxxix,  p.  195.  But  though  Stromeyer's  priority 
in  the  practical  use  of  tenotomy  is  undisputed,  the  priority  in  the  suggestion  is  due 
to  Delpech,  as  Stromeyer  has  expressly  pointed  out.  John  Hunter,  after  he  had 
suffered  in  his  own  person  from  rupture  of  the  tendo  Achillis  (see  p.  497),  investi- 
gated the  process  of  union  after  subcutaneous  division  of  the  tendo  Achillis  in  dogs, 
and  his  preparations  are  still  in  the  Museum  of  the  College  of  Surgeons.  He  came 
to  the  perfectly  correct  conclusion  that  the  process  "  was  similar  to  that  of  fractured 
bones  where  the  skin  is  not  wounded."  In  fact.  Hunter  may,  as  Mr.  Adams  has  said, 
be  regarded  as  the  originator  of  subcutaneous  surgery. 

*  The  process  of  union  in  divided  tendons  has  been  most  minutely  described  by 
Mr.  W.  Adams,  On  the  Reparative  Process  in  Human  Tendons  after  Division.  I 
would  refer  the  reader  to  the  fourth  chapter  of  that  work  for  many  details  for  which 
space  fails  me  here. 


506 


ORTHOPAEDIC    SURGERY. 


tendon  may  adhere  to  a  neighboring  bono,  and  the  function  of  the  di- 
vided musi'le  may  thus  be  lost,  at  any  rate  for  the  time.  Still  it  seems 
that  these  adhesions  often  give  way  ultimately,  and  the  muscle  resumes 
its  functions;  and  even  if  not  the  limb  will  in'obably  be  very  useful.  The 
tendo  A  chillis,  which  is  the  most  important  of  the  tendons  usually  di- 
vided, lies  too  far  away  from  the  tibia  to  be  subject  to  this  accident. 

In  other  cases  the  tendon,  if  divided  near  its  insertion,  may  form  for 
itself  an  entirely  new  attachment,  as  was  the  case  in  the  instance  from 
which  Fig.  221  was  taken.  But  in  such  a  case  the  operation  will  proba- 
bly lie  as  successful  as  if  the  two  ends  of  the  tendon  had  been  united  in 
the  ordinary  way. 

I  mention  these  irregularities  in  the  method  of  union,  inasmuch  as  they 
have  been  made  the  ground  for  decrying  the  operation  of  tenotomy  alto- 

FlG.  221. 


Fig.  220.— a  specimen  .sliowing  the  condition  of  the  tendo  Achillis  in  an  adult  22  days  after  its  divi- 
sion. The  operation  had  Vjeen  performed  in  order  to  assist  in  the  reduction  of  a  compound  fracture  of 
the  leg.  Amputation  became  necessary  at  the  above  period. — From  St.  George's  Hospital  Museum, 
Ser.  iv,  No.  20. 

Fio.  221. — An  eye,  showing  the  union  of  the  tendon  of  the  external  rectus  uuiscle,  after  its  division  in 
a  case  of  squint.  The  patient  died  of  phtliisis  a  month  after  the  operation.  The  muscle  (wliich  isseen 
at  the  upper  part  of  the  figure)  is  now  conuecttd  to  the  sclerotic  by  a  lonL'thin  Innidle  of  fibrous  tissue. 
The  insertion  of  the  original  tendon  into  the  tunica  albuginea  is  perfectly  distinct,  and  appears  quite 
separate  from  the  new  unitins  material.  The  latter  was  so  firm  that  itallowid  of  forcible  traction 
without  giving  way.  The  deformity  appeared  to  be  cured. — St.  George's  Hospital  Museum,  Ser.  iv, 
No.  7. 

gether,  except  as  applied  to  the  tendo  Achillis,  and  for  substituting  exten- 
sion for  it  as  the  general  method  for  treating  clidjfoot.'  Mr.  Barwell  is 
impressed  with  tlie  belief  that  after  the  division  of  the  tibialis  posticus 
and  othei-  deeply  seated  tendons  the  tendon  often  does  not  unite  in  its 
natural  relations,  and  that  a  lameness  is  lei't — "  less  apparent  perhaps,  but 


1  Barwell,  On  certain  grave  Evils  attending  Tenotomy,  and  on  a  New  Method 
of  Curing  Dofonnilics  of  llic  Foot.     ]\Icd.-CIiir.  Trans.,  vol.  .\Iv,  p.  25. 


TALIPES    EQUINUS.  507 

certainly  more  incurable  than  the  orit^inal  disease."  I  can  only  say  that 
after  the  appearance  of  Mr.  Barwell's  paper  I  have  carefnlly  examined 
man}'  cases  under  my  own  and  other  surgeons'  care  in  which  these  ten- 
dons have  been  divided,  and  have  failed  to  verify  Mr.  Barwell's  statement. 
The  foot,  in  favorable  cases,  is  very  nearly  natural.  Beyond  some  flat- 
tening of  the  arch  and  widening  of  the  sole,  there  is  little  change  in  its 
external  appearance,  and  the  patients  vvalk  nimbly  and  with  no  percepti- 
ble limp.  Nor  is  Mr.  Barwell's  method  of  extension,  by  means  of  india- 
rubber  cords,  hooked  on  to  splints  which  are  kept  in  place  by  plaster,  at 
all  easy  to  apply  successfully  in  cases  where  the  deformity  is  serious, 
since  the  traction  necessary  to  correct  the  deformity  will  either  |)ull  the 
splints  off,  or,  if  they  are  more  securely  fastened  by  the  strapping,  the 
latter  will  cut  into  tlie  skin.  My  own  trials  of  this  method  have  conse- 
quentl\'  been  disappointing;  yet  its  principle,  that  of  substituting  gradu- 
ally increasing  elastic  tension  for  the  muscles  which  are  paralyzed,  is  so 
obviously  sound  for  the  treatment  of  paralytic  deformity,  that  I  thought 
it  right  to  direct  the  reader's  attention  to  it.  I  consider  it  a  valuable 
method  of  treatment  in  the  slighter  cases  of  paralytic  deformit_y,  though 
Mr.  Barwell's  statement  of  the  evils  attending  tenotomy  seems  overdrawn, 
and  tenotomy  is  still  in  general  use  in  all  ordinary  cases. 

Tenotomy  is  generally  employed  in  the  case  of  clubfoot ;  sometimes  as 
the  case  from  which  Fig.  220  was  drawn,  to  facilitate  the  reduction  of  a 
fractured  bone,  sometimes  of  a  dislocation  ;  also  for  squint  and  wryneck, 
and  in  various  deformities,  as  those  produced  by  diseased  hip,  knee,  etc. 
Muscles  also  are  occasionally  divided,  either  subcutaueously  or  otherwise, 
in  plastic  operations,  as  the  levator  palati  mollis,  in  staphyloraphy.  In 
all  these  cases  the  object  of  the  surgeon  is  to  divide  the  tendon  or  muscle 
as  cleanly  and  with  as  small  a  wound  as  possible ;  and,  if  the  operation 
be  subcutaneous,  to  keep  the  parts  quiet  until  primary  union  is  insured. 
The  attempt  to  put  the  parts  at  once  into  the  desired  position  after  sub- 
cutaneous tenotomy  may,  indeed,  be  successful,  but  it  is  somewhat  risk}'^, 
for  suppuration  may  easily  follow,  and  then  time  vvill  be  lost  instead  of 
gained;  or  the  divided  tendon  may  be  matted  to  the  parts  around,  and 
the  attempt  to  cure  the  deformity  prove  an  entire  failure ;  whilst  the  slight 
delay  in  waiting  for  primary  union  does  not  increase  the  difficulty  of 
treating  the  case  at  all,  since  the  union  is  perfectly  soft  and  extensible 
then  and  for  a  long  time  afterwards. 

I  now  turn  to  the  various  kinds  of  clubfoot. 

Talipes  equmus  is  the  deformity  produced  by  a  contracted  state  of  the 
gastrocnemius  muscle  drawing  the  os  calcis  directly  upwards,  and  causing 
the  patient  to  walk  on  the  metatarso-phalangeal  joints  and  the  toes,  the 
foot  bearing  a  strong  resemblance  to  that  of  a  horse,  whence  the  name. 
The  two  annexed  representations  (Figs.  222,  223,  p.  508)  of  a  prepara- 
tion, taken  from  an  old  neglected  case  of  this  deformity,  will  give  a  better 
idea  of  its  anatomy  than  words  can  do.  It  will  be  seen  that  the  heel-bone 
is  drawn  into  a  tolerably  vertical  position,  the  tarsus  is  much  curved  for- 
wards, and  the  muscles  of  the  sole  of  the  foot,  with  the  plantar  fascia, 
are  very  much  contracted,  the  long  muscles  in  front  proportionall}'- 
stretched,  those  on  the  inner  and  outer  aspects  of  the  foot  not  materially 
affected. 

The  cure  of  the  deformity  is  to  be  sought  in  the  elongation  of  the  con- 
tracted gastrocnemius  muscle.  In  very  slight  incipient  cases  this  might 
perhaps  be  done  by  repeated  manipulations  and  by  the  gradual  traction 
of  a  splint  of  ductile  metal  applied  in  front,  the  angle  being  carefully 
increased  till  the  foot  is  drawn  up  to  and  beyond  a  right  angle. 


508 


ORTHOPAEDIC    SURGERY. 


Tenotomy  offers  a  ready  means  of  restorino-  the  position  of  the  foot,  and 
experience  proves  that  the  muscle  after  its  elongation  may  recover  its 
functions  sufficiently  for  all  the  purposes  of  ordinary  life.     So  that  if  the 


Fig.  222. 


Fig.  222. — A  preparation  of  talipes  equinus  seen  from  the  inner  side,  a,  tibialis  anticus;  h,  extensor 
propriiis  pollieis;  c,  extensor  longus  digitonim;  rf,  skin,  with  contracted  plantar  fascia  ;  e,  tibialis  pos- 
ticus;/, tendo  Achillis;  h,  tendon  of  flexor  longus  pollicis;  k,  flexor  longus  digitoruni. 

Fig.  22:J.— Tlie  same  preparation  seen  from  the  outer  side,  a,  tibialis  anticus;  6,  extensor  proprius 
pollicis;  c,  extensor  longus  digitorum  ;  (f,  flexor  brevis  digitorura  ;  c,  plantar  fascia;/,  tendo  Achillis; 
5^,  A,  peronieus  brevis  and  longus;  i,  peronteus  tertius. — From  a  preparation  in  St.  George's  Hospital 
Mu.seum,  Ser.  iv,  No.  22. 

deformitj'  is  at  all  sti'ongly  prononnced — that  is,  if  the  foot  cannot  be 
brought  to  a  right  angle,  or  on  being  released  flies  strongly  back — it  seems 
of  little  use  to  waste  time  on  less  ett'ectual  treatment.  The  tendo  Achillis 
should  be  divided  by  turning  the  child  on  its  belly  and  introducing  the 
tenotome  on  the  inner  side  below  and  as  close  to  the  tendon  as  possible, 
a  short  distance  above  the  point  of  its  attachment,  where  it  seems  thinnest, 
the  foot  being  still  extended.  When  the  knife  is  fairly  under  the  tendon 
the  foot  is  to  be  strongly  flexed  by  the  assistant,  while  the  surgeon,  with 
a  slight  sawing  motion,  presses  the  knife's  edge  against  the  tightened 
tendon.  As  soon  as  it  has  been  sufficiently  divided  the  extending  force 
will  rupture  it  with  an  audible  snap,  when  the  knife  should  be  instantly 
turned  flat,  so  that  the  skin  may  not  be  cut,  and  should  be  withdrawn. 
If  the  operation  has  been  dexterously  performed  hardly  a  drop  of  blood 
will  escape.  The  wound  should  be  stra[)ped,  and  the  foot  placed  on  a 
splint  in  the  extended  position  in  which  it  was  found  before  the  operation. 
No  attempt  should  be  made  to  bring  it  to  the  natural  angle  till  the  wound 
is  soundly  healed,  which  will  probably  lie  the  case  in  about  five  days. 
In  complicated  cases  the  division  of  the  plantar  fascia,  and  possibly  of 
some  of  the  muscles  of  the  sole,  is  necessary  in  order  to  unfold  the  tarsus, 
as  will  be  sufficiently  seen  from  Figs.  222,  223. 


TAIilPES     VARUS. 


509 


Scarpa's  shoe  is  to  be  R[)plie(l  when  the  wouikI  is  lienled,  in  order  to 
stretch  the  uniting  material  and  elongate  the  muscle  to  the  extent  neces- 
sary to  bring  the  sole  of  the  foot  flat  to  the  ground.  When  this  is  done 
(which  in  a  favorable  case  may  be  in  about  two  months)  a  boot  with  irons 
is  to  be  applied,  to  prevent  recontraction,  and  if  the  child  is  old  enough 
he  may  be  allowed  to  walk. 

Talipes  Varus. — The  severer  forms  of  talipes  equinns,  such  as  that  rep- 


FlG.  22-1. 


Fig.  225. 


Fig.  224. — Shoe  for  the  treatment  of  simple  talipes  equinus  in  infancy. — From  Holmes's  Surg.  Treat, 
of  Children's  Diseases. 

Fig.  225.— Severe  adult  congenital  varus,  viewed  from  the  front  and  inside,  a,  the  tibia  cut  down,  in 
order  to  show  the  relatively  posterior  situation  of  the  fibula;  b,  the  external  malleolus;  c,  the  fibula; 
d,  the  posterior  extremity  of  the  os  calcis  drawn  abnormally  inwards;  e,  the  astragalus  unduly  promi- 
nent on  the  dorsum  of  the  foot;  /,  the  navicular  bone  in  contact  with  the  internal  malk'olus;  g,  the 
cuboid,  its  posterior  surface  applied  to  the  ground. — From  Little,  in  Syst.  of  Surg.,  vol.  iii,  p.  6G5,  2d  ed. 

resented  above,  are  commonly  congenital;  and,  as  Dr.  Little  has  ob- 
served, such  cases  of  congenital  equinus  usually  remain  throughout  life 
purely  equinus — i.e.^  the  foot  is  perfectly  straight,  without  any  deviation 
to  the  inside  or  the  outside.  But  the  common  form  of  congenital  club- 
foot is  talipes  varus,  or  equinovarus.  In  the  pure  T.  varus  the  os  calcis 
would  be  on  the  same  horizontal  level  as  the  metatarsus;  but  if  this  is 
ever  the  case  it  must  be  very  rare.  In  practice  the  os  calcis  is  always 
found  more  or  less  elevated — i.  e.,  the  case  partakes  more  or  less  of  the 
essential  characters  of  T.  equinus.  The  term  T.  varus  is  usually  applied 
to  those  in  which  the  heel  is  not  very  much  elevated;  when  it  is  so  the 
deformity  is  named  T.  equinovarus;  but  in  ordinary  nomenclature  they 
may  be  regarded  as  synonymous. 

The  deformity  consists  in  a  simultaneous  contraction  of  the  tendo 
Achillis  and  the  tendon  of  the  tibialis  posticus,  that  of  the  tibialis  anticus 
being  also  almost  always  contracted,  and  veiy  often  the  flexor  longus 
digitorura  as  well.  The  internal  portion  of  the  plantar  fascia  is  also  con- 
stantly found  contracted  ;  and  this,  if  the  deformity  is  inveterate,  involves 
also  the  contraction  of  one  or  more,  or  all,  of  the  short  muscles  of  the  sole. 

The  deformity  of  course  increases  the  longer  it  is  neglected.  When 
the  child  begins  to  walk  he  rests  on  the  outer  side  and  partly  on  the  dor- 
sum of  the  foot,  on  which  part  large  bursie  usually  form.  If  the  skeleton 
of  the  foot  be  examined  (Fig.  225)  in  a  case  of  old  deformity,  the  ankle- 


510  ORTHOP.llDIC    SURGERY. 

joint  will  be  found  distorted,  the  fibula  being  drawn  behind  the  tibia,  the 
internal  malleolus  almost  or  quite  in  contact  with  the  scaphoid  bone,  the 
astragalus  jnished  out  towards  the  outer  side  of  the  dorsum,  tlie  cuboid 
bone  turned  downwards,  so  that  its  dorsal  face  su[)i)orts  the  arch  of  the 
tarsus;  the  metatarsus,  which  is  curved  towards  the  calcaneum,  is  more 
or  less  vertical  instead  of  horizontal.  In  old  cases  all  the  bones  are 
changed  in  shape,  and  the  ligaments,  muscles,  and  fasciae  have  also 
undergone  corresponding  changes.  Such  cases  are,  of  course,  incurable; 
or,  if  the  position  of  the  foot  is  to  be  remedied  at  all,  it  can  only  be  so 
by  excising  some  of  the  deformed  bones.  But  in  earlj'  life,  while  the 
structures  are  yielding,  and  the  parts  have  not  undergone  any  irremediable 
change,  a  ver}-  useful  foot  indeed  may  be  obtained.  In  all  the  cases  of 
cure  which  I  have  seen,  a  certain  degree  of  flattening  of  the  sole  re- 
mained, and  the  patient,  if  severely  tested,  would  not  have  been  able  to 
run.  iiop,  or  leap  from  a  height  with  the  same  force  or  security  as  one 
who  had  the  natural  arch  and  spring  of  the  foot,  but  for  ordinary  loco- 
motion there  is  often  little  to  be  desired. 

The  treatment  by  manual  extension  or  by  india-rubber  bands  or  other 
mechanism  may  succeed  in  the  slighter  cases,  but  for  cases  of  ordinary'- 
severity  the  section  of  the  tendo  Achillis  and  that  of  the  two  tibial  ten- 
dons is  commonly  necessary.  Very  often  also  the  plantar  fascia  and  the 
muscles  in  the  sole  of  the  foot  will  require  division.^  Many  surgeons 
prefer  to  divide  the  tibial  tendons  first,  and  to  convert  the  deformity  into 
one  of  simple  eqninus  before  dividing  the  tendo  Achillis,  and  this  is  no 
doubt  the  better  plan  in  the  graver  cases  of  the  deformity,  since  the  heel 
forms  a  firmer  point  d'apjjui  for  the  instrument  than  if  the  great  tendon 
has  been  divided.  The  operation  of  dividing  the  tendon  of  the  tibialis 
posticus  in  a  fat  bab}^  is  not  always  an  eas}'  one,  and  several  cases  have 
occurred  in  which  the  child,  having  accidentally  died  soon  after  the  sup- 
posed tenotomy,  it  has  been  proved  by  dissection  that  the  tendon  has 
been  missed.  The  small  size  of  the  tendon  and  the  depth  at  which  it 
lies  buried  account  for  these  mistakes.  Another  danger  is  that  of  wound- 
ing the  posterior  tibial  artery,  which  lies  close  to  the  tendon  in  the  leg. 
For  this  reason  apparently  some  surgeons  have  practiced  the  division  of 
tiie  tendon  in  the  tarsus,  but  in  the  infant  it  is  very  dithcult  indeed  to 
find  it  there.  The  sharp  tenotomy  knife  is  to  be  introduced  close  to  the 
posterior  edge  of  the  tibia,''^  about  an  inch  above  the  ankle  ;  and  the  fascia 
liaving  been  freely  opened  (including  the  sheath  of  the  muscles),  a  blunt- 
pointed  tenotome  is  sul)stituted  for  it,  and  its  edge  turned  towards  the 
tendon.  An  assistant  holds  the  foot  inverted  during  this  stage  of  the 
operation.  Then  he  forciiily  eveits  the  foot,  and  as  the  o[)erator  raises 
his  knife  tiie  tendon  is  felt  to  yield.  If  the  operator  believes  that  he  has 
missed  the  tendon  he  must  reintroduce  his  knife  close  to  the  bone,  pass 
it  somewhat  more  deei)ly,  and  repeat  the  i)revious  mananivres.  It  is  very 
dillicult  in  relapsed  cases,  where  the  tendon  has  been  previously  divided, 
to  l)e  sure  whetlier  it  has  been  severed  or  not.  The  assistant  often  feels 
the  snap  of  the  divided  tendon  more  plainly  than  the  surgeon.  If  pro- 
fuse bleeding  and  blanching  of  the  foot  testify  to  a  wound  of  the  poste- 


'  Dr.  Geurgi!  Bufhaiiim,  of  Ghisf^ow,  lias  roceiilly  called  attention  to  the  necessity 
in  many  cases  of  clubfoot  for  deep  incision  in  the  sole  of  the  foot  for  the  unfniding 
of  the  contracted  tarsus  and  metatarsus  (see  his  address  in  Clinical  Surgery,  1874,  p. 
24).  A  glance  at  Fig.  222  will  show  how  the  plantar  muscles  are  contracted  in  these 
cases. 

''  If  the  edge  of  the  tibia  cannot  be  felt  the  knife  is  to  be  inserted  about  midway 
between  the  anterior  and  posterior  borders  of  the  leg,  and  the  bone  is  to  be  felt  with 
the  i)oint  of  the  knife. 


TALIPES    VARUS. 


511 


rior  tibial  artorv,  careful  grarliiatecl  pressure  should  be  made  on  the 
wound,  and  the  linil)  be  neatly  and  firmly  banda<yed  (but  not  too  tiglit) 
from  the  toes  ni)wards  on  a  splint;  and  no  extension  should  be  made  for 
at  least  a  fortnight.  'Plie  accident  is  believed  to  hapjien  very  often,  but 
in  only  one  case  was  it  ever  thought  necessary  to  tie  the  artery  afterwards, 
and  then,  it  is  believed,  only  in  consequence  of  extension  having  been 
used  too  soon.  Tlie  flexor  longus  digitorum  is  often  divided  at  the  same 
time,  either  accidentally  or  purposely.  Much  has  lieen  said  about  the 
risk  of  loss  of  motion  afterwards  in  consequence  of  the  adhesion  of  the 
divided  ends  of  tlie  tendon  to  its  sheath 

or  to  the  bone;  but  Mr.  Adams's  dis-  fig.  220 

sections^  have  shown  that  such  adhe- 
sion is  not  very  common,  and  that 
when  it  occurs  it  does  not  by  any 
means  necessarily  involve  the  loss  of 
the  action  of  the  muscle,  since  the  ad- 
hesion often  stretches  to  an  extent 
which  allows  the  muscle  considerable 
play  ;  and  I  may  add  that  I  have  ex- 
amined patients  in  whom  the  action 
of  tliis  muscle  seemed  to  have  been 
lost,  yet  who  had  very  useful  feet.  Tlie 
tibialis  anticustendonis  easily  divided, 
as  it  passes  in  front  of  the  ankle,  by 
merely  inserting  the  knife  flat  beneath 
it,  and  turning  its  edge  towards  the 
tendon,  while  the  assistant  manipulates 
the  foot  suitably  to  tlie  convenience  of 
the  ojierator.  The  tendon  is  displaced 
Inwards  by  the  adduction  of  the  foot, 
and  the  arteiyand  nerve  are  quite  out 
of  danger. 

No  special  directions  are  required 
for  dividing  the  contracted  fascia  and 
muscles  in  the  sole. 

Numerous  apparatus  for  the  treat- 
ment of  varus  are  in  use,  but  space 
forbids  me  to  dwell  with  any  minute- 
ness on  the  subject.  I  append  a  rep- 
resentation of  one  which  seems  to  me  as  useful  and  as  little  cumbrous  as 
any,  and  which  will  illustrate  the  general  principles  on  which  they  are 
constructed.  The  heel  being  carefully  kept  in  the  hole  made  for  it  in  the 
back  of  the  footpiece,  the  foot  is  to  be  secured  in  the  latter,  the  sole  of  the 
footpiece  being  applied  to  the  foot,  not  the  foot  forced  on  to  the  sole.  It  is 
kept  in  position  by  straps  over  the  ankle  and  toes,  as  seen  in  the  figure. 
Then  the  leg  and  thigh  are  secured,  and  the  instrument  is  in  position. 
The  joint  at  the  knee  is  made  free,  so  that  the  leg  and  footpiece  may  be 
the  less  liable  to  displacement.  One  of  the  screws  changes  the  angle  of 
inclination  of  the  sole  to  the  horizon,  and  the  other  regulates  the  inclina- 
tion of  the  axis  of  the  foot  to  that  of  the  leg,  the  former  correcting  the 
tendency  to  varus,  the  latter  that  to  equinus.  The  great  point  in  the 
successful  management  of  cases  of  clubfoot  is,  after  the  complete  division 
of  the  attected  tendons,  to  manage  the  instruments  with  so  much  gentle- 


Sboe  for  varus.— Holmes's  Surg.  Treat,  of 
Children's  Diseases. 


1  Path.  Trans.,  vol.  xxi,  p.  417,  and  vol.  xxiii,  p.  308. 


512  ORTHOPAEDIC    SURGERY. 

iiess  that  the  skin  may  never  become  excoriated  or  ulcerated  by  the  pres- 
sure of  the  straps,  and  that  the  foot  may  always  be  well  applied  to  the 
solepiece.  The  inclination  of  the  various  parts  of  the  apparatus  should, 
therefore,  be  varied  very  gradually,  almost  imperceptibly,  and  tlie  appa- 
ratus sliould  be  frequently  removed,  well  padded  in  every  part  where  pres- 
sure may  be  apprehended,  and  the  position  of  the  straps  slightly  altered  if 
any  redness  a})pears. 

Dr.  Little  gives  two  or  three  months  as  the  average  period  required  in 
the  infant  for  the  mechanical  treatment  of  the  highest  grade  of  the  defor- 
niitv,  in  wliich  the  operation  and  the  meclianical  treatment  have  been 
divided  into  two  or  three  stages.  After  this  the  child  may  be  allowed  at 
first  to  move  about  in  the  apparatus,  and  then  a  boot  witli  side-irons  should 
be  substituted  during  the  day,  the  varus-shoe  being  replaced  at  night,  so 
long  as  any  tendency'  to  distortion  is  seen  or  apprehended. 

'TaiijJes  valgus,  in  which  the  sole  of  tlie  foot  instead  of  being  flat  looks 

outwards,  is  a  deformity  usually  noncongenital,  dependent  on  spastic 

contraction    of  tlie    peronei   tendons,    or   partial 

Fig.  227.  paralysis  of  the  tibiales.     It  is   frequently  com- 

plicated  with   T.  equiuus  from   weakness   of  the 

fer — -^  flexors,  or  with  T.  calcaneus  from  loss  of  power 

te         /  of  the  gastrocnemius. 

p        /  The  grade  of  the  deformity  will  indicate  the 

M'     J  treatment  required.     It  is  unadvisable  to  divide 

m  00^"^~-<^  tendons  unless  absolutely  necessary  ;    but   occa- 

M     '  \^         sionally  the  peronei  tendons,  or  perhaps  onl^-  the 

^vjiss^^^^^^^^^^^^^*^^^  peroneus  brevis  must  be  divided,  liefore  apparatus 

Talipes caicaneo-vai,«s con-  ^au  be  applied  to  rectify  the  positiou  of  the  sole; 

genitus.   From  a  model  in  the   and  wheu  the  tendo  Achillis  IS  Contracted  it  IS 

Museum  of  St.  George's  Hos-  very  frequently  necessary  to  divide  it. 

pitai.    In  this  case  the  foot        Talipes   Calcaneus.— PviYQ  T.  calcaneus  is  still 

liad  SIX  toes.— Holmes's  Surg.  J-  -,   •.    ■        ..^^  i  ^ 

Treat,  of  Children's  Diseases,  more  rare,  and  It  IS  Still  more  rarely  necessary  to 
divide  the  flexor  tendons. 

Flatfoot. — The  variety  of  valgus  which  is  most  commonly  met  with  is 
the  ordinary  flatfoot,  or  spurious  valgus.  This  deformity  depends  on  a 
yielding  of  the  calcaneo-scaphoid  ligament  which  supports  the  head  of 
the  astragalus  and  of  the  tendon  of  the  tibialis  posticus  muscle  which 
assists  that  ligament  and  forms  so  powerful  a  bond  of  union  between  all 
the  liones  of  the  tarsus.  The  long  plantar  ligament  is  also  relaxed,  as 
are  doubtless  all  the  ligamentous  structures  of  the  tarsus.  The  conse- 
quence is  that  in  extreme  cases  the  arch  of  the  foot  is  obliterated,  the 
astragalus  descending  till  it  touches  the  ground.  In  the  worst  cases  the 
anterior  part  of  the  foot  is  even  drawn  upwards  by  the  tibialis  anticus 
and  the  extensors  of  the  toes  till  the  sole  becomes  convex  antero-poste- 
riorly,  instead  of  concave.  The  peronei,  being  no  longer  balanced  by 
their  chief  antagonist  muscle,  draw  the  sole  outwards.  In  extreme  cases 
there  is  considerable  pain  in  motion,  which  seems  to  depend  on  a  stretched 
condition  of  the  plantar  nerves.  This  extreme  grade  is  rarely  met  with, 
but  a  slighter  degree  of  flatfoot  is  a  very  ordinary  deformity  in  children, 
especially  if  they  are  previously  weakly,  who  are  obliged  to  keep  standing 
for  too  long  at  a  time  (as  in  factory  labor)'  or  to  carry  heavy  weights. 

The  cure  of  this  affection  in  its  early  stage  is  easy,  whilst  in  aggravated 
cases  only  imperfect  relief  can  be  alfordcd.  In  the  first  place,  the  young 
persons  should  be  relieved  from  the  labor,  or  the  protracted  standing, 

'  See  a  paper  by  Mr.  C.  Roberts,  in  St.  George's  Hospital  Reports,  vol.  vii. 


TALIPES    CAVUS. 


513 


which  has  caused  the  deformity  ;  the  arch  of  the  foot  should  be  supported 
and  pressed  upwards  by  a  spring  or  a  pad  fixed  on  the  inner  side  of  the 
sole  of  the  boot  or  shoe  ;  any  tendency  to  eversion  of  the  foot  should  be 
opposed  by  side-supports  ;  the  weakened  muscles  should  be  galvanized  ; 
the  patient  should  be  allowed  long  periods  of  rest  in  the  recumbent  posi- 
tion, but  the  structures  should  at  the  same  time  be  strengthened  by  such 

Fig.  228. 


A.  Drawing,  from  a  model  in  the  Museum  of  St.  George's  Hospital,  of  ordinary  flatfoot,  or  noncon- 
genital  talipes  valgus. — Holmes's  Surg.  Treat,  of  Children's  Diseases,  b.  The  same  model  drawn  from 
behind. 

an  amount  of  brisk  exercise  as  can  be  taken  without  fatigue,  and  the 
general  health  should  be  carefull}'  attended  to.  In  the  severer  cases 
section  of  the  peronei  tendons  may  be  required,  but  ought  not  to  be 
resorted  to  except  under  the  plainest  necessity. 

Talipes  Cavus. — A  rare  form  of  talipes  is  described  under  the  name  of 
T.  cavus,  in  which,  without  any  contraction  of  the  long  tendons,  the 
plantar  fascia  and  short  muscles  of  the  sole  are  contracted  so  as  to  bring 
the  metatarsus  nearer  to  the  heel.  This  has  already  been  discussed  as  a 
common  accompaniment  of  the  oi'dinary  congenital  clubfoot,  and  it  is 
also  a  striking  feature  in  many  cases  of  congenital  talipes  calcaneus.  As 
a  substantive  deformity  I  am  not  acquainted  with  it,  and  it  would  in  any 
such  case  be  a  serious  question  whether  its  treatment  would  not  involve 
as  much  loss  of  power  as  the  deformity  itself. 

Relapsed  Clubfoot. — Cases  of  relapsed  clubfoot  are  often  very  difficult 
to  treat ;  the  tendons  which  had  been  divided  having  perhaps  acquired 
adhesions  to  the  neighboring  parts,  or  being  so  matted  to  the  cellular 
tissue  around  that  it  is  by  no  means  easy  to  satisfy  one's  self  as  to  their 
having  been  satisfactorily  divided.  This  applies  especially  to  the  tibialis 
posticus.  The  fact  furnishes  an  additional  motive  for  care  in  the  original 
treatment  of  the  case.  But  in  mau}^  cases  of  relapse,  provided  the  cure 
has  at  the  time  been  complete,  no  further  operation  is  necessary,  for  the 
foot  can  be  brought  straight  again  by  manipulation  and  instrumental 
treatment. 

33 


514  ORTHOP.T^DIC    SURGERY. 

Irregular  Deformifies. — It  would  hardly  be  possible  to  enumerate  and 
describe  the  various  irregular  deformities  which  follow  ui)oii  spastic  con- 
traction of  muscles  in  infancy,  the  result  of  injury  or  disease  of  the  nervous 
centres,  or  upon  inftmtile  paralysis.  The  principles  of  treatment  are  the 
same  in  these  distortions  as  in  the  ordinary  clubfoot,  viz.,  to  endeavor  if 
possible  to  correct  the  position  of  the  limb  by  properly  contrived  appa- 
ratus ;  and  if  this  is  not  possible,  to  divide  any  muscular,  tendinous,  or 
ligamentous  structure  which  offers  definite  resistance,  and  then  appl,y  the 
apparatus,  and  continue  the  treatment  till  the  limbs  are  straight  and 
have  recovered  as  much  motion  as  the  condition  of  the  muscles  will  allow. 

Clubhand. — One  of  the  most  grievous  of  these  irregular  deformities  is 
"  clubhand,"  in  which  the  tendons  of  the  wrist  and  fingers  are  contracted, 
and  the  hand  variously  distorted,  generally  in  the  sense  of  flexion.  The 
treatment  is  not  very  successful;  and,  as  Dr.  Little  has  pointed  out, 
tenotomy  is  by  no  means  promising  in  such  cases.  As  much  good  seems 
to  be  done  by  the  persevering  use  of  manipulation,  friction,  and  galvanism, 
aided  by  mechanical  supports  and  by  active  movement  as  far  as  possible, 
as  can  be  expected  from  tenotomy.  In  fact,  in  the  few  cases  in  which  I 
have  myself  seen  the  operation  practiced  it  has  seemed  useless,  unless, 
perhaps,  as  an  adjunct  to  mechanical  treatment. 

Contracted  Palmar  Fo.i<cia. — The  hand  is  liable  to  a  very  inconvenient 
deformit}'  from  the  contraction  of  the  palmar  fascia  and  of  subjacent 
tendons,  which  is  in  many  respects  analogous  to  rheumatism,  and  is 
usually  regarded  as  a  rheumatic  symptom,  though  it  has  not  the  pain 
which  is  characteristic  of  rheumatism  ;  and  the  patients  often  refer  it  to 
injury  or  to  the  constant  irritation  of  some  form  of  manual  labor.  The 
fingers  affected  are  generally  the  ring  and  little  fingers,  sometimes  the 
middle  finger  only.  The  deformity  may  generally  be  remedied  by  a  free 
division  of  the  fascia  and  tendon,  and  the  application  of  an  appropriate 
extending  apparatus. 

Knock-knee  is  a  most  troublesome  affection  as  it  is  usually  seen  in  out- 
patient hospital  practice;  for  the  ignorant  parents  of  such  children  have 
generally  gone  on  the  assumption,  which  is  so  easily  adopted  by  people 
who  are  I)oth  poor  and  busy,  that  "the  child  will  grow  out  of  it,"  and  have 
neglected  it  till  it  is  hardly  in  a  curable  condition.  No  doubt  children 
do  grow  out  of  knock-knee  to  a  certain  extent,  if  the  disease  is  only 
moderately  severe,  i.  e.,  the  limbs  as  they  strengthen  become  straighter, 
and  the  gait  so  firm  that  the  remaining  obliquity  is  not  noticed  through 
the  clothes.  But  some  obliquity  will  l)e  found  on  examination,  and  even 
this  partial  recovery  is  only  obtained  in  the  milder  cases.  When  the 
knees  have  become  very  oblique  further  standing  and  walking  tends 
rather  to  stretch  the  overstrained  ligaments  further  and  increase  the 
deformity  than  to  diminish  it  by  strengthening  the  muscles.  The  dis- 
ease consists  in  relaxation  of  the  ligaments  and  muscles,  whereby  the 
natural  pressure  of  the  lower  end  of  the  femur  inwards  acting  on  the 
weakened  internal  lateral  ligament  stretches  it.  Knock-knee  is  frecjuently 
combined  with  rickets,  and  during  the  softened  condition  of  the  bones 
their  articular  ends  may  become  much  altered  in  shape  by  pressure,  and 
thus  an  incurable  deformity  may  result.  The  ordinary  knock-knee  re- 
quires that  the  displaced  bones  should  l)e  drawn  outwards  by  means  of  a 
strap  or  elastic  spring,  which  is  fixed  to  a  rigid  upright  on  the  outside  of 
the  leg,  tills  upright  being  supported  by  a  pelvic  girdle,  and  being  let  into 
the  sole  of  a  strong  boot.     By  this  apparatus  the  knee  is  kept  fixed,  and 


WRYNECK.  515 

this  is  essential  for  a  time.  But  when  the  obliquity  has  been  corrected 
to  some  extent,  a  joint  is  introduced  into  the  upright,  and  the  child  is  per- 
mitted and  encouraged  to  use  tlie  flexor  and  extensor  muscles  of  the  leg. 
With  regard  to  rickety  deformities,  and  the  possibility  of  curing  them 
in  rare  cases  by  subcutaneous  or  otiier  section  of  the  bones,  I  must  refer 
to  page  457. 

Wryneck  is  a  common  deformity  in  children  from  spastic  contraction 
of  the  sternomastoid  muscle,  by  which  the  head  is  drawn  down  towards 
that  shoulder,  and  the  chin  turned  to  the  opposite  side ;  the  contracted 
muscle  stands  out  strongly  under  the  skin,  especially  when  its  action  is 
opposed  by  manipulation,  and  measurement  from  the  ear  to  the  sterno- 
clavicular joint  on  the  two  sides  will  at  once  show  the  extent  of  the  con- 
traction. Not  uncommonly  the  size  of  the  features  on  the  affected  side  is 
strikingly  less  than  on  the  opposite.  Cases  are  found  in  which  the  con- 
traction atfects  onl}'  the  clavicular  origin  of  the  muscle,  the  sternal  tendon 
being  natural ;  or  the  reverse  may  be  the  case  ;  but  it  is  more  common  for 
both  parts  to  be  implicated.  If  the  deformity  be  neglected  the  clavicle 
itself  may  yield  and  be  curved  upwards.  Tlie  deformity  is  no  doubt 
usually  due  to  congenital  causes,  though  it  is  often  not  noticed  till  some 
years  after  birth.  The  contraction  involves  other  muscles  of  the  neck 
also — the  trapezius,  scaleni,  and  others — but  to  a  less  extent;  and  the 
division  of  the  sternomastoid  enables  the  surgeon  to  rectify  the  position 
of  the  head.  No  milder  measure  has  succeeded  in  any  case  which  I  have 
seen,  but  it  is  said  that  slighter  cases  may  be  cured  by  manipulation  and 
by  instruments. 

Division  of  the  Sternomadoid. — The  operation  is  perfectly  free  from 
danger,  if  carefully  performed,  since  the  muscle  stands  out  well  from  tlie 
vessels  below  it,  whicii  are  again  separated  by  a  strong  membrane  ;  but  a 
careless  operator  might  possibly  hit  the  internal  jugular  vein,  especially 
in  trying  to  divide  the  whole  muscle  from  the  same  puncture.  It  is  safer, 
however,  to  make  a  different  puncture  for  each.  The  head  should  be  put 
well  on  the  stretch,  so  as  to  cause  the  muscle  to  stand  out  fairly,  and  the 
knife  should  be  entered  behind  the  clavicular  fibres  about  half  an  inch 
above  the  clavicle  and  passed  beneath  the  muscle.  Then  its  edge  is 
turned  towards  the  fibres,  and  they  are  divided  completely.  Then  the 
surgeon  deals  similarly  with  the  sternal  tendon.  This  plan  is  far  better 
in  my  opinion  than  that  of  dividing  the  muscle  from  above,  by  passing 
the  knife  between  the  skin  and  the  muscle  and  turning  its  edge  down- 
wards, which  is  recommended  by  some  surgeons.  After  the  operation 
the  head  can  be  considerably  raised  at  once  ;  but  it  is  well  to  leave  the 
patient  alone  for  a  few  days,  and  then  I  think  it  better  to  apply  an  in- 
strument consisting  of  a  frame  adapted  to  the  pelvis  and  shoulder,  with 
an  upright  along  the  spine,  terminating  above  in  a  padded  plate  which 
rests  on  the  back  of  the  head,  and  carries  two  arms,  which  are  fixed  on 
one  temple  and  on  the  opposite  side  of  the  chin,  so  as  to  have  a  firm  hold 
of  the  head.  The  upright  is  jointed  opposite  the  root  of  the  neck,  and 
is  provided  with  three  screws,  one  of  which  raises  the  chin  and  turns  it 
to  or  even  across  the  middle  line;  the  second  extends  the  cervical  spine, 
drawing  the  chin  away  from  the  sternum  ;  and  the  third  brings  the  head 
and  neck,  considered  as  a  whole,  into  the  proper  position  as  regards  the 
trunk. ^  Other  surgeons  trust  to  manipulations,  or  to  an  arrangement  of 
strapping  and  bandages,  to  restore  the  position  of  the  head;  but  I  con- 

*  A  flgui-e  of  this  apparatus,  which  I  have  found  most  efBcient,  will  be  found  in 
the  second  edition  of  my  work  on  the  Surgical  Treatment  of  Children's  Diseases, 
p.  666. 


516  ORTHOPEDIC    SURGERY. 

fess  that  I  think  the  use  of  an  apparatus  renders  success  much  more 
certain  and  the  treatment  less  troublesome.  Manipulation,  however, 
should  not  be  neglected.  It  may  be  practiced  twice  a  day,  when  the 
instrument  is  removed  for  the  purpose  of  washing.  Tiie  patient  is  seated 
on  the  floor,  between  the  knees  of  the  surgeon  or  attendant,  who  gently 
draws  the  head  into  the  desired  position.  And  when  the  chin  has  been 
got  into  a  position  somewhat  on  the  other  side  of  tiie  middle  line  from 
that  in  which  it  had  been  fixed,  and  has  been  kept  there  for  about  three 
weeks,  the  apparatus  may  be  gradually  disused  and  manipulation  con- 
tinued for  a  few  weeks  longer. 

The  ordinary  spasmodic  wryneck  is  not  to  be  confounded  with  wryneck 
from  disease  of  the  cervical  vertebrae.  In  such  cases  the  characteristic 
symptoms  of  disease  of  the  spine  will  be  found  on  careful  examination, 
and  no  operation  will  be  proposed.  There  are,  again,  cases  in  childhood 
in  which  wryneck  appears  to  depend  either  on  irritation  from  worms,  or 
on  some  mental  cause  difficult  to  detect,  but  somewhat  analogous  to 
adult  hysteria.  In  such  cases  the  contraction  is  not  permanent,  but  ap- 
pears and  disappears  from  time  to  time.  In  these  cases,  also,  no  opera- 
tion should  be  performed.  General  treatment,  with  manipulation,  or 
some  contrivance  to  fix  the  head  in  a  proper  position,  will  suffice.  The 
diagnosis  may  always  be  made  by  inducing  anaesthesia,  and  then  noting 
that  there  is  no  real  permanent  shortening  of  the  muscle.  Adults,  again, 
suffer,  though  rarel}',  from  a  very  obstinate  and  intractable  form  of  spas- 
modic wryneck,  somewhat  allied  to  paralysis  agitans,  in  which  generally 
the  other  muscles  of  the  neck  are  affected,  and  sometimes  the  trapezius 
as  much  as,  or  more  than,  the  sternomastoid,  drawing  the  head  down 
towards  the  shoulder,  liable  to  remissions  and  exacerbations,  evidently 
due  to  mental  causes  in  part,  and  varying  with  the  state  of  the  mind. 
The  disease  may  be  due  to  irritation  propagated  from  the  medulla  along 
the  spinal  accessorj'^  nerve ;  but  the  exciting  cause  of  this  irritation  is 
unknown.  In  one  case  Mr.  Campbell  De  Morgan  obtained  a  cure  by  re- 
moving a  part  of  the  external  branch  of  the  spinal  accessory  nerve,  and 
in  other  cases  benefit  has  followed  on  the  very  free  administration  of  the 
Succus  Conii,  as  recommended  by  Dr.  John  Harley ;'  but  the  disease 
usuall}^  defies  treatment. 

Emotional  and  Hynterical  Contractions. — Wryneck  is  often  also  purely 
hysterical,  and  these  cases  are  of  all  others  the  most  difficult  to  treat. 
They  are  often  also  difficult  of  diagnosis ;  but  the  ordinary  rules  which 
are  applicable  to  the  diagnosis  of  other  hysterical  disorders,  and  the 
results  of  an  examination  under  anaesthesia,  will  usually  settle  the  diag- 
nosis. But  they  will  often  be  most  rebellious  to  treatment ;  and  this, 
indeed,  is  true  also  of  all  other  forms  of  emotional  or  hysterical  contrac- 
tion. Operation  seems  to  aggravate  the  disease.  The  section  of  the 
sternomastoid  in  wryneck  has  been  promptly  followed  by  contraction  of 
the  opposite  muscle.  Forcible  extension  of  an  elbow,  the  seat  of  hyster- 
ical contraction,  has  l>een  tlie  starting-point  of  nervous  disorders  which 
have  been  held  to  justify  amputation,  leaving  the  patient  still  uncured; 
and  other  similar  instances  might  be  quoted.  As  in  other  nervous  dis- 
orders, the  less  active  the  surgeon  is  the  better.  It  may  sometimes  be 
advisable  to  put  the  parts  in  a  natural  position  under  anaesthesia  and  fix 
them  so,  and  thus  give  the  patient  an  irrefragable  proof  that  the  deformity 
is  not  incura!)le.  But  the  chief  reliance  must  be  placed  in  medical  and 
general  treatment,  with  manipulation  and  calisthenic  exercises  when  they 
are  indicated. 

^  Med.-Chir.  Trans.,  vol.  Ivii. 


INJURIES    OF    NERVES.  517 


CHAPTEE    XXVII. 

AFFECTIONS  OF  NERVES. 

Wounds  of  nerves  occur,  of  course,  from  injuries  of  all  kinds,  but  are 
peculiarly  common  in  gunshot  wounds.  They  never  occur  uncompli- 
cated, but  in  some  cases  the  wound  of  the  nerve  is  the  chief  feature  in 
the  injury.  The  symptoms  of  wound  of  a  nerve  vary  according  as  the 
nerve  is  sensory,  muscular,  or  mixed,  and  as  the  wound  is  partial  or 
complete.  Complete  division  of  a  large  mixed  nerve  (of  which  the  most 
familiar  example  is  the  ulnar  or  median,  at  the  wrist)  produces  total  loss 
of  the  function  of  the  muscles  supplied  from  below  the  point  of  division, 
and  loss  of  sensation  in  the  part  corresponding  to  its  distribution,  to- 
gether with  a  sensible  loss  of  temperature  in  the  limb  below,  and  loss  of 
nutrition,  sometimes  leading  to  low  eruptions  on  the  skin.'  Division  of 
a  purely  muscular  nerve,  such  as  the  portio  dura,  is  usually  accompanied 
only  by  muscular  parahsis  ;  at  least  as  far  as  is  known,  for  thermometric 
observations  in  such  cases  are  difficult  and  uncertain.  Division  of  sym- 
pathetic trunks  is  known  to  be  accompanied  by  dilatation  of  the  capillaries 
and  increased  heat  of  the  parts,  from  experiments  on  animals ;  but  in 
man  such  lesions  could  only  form  subordinate  features  in  complicated 
injuries.  The  anatomical  phenomena  of  wounds  of  nerves  and  of  their 
repair  is  thus  described  by  Dr.  Lockhart  Clarke  :  "  Both  portions  of  the 
divided  nerve  retract  a  little,  and  their  extremities,  especially  the  upper 
one,  enlarge  and  become  more  vascular,  while  coagulable  lymph  exudes 
around  and  between  them.  In  a  short  time  this  exudation  becomes 
gradually  firmer,  and  is  found  to  contain  cells  and  nuclei,  and  then  fine 
nerve-fibres,  which  proceed  from  the  extremity  of  the  central  portion  of 
the  nerve  to  that  of  the  peripheral  portion,  which,  on  being  separated 
from  its  nervous  centre,  undergoes  a  gradual  atrophy  or  degeneration. 
These  newly  formed  fibres  are  finer  and  grayer  than  those  of  the  central 
portion  of  the  divided  nerve,  and  it  is  not  till  after  a  period  of  some 
months  that  they  become  fully  developed.  In  the  meantime  a  regenera- 
tion of  fine  fibres  is  going  on  in  the  peripheral  or  atrophied  portion  of 
the  nerve  ;  but  it  is  a  long  time  before  these  fibres  acquire  the  normal 
size  and  appearance.  The  same  kind  of  reparative  [)rocess  takes  place 
when  a  portion  of  a  nerve  has  been  excised,  only  it  occupies  a  longer 
period."-  The  remote  consequences  of  wounds  of  nerves  are  very 
various.  I  have  seen  a  case  in  which  the  total  division  of  the  musculo- 
spiral  nerve— evidenced  by  complete  loss  of  sensation  in  the  parts  sup- 
l>lied  by  the  radial  and  by  loss  of  power  in  all  the  extensor  muscles  of 
the  limb — was  followed  after  the  lapse  of  some  months  by  gradual,  but 
ultimately  complete,  recovery  of  all  the  functions  of  the  nerve.  Mr. 
Syme  has  put  on  record  a  case  in  which  the  ulnar  nerve  was  divided  in 
an  excision  of  the  elbow,  and  in  which  the  functions  of  the  nerve  were 
also  regained  ;  and  here,  on  dissecting  the  parts  some  years  afterwards, 
the  ends  of  the  divided  nerve  were  found  united  by  a  kind  of  splint  or 

1  See  a  paper  by  Mr.  Jonathan  Hutchinson  on  Injuries  of  Nerve-trunks.   (Lon- 
don Hosp.  Reports,  vol.  iii,  p.  321.) 

2  Syst.  of  Surg.,  vol.  iv,  p.  103,  2d  ed. 


518  AFFECTIONS    OF    NERVES. 

ferrule  of  fibrous  tissue  (exactly  as  fracture  is  united  by  provisional  callus)/ 
inside  which  the  ends  themselves  seemed  to  be  ununited,  though  in  con- 
tact. But  in  other  cases  there  seems  no  doubt  that  a  permanent  irrita- 
tion is  generated  in  the  substance  of  the  wounded  nerve,  which  is  re- 
flected down  other  nerves,  originating  from  the  same  part  of  the  cerebro- 
spinal centre,  and  that  thus  the  whole  limb  may  ultimately  become  more 
or  less  paralyzed.*  There  are  numerous  other  reflex  symptoms  produced 
by  injuries  to  the  nerves,  but  they  are  too  miscellaneous  and  too  rare  to 
make  it  worth  while  to  summarize  them  here,  and  in  most  of  the  recorded 
cases  the  real  s3-mptoms  have  doubtless  been  mixed  with  many  which 
were  of  an  hysterical  character.  I  would  refer  the  reader  to  an  interest- 
ing article  by  Dr.  Brown-Sequard  and  Dr.  Lockhart  Clarke,  in  the  fourth 
volume  of  the  System  of  Siir-gery,  2d  edition.  Partial  division  of  nerves, 
or  their  permanent  irritation  by  the  lodgment  of  a  foreign  body,  or  a 
ligature,  is  liable  to  produce  symptoms  even  more  formidable  than  those 
caused  by  their  complete  division,  though  essentially  of  the  same  char- 
acter. Tlie  abiding  irritation  which  sometimes  ensues  on  the  implication 
of  a  divided  nerve  in  a  cicatrix  is  of  the  same  nature.  A  common  ex- 
ample of  it  is  the  irritation  and  jerking  which  occasionally  attacks  the 
stump  of  an  amputation.  Sometimes  the  nerve  is  compressed  by  the 
formation  of  callus  around  a  fracture. 

The  symptoms  caused  by  injury  to  a  nerve  must  be  treated  according 
to  their  gravity.  Since  there  can  be  no  doubt  that  many  of  the  worst 
symptoms  depend  on  some  constant  irritation,  the  result  of  partial  divi- 
sion, the  lodgment  of  a  foreign  substance,  or  the  implication  of  one  or 
more  nerves  in  the  cicatrix,  it  is  right  in  such  cases  to  cut  down  on  the 
nerves  which  seem  implicated,  and  either  divide  them  completely  or 
remove  a  portion  of  tliem.  In  cases  depending  on  lesion  of  one  of  the 
digital  nerves  it  may  often  be  better  to  sacrifice  the  finger,  and  in  painful 
stumps  to  reamputate,  taking  care  to  cut  all  the  large  nerve-trunks  so 
short  that  they  cannot  be  implicated  in  the  scar. 

But  in  slighter  cases  the  symptoms  will  probably  subside  by  galvanism 
of  the  aff'ected  nerve,  sedulously  employed,  blisters,  the  application  of 
belladonna  in  ointment,  and  the  hypodermic  injection  of  morphia,  if  there 
is  much  pain,  with  careful  attention  to  the  general  health. 

In  all  recent  wounds,  in  which  large  nerves  are  divided,  great  care 
should  be  taken  to  put  their  extremities  into  accurate  apposition,  and  it 
may  be  right  to  pass  a  silver  or  gut  suture  through  the  soft  parts  around 
or  tlie  sheath  of  the  nerve,  so  as  to  keep  them  in  accurate  contact. 

Besides  the  direct  and  remote  consequences  of  wounds,  there  are  a  few 
other  affections  of  nerves  which  are  occasionally  met  with,  though  as  a 
rule  the  symptoms  which  are  caused  by  lesions  of  nerves  are  only  some- 
what subordinate  features  of  surgical  diseases  and  injuries. 

Neuralgia,  in  its  strict  sense — i.e.,  pain  referred  to  the  course  and  dis- 
tribution of  some  one  or  more  of  the  sensory  nerves — is  a  disease  which 
is  almost  always  periodic  in  its  attacks,  and  bears  a  strong  resemblance 
to  ague  in  its  course,  causation,  and  cure,  and  falls  more  especially  under 
the  care  of  the  physician.  Still  surgeons  are  so  often  consulted  about  it, 
and  an  accurate  diagnosis  of  many  surgical  affections  depends  so  much 
on  a  knowledge  of  the  i)henomena  of  true  neuralgia,  that  I  must  say  a 
few  words  about  it.     The  word  neuralgia  is  used  loosel}'  to  describe  any 

1  See  a  case  related  by  Mr.  Cullender,  in  Path.  Trans.,  vol.  xv,  p.  180,  in  which 
the  ulnar  nerve  seems  to  have  been  divided  in  excision  of  the  elbow,  and  where  the 
whole  limb  became  paralyzed. 


NEUROTOMY.  519 

gainful  affection  for  which  no  anatomical  or  organic  cause  is  known,  and 
there  is  no  objection  to  this  use  of  the  word  if  some  otlier  term  were  nsed 
to  distinguish  the  cases  wliich  are  of  hysterical,  dyspeptic,  mental,  or 
obscure  origin  from  the  truly  neuralgic— ?'.e.,  those  in  which  tliere  is  dis- 
tinct evidence  of  an  affection  limited  to  a  precise  nerve,  and  dependent, 
we  cannot  doubt,  on  some  anatomical  disturbance  of  its  tissue,  though 
this  may  be  transient  and  imperceptible  to  our  senses. 

The  phenomena  of  true  neuralgia  are  best  studied  in  the  familiar  affec- 
tion known  as  tic,  or  brow  ague,  which  follows  the  course  of  the  supra- 
orbital branch  of  the  fifth  nerve.  This  commences  very  commonly  b}'  an 
increased  afflux  of  blood,  the  pulsation  in  the  little  artery  which  accom- 
panies the  nerve  becoming  plainly  perceptible  to  the  sight  and  touch  as 
the  pain  is  coming  on.  Then  tlie  neighborhood  of  the  nerve  becomes 
very  tender  to  the  touch,  and  this  is  followed  by  pain,  often  agonizing, 
extending  along  tlie  ramifications  of  the  nerve.  In  other  cases  all  the 
branches  of  this  or  one  of  the  other  divisions  of  the  fifth,  or  even  all  the 
branches  of  the  trifacial  nerve  are  similarly  affected,  producing  in  the 
latter  case  what  is  called  hemicrania.  It  would  be  beside  my  purpose  to 
speculate  on  the  cause  of  this  affection,  or  to  spend  any  time  on  discuss- 
ing its  treatment.  I  merely  wish  here  to  direct  the  reader's  attention  to 
it  as  illustrating  an  affection  of  tlie  nerves  quite  unconnected  with  in- 
flammation, for  the  symptoms,  intolerably  severe  at  one  minute,  may  have 
entirely  disappeared  at  another,  and  also,  for  the  same  reason,  not  due 
to  any  abiding  irritation  in  the  course  of  the  nerve.  I  may,  however, 
add  that  the  cure  of  this  disorder  must  be  sought  in  the  discovery  and 
removal  of  its  cause,  in  the  amendment  of  any  disorder  of  the  general 
health,  and  in  cases  where  no  cause  can  be  ascertained,  in  the  adminis- 
tration of  antiperiodic  remedies,  as  quinine  and  arsenic,  with  free  purga- 
tion, and  the  local  application  of  aconite,  or  the  subcutaneous  injection 
of  morphia,  or  morphia  and  atropine,  before  the  paroxysm.  It  is  curious, 
and  is  valuable  as  a  diagnostic  sign,  that  though  the  parts  near  the 
affected  nerve  may  be  excessively  tender  to  the  touch,  yet  firm  pressure 
will  generally  relieve  the  pain,  and  patients  with  lirow  ague  often  learn 
to  give  themselves  some  relief  by  pressing  the  finger  firmly  into  the  supra- 
orbital notch. 

Many,  however,  of  the  cases  classed  as  true  neuralgia  are  really  not 
periodic,  but  permanent  affections,  due  to  the  implication  of  the  nerve  in 
inflammation  of  the  bone  in  or  near  which  it  lies,  or  to  its  inflammation 
from  some  other  cause,  or  to  its  being  involved  in  cancerous  or  other 
ulceration,  or  compressed  by  a  tumor.  But  in  all  these  cases  the  symp- 
toms are  persistent  and  continuous,  though  not  therefore  necessarily  equal 
in  severity  at  all  times.  In  other  cases,  from  some  irritation  applied  to 
the  motor  nerves,  or  to  the  part  of  the  nervous  centre  with  which  they 
are  connected,  strange  convulsive  movements  are  produced.  Spasmodic 
wryneck  is  the  best  known  of  these  affections,  and  it  manifests  itself  as 
an  affection  of  the  trapezius  or  sternoinastoid  and  trapezius,  which  is  often 
propagated  to  the  other  muscles  of  the  neck  and  head,  jerking  the  head 
about  in  various  directions.  From  this  origin  the  affection  may  be  re- 
flected to  the  nerves  of  the  cervical  or  also  of  the  brachial  plexus,  causing 
neuralgic  pains  in  the  course  of  their  sensitive  branches,  with  possibly 
some  affection  also  of  the  motor  nerves. 

Neurotomy. — In  all  cases  of  obstinate  neuralgia,  or  of  obstinate  spasm, 
the  question  will  ultimately  occur  whether  any  relief  can  be  given  by 
surgical  operation,  and  if  so,  whether  the  s3MBptoms  are  severe  enough 
to  warrant  the  attempt.     I  say  this  question  occurs  ultimately^  for  it  is 


520 


AFFECTIONS    OF    XERVES. 


Fig.  229. 


not  until  all  known  medical  treatment  has  failed  that  the  division  of  the 
aflected  nerve  ought  ever  to  be  tried,  except  in  cases  where  the  pain 
obviously  depends  on  some  irritation  which  cannot  be  removed  applied 
to  a  definite  part  of  the  trunk.  In  such  a  case  it  ma}^  fairly  be  expected 
that  the  division  of  the  trunk  above  this  part  will  relieve  the  symptoms. 
When  the  cause  of  neuralgia  is  central  or  is  unknown  the  operation  is 
far  less  promising,  though  under  proper  circumstances  it  is  quite  right 

to  give  it  a  trial.  There  are  two 
methods  of  dividing  a  nerve ; — 
one — which  is  the  less  formidable 
as  an  operation — is  to  make  a  sub- 
cutaneous puncture,  or  a  small 
incision  down  to  the  bone  in  the 
known  course  of  the  nerve,  by 
which  the  trunk  is  divided  along 
with  the  parts  in  relation  with  it. 
But  this  is  much  less  satisfactory 
than  the  other,  both  because  the 
operator  maj'  after  all  miss  the 
nerve,  and  because  the  latter  may 
soon  reunite  and  the  symptoms 
recur.  The  more  effectual  method 
is  to  expose  the  nerve  by  a  regu- 
lar disection,  and  remove  a  piece 
about  half  an  inch  long.^ 

Neuroma. — Tumors  are  some- 
times painful  from  their  pressure 
on  nerves,  and  in  some  of  the 
"painful  subcutaneous  tumors," 
as  the}^  are  called,  a  definite  nerve 
has  been  found  implicated  in  the 
tumor.  At  other  times,  however, 
there  has  been  no  such  explana- 
tion of  the  pain,  which  is  tiien  to 
be  regarded  as  "  hysterical."  Like 
other  forms  of  hysteria,  this  pain 
in  simple,  fibrous,  or  fatt}^  tumors 
generally  occurs  in  women. 

But  tliere  are  tumors  formed  in 
the  substance  of  nerves,  and  called 
on  that  account  neuromata,  of 
which  a  remarkable  example  is 
depicted  here  (Fig.  229).  They 
are  of  a  fibrous  or  fibro-cellular 


Neuroma.  A  large  oval  tumor,  six  inches  long  by 
four  wide,  implicating  the  sciatic  nerve  and  its  pos- 
terior tibial  branch.  The  surface  of  the  tumor  is  nodu- 
lated. It  is  liollow,  presenting  a  large  central  cavity, 
with  soft  shreildy  walls.  The  trunk  of  the  nerve,  a,  is 
seen  passing  into  tlie  tumor  above  and  emerging  be- 
low at  a  point  below  the  popliteal  space.  Various  fila- 
ments are  represented  spread  out  on  the  walls  of  the 
tumor,  6  b,  and  many  other  nerves  can  be  detected  by 
examination  in  the  central  cavity.  For  about  one 
and  a  half  inches  above  the  tumor  the  nerve  is  much 


thickened  and  indurated.  All  that  is  known  of  the 
history  i.s  that  the  limb  was  amputated.  The  chief  StrUC!,Ure,  grOW  generally  slowlj^, 
massof  the  tumor  was  found  ou  microscopical  exami-  aj,(|  ^re  ofteu  the  SCat  of  Vei*y 
nation  to  consist  of  fibrous  tissue,  of  various  consis- 
tence, granular  aiuorplious  material,  round  and  oval 
cells  of  the  si/e  of  pus-gloliules  for  the  most  part, 
elongating  fibre-cells,  and  remnants  of  nerve-tubes. — 
From  a  specimen,  Ser.  viii.  No.  172,  in  St.  George's 
Hospital  Museum,  described  in  vol.  iv  of  Beale's 
Archives. 


acute  pain.  The  fibres  of  the 
nerve  will  be  found  spread  out 
over  them  and  imbedded  in  their 
substance.  They  are  incurable 
except    by    removal ;    and    when 


'  Some  int'ire.stintj  and  typical  ca.sos  of  noiu-otomy  in  puinful  affections  of  the  limbs 
will  b('  found  rolatisd  by  .Mr.  Rfidfern  Davies,  in  the  Dublin  C^uiirtorly  Journal  of 
Medical  Science,  November,  1800. 


DISEASES    OF    THE    ARTERIES.  521 

such  removal  would  involve  the  destruction  of  the  main  nerve  of  the 
limb  and  its  consequent  paralysis,  amputation  becomes  necessar}-. 


CHAPTER   XXVIII. 

DISEASES    OF    THE    ARTERIES. 

Atheroma  and  Calcification.  —  The  degenerative  changes  which  are 
found  in  the  arteries  appear  under  two  chief  forms,  viz.,  atheroma,  a 
softening,  pulpy  change,  akin  to  fatty  degeneration  ;  and  calcification, 
or  so-called  ossification,  in  which  the  arterial  tube  becomes  rigid  and 
brittle.  The  latter,  however,  is  a  late  stage  or  consequence  of  the  former. 
In  atheroma  the  internal  and  middle  coats  of  the  artery  are  found  thick- 
ened by  a  material  which  is  variously  regarded  by  different  authors  as 
the  result  of  chronic  inflammation  affecting  the  middle  coat,  and  so  push- 
ing the  internal  coat  inwards  and  afterwards  invading  it ;  or  as  deposited 
on  the  internal  surface  of  the  artery'  from  the  circulating  blood,  and  then 
giving  rise  to  fatty  degeneration.  The  former  view  of  the  inflammatory 
nature  of  atheroma  is  maintained  with  great  ability  by  Dr.  Moxon,'  and 
is  the  one  which  certainly  appears  to  me  the  more  probable  and  the  more 
consistent  with  the  phenomena  of  the  disease.  The  latter,  however,  rests 
on  the  great  authority  of  Gulliver,^  and  is  the  view  usually  adopted. 

However  originating,  the  disease  soon  causes  visible  opaque  patches 
of  a  yellow  color,  and  thicker  on  section  than  the  neighboring  portions 
of  the  internal  coats.  In  these  patches  there  are  found  on  microscopic 
examination  oil-globules,  cholesterin,  and  the  degenerated  tissue  of  the 
internal  coat  of  the  vessel,  besides  cell  formations  which  are  described 
by  Rindfleisch,  Moxon,  and  others  as  inflammatory. 

The  progress  of  atheroma  is  in  one  of  three  directions:  1.  The  ather- 
omatous patch  may  soften  into  matter  somewhat  resembling  pus,  which 
passes  into  the  tube  of  the  artery,  leaving  a  small  cavit}' — the  atheroma- 
tous ulcer — in  the  internal  coat  and  inner  part  of  the  middle  coat.  The 
vessel  at  such  a  spot  is  much  weakened,  and  may  give  way  either  totally 
and  at  once  or  partially  and  gradually,  so  as  to  form  an  aneurism.  This 
softening  is  regarded  as  the  acutest  form  of  the  inflammation  which  has 
produced  the  disease.  2.  The  athei'omatous  matter  may  become  organized 
into  a  low  form  of  fibrous  tissue,  with  wliicli  fatty  matter  is  mingled,  until 
the  coats  of  the  vessel  become  "opaque,  dull,  and  condensed  into  a 
material  similar  to  hardened  albumen  and  eventually  to  ligament" 
(Moore).  In  this  change  also,  I  believe,  aneurism  often  finds  its  com- 
mencement, the  difference  in  elasticity  at  the  points  where  the  healthy 
and  diseased  parts  of  the  vessel  join  predisposing  it  to  give  way  at  that 
part.  3.  The  salts  of  lime  are  deposited  in  the  atheromatous  matter  by 
a  still  more  chronic  process  ;  and  then  sometimes  the  whole  vessel  is 
graduallj'  involved  in  this  calcareous  degeneration,  so  that  it  becomes  a 

1  On  the  Nature  of  Atheroma  in  the  Arteries,  from  Guy's  Hospital  Reports. 

2  Med.-Chir.  Trans.,  vol.  xxvi. 


522  DISEASES    OF    THE    ARTERIES. 

perfectly  brittle  and  rigid  tube,  incapable  of  either  contraction  or  dilata- 
tion, or  of  any  change  in  length.  Such  arteries  may,  of  course,  be  rup- 
tured by  any  slight  force,  and  they  are  quite  incapable  of  [)erforming  one 
of  the  chief  functions  of  arteries, — that  of  regulating  tlie  blood-supply 
according  to  the  demand.  Hence  the  frequent  occurrence  of  gangrene 
in  such  cases.  This  process  of  calcification  is  popularly  denominated 
ossification  of  arteries  ;  but  there  is  no  proof  that  true  bone  is  ever  found 
in  such  a  patcii,  though  a  certain  resemblance  to  bone-cells  has  been 
thought  to  be  discovered  in  the  calcareous  deposit. 

Sometimes  in  extensive  calcification  of  the  aorta  the  blood  makes  a  way 
between  the  internal  rigid  and  the  external  elastic  portion  of  the  artery, 
i.  e.,  either  between  the  external  and  middle  coats  or  (as  Dr.  Peacock  has 
shown  to  be  almost  always  the  case)  between  the  layers  of  the  middle 
coat,  and  distends  the  outer  part  of  the  artery  into  what  is  known  as  a 
"dissecting  aneurism  "  (Fig.  234,  p.  525). 

Both  atheroma  and  calcification  are  frequent  causes  of  secondary 
haemorrhage  after  surgical  operation,  the  latter  more  especiall}^ ;  in  fact, 
the  arteries  are  sometimes  found  so  "ossified"  in  amputations  performed 
on  aged  people  that  they  break  off  when  an  attempt  is  made  to  tie  them. 
In  such  extreme  cases  of  calcification  the  ligature  must  be  used  very 
gently,  and  onl^^  tied  just  tight  enough  to  command  the  bleeding ;  or 
what  is,  I  think,  safer,  acupressure  may  be  employed.  But  secondary 
hfemorrhage  is  almost  sure  to  ensue.  Atheromatous  arteries  also  are  very 
liable  to  secondary  hoemorrhage,  being  already  badly  nourished,  and  more 
prone  to  degeneration  than  to  repair.  I  have  shown  from  the  records  of 
St.  George's  Hospital  that,  judging  from  the  result  of  fata-1  cases  only, 
it  would  seem  that  secondary  htiemorrhage  is  almost  always  due  to  disease 
of  the  arteries.     (St.  George''s  Hoi<pilal  Reports.,  vol.  i,  p.  319.) 

Calcification  is  a  disease  which  is  almost  confined  to  advanced  life,  but 
it  has  been  found  in  younger  subjects  also.  Mr.  Moore  calls  attention  to 
the  fact  that  it  is  not  found  in  the  pulmonary  artery  or  in  any  part  of  the 
venous  system,  in  support  of  the  view  which  he  holds  that  the  disease 
commences  on  the  internal  surface  of  the  vessel  as  a  deposit  out  of  the 
arterial  blood. 

Atheroma  has  been  found  to  occur  very  commonly  in  soldiers,  and  in 
persons  who  are  in  the  habit  of  indulging  in  alcohol;  and  it  is  believed 
by  many  pathologists  to  be  a  frequent  result  of  syphilis,  the  deposit  in 
this  syphilitic  variety  of  atheroma  being  of  the  fibroid  texture.  1  cannot 
profess  myself  quite  satisfied  of  the  reality  of  the  connection  which  has 
been  thus  assumed  between  two  such  common  affections  as  syphilis  and 
atheroma;  but  the  connection  between  atheroma  and  spirit-drinking 
seems  more  certain.  We  should  not  forget,  however,  that  arterial  disease 
attacks  persons  also  of  the  must  regular  habits  of  life,  and  is  not  unknown 
in  tiie  lower  animals.  The  signs  of  this  affection  are  wholl}'  unknown. 
Persistent  pains,  reputed  rheumatic,  often  turn  out  to  be  due  to  disease 
of  arteries,  and  a  high  degree  of  arcus  senilis  in  the  cornea,  especially  if 
the  patient  is  not  in  advanced  age,  gives  reason  for  suspecting  atheroma; 
but  the  suspicion  is  often  refuted  l)y  dissection.  Advanced  calcification 
often  renders  the  arteries  so  hard  that  their  condition  is  i)lainl3'  percepti- 
ble to  the  touch  in  any  superficial  vessel. 

Occlusio))  and  Emholi^^m. — Arteries  may  be  occluded  by  the  pressure 
of  tumors,  though  the  main  arteries  have  a  wonderful  power  of  escaping 
and  resisting  pressure;  but  the  usual  cause  of  obliteration  of  an  artery — 
at  least  of  a  large  one — is  embolism^  i.  e.,  the   impaction  of  a  clot.     This 


ANEURISM.  523 

generally  occurs  at  or  near  the  bifurcation,  or  giving  off  of  some  large 
branch.'  The  clot  is  generally  formed  on  a  nucleus  of  fibrin  which  is 
brought  down  to  the  part  from  a  diseased  endocardium,  being  washed  off 
the  surface  of  the  heart  or  one  of  its  valves,  as  long  ago  pointed  out  by 
the  late  Dr.  Kirkes;'"  but  clots  formed  in  aneurisms  or  diseased  arteries, 
or  even  in  the  veins,  may  prove  the  starting-point  of  einl)olism.''  This 
plug  of  fibrin  being  detained  in  the  artery  attracts  more  fibrin  to  itself 
(just  as  fibrin  is  whipped  out  of  the  blood  in  a  basin)  till  the  whole  tube 
of  the  artery  is  ol)literated.  The  obliteration  is  sometimes  accompanied 
with  a  good  deal  of  pain.  The  pulse  below  is,  of  course,  lost,  and  some- 
times the  limb  becomes  gangrenous.  A  similar  result  usuall_y  occurs  in 
the  brain,  where  the  softening  which  so  constantly  ensues  after  embolism 
of  the  cerebral  arteries  may  be  looked  on  as  a  form  of  gangrene. 

The  occurrence  of  embolism  can  often  be  diagnosed.  In  the  case 
figured  on  p.  79  the  symptoms  were  unmistakable,  and  the  seat  of  lodg- 
ment of  the  clot  could  be  exactly  defined.  But  as  a  general  rule  nothing 
can  be  done,  since  the  heart  disease  forbids  any  surgical  treatment; 
otherwise  there  is  no  more  reason  why  a  limb  should  not  be  amputated  for 
embolism  than  after  the  ligature  of  an  artery. 

Embolic  clots  when  lodging  in  diseased  arteries  (and  even  perhaps 
sometimes  in  sound  ones)  ma}'  form  the  starting-point  of  aneurism,  the 
vessel  dilating  behind  the  obstruction.* 

Arteritis. — Formerly  elaborate  descriptions  were  given  of  the  appear- 
ance of  arteries  when  in  a  state  of  acute  inflammation,  and  there  are 
doubtless  cases — very  rare  ones — in  which  long  tracts  of  artery,  some- 
times the  whole  of  the  main  arteries  of  a  limb,  have  been  found  filled  with 
fibrin  and  obliterated.  Such  cases  are  classed  as  instances  of  arteritis, 
and  they  may  be  so.  It  is,  at  any  rate,  diflflcult  to  understand  them  in 
any  other  wa3\  But  the  descriptions  of  arteries  acutely  inflamed,  with 
red  lining  membrane,  etc.,  were  no  doubt  mistakes,  caused  by  confound- 
ing post-mortem  staining  with  inflammatory  injection.  Little  is  known 
of  acute  arteritis  pathologically,  and  surgically  it  can  hardly  be  said  to 
have  any  importance. 

Aneurism. — The  term  aneurism  means  a  tumor  formed  by  the  enlarge- 
ment of  an  artery.  If,  therefore,  the  word  be  correctly  used,  there  must 
be  in  every  aneurism  an  investing  membrane,  or  sac,  which  communi- 
cates with  the  cavity  of  the  artery,  and  which  contains  blood,  either  fluid 
or  coagulated.  This  investing  membrane  may  be  formed  either  by  all 
the  coats  of  the  vessel  or  by  only  one  or  two  of  them,  or  by  the  cellular 
tissue  external  to  the  artery,  and  the  classification  of  the  tumors  is  by 
many  authors  based  on  this  circumstance.  By  others  aneurisms  are 
divided  according  to  their  shape  and  the  nature  of  the  communication 
between  the  sac  and  the  artery.  Unfortunately  for  the  intelligiltilit}^  of 
the  subject,  the  term  aneurism  is  often  applied  to  an  affection  in  which 
there  is  no  sac,  and,  in  the  proper  sense  of  the  word,  no  tumor,  i.  e.,  to  a 
subcutaneous  rupture  of  an  artery  leading  to  the  effusion  of  blood  into  the 

1  See  Fig.  11,  p.  79. 

2  Mcd.-Chir.  Trans.,  vol.  xxxv. 

'  Some  years  ago  a  patient  was  operated  on  for  the  radical  cure  of  hernia.  In  pass- 
ing one  of  the  ligatures  the  operator  had  the  misfortune  to  perforate  the  external  iliac 
vein,  without  being  aware  of  it.  The  ligature  was  left  in  the  cavitj'  of  the  vein,  and 
caused  coagulation  of  the  blood.  The  patient  died  of  apoplexy,  which  was  found  to 
have  bcf^n  produced  by  one  of  the  clots  which  had  passed  through  the  heart  and 
lodged  in  an  artery  in  the  brain. 

*  Syst.  of  Surg.,  2d  ed.,  vol.  iii,  p.  421. 


524  .  DISEASES    OF    THE    ARTERIES. 

cellular  tissue.  This  is  what  is  often  intended  by  a  ^'•diffused  aneurism  " 
— a  terra  which  in  that  sense  should,  I  think,  be  disused,  since  both  the 
pathology  and  treatment  of  such  an  atFection  ditfer  entirely  from  those  of 
common  aneurism.' 

Causes. — The  causes  of  aneurism  are  to  be  sought  in  anything  which 
disturbs  the  balance  of  the  circulation,  so  as  to  cause  the  wall  of  the 
arterv  to  become  unfit  to  resist  the  heart's  action.  Thus-  the  artery  be- 
comes degenerated  by  atheroma,  and  tlie  atheromatous  portion  gives  way. 
Sometimes  all  the  coats  give  w-ay,  so  that  the  artery  bursts ;  more  usually 
the  external  coat  remains  entire  and  becomes  expanded  over  the  blood. 
Such  commencing  dilatations  are  constantly  seen  in  atheromatous  aortfe. 
At  first  the  atheromatous  patch  shares  in  the  expansion,  and  the  aneu- 
rismal  pouch  is  then  formed  by  all  three  coats  of  the  vessel  (Fig.  230). 
Soon  the  two  internal  coats  are  worn  away,  and  on  dissection  it  will  be 
found  that  the}'  can  only  be  followed  a  short  distance  from  the  mouth  of 
the  sac,  which  is  then  formed  by  the  external  coat  only  (Fig.  231).  It 
appears  certain,  also,  that  chronic  inflammation  may  so  soften  the  struc- 
ture of  the  middle  coat  of  the  vessel  that  it  is  incapable  of  resisting  the 
usual  force  of  the  circulation.^  Such  chronic  inflammation  is  believed  by 
many  pathologists  to  be  a  frequent  consequence  of  syphilis,  and  the  prev- 
alence of  aneurism  among  soldiers  is  thus  accounted  for.  And  again,  it 
seems  certain  that  the  alnise  of  alcohol  is  a  predisposing  cause  of  aneu- 
rism, though  whether  it  acts  by  producing  arterial  degeneration  or  by 
irritating  the  heart,  and  exciting  it  to  increased  action,  is  not  clear.  It 
seems  also  certain  that  habitual  strain  on  the  heart  may  act  in  the  same 
wa}- ;  and  the  use  of  the  old  stock  and  of  the  knapsack  in  the  army,  in- 
ducing a  strain  on  all  the  respiratory  and  circulating  organs,  is  by  many 
arm}"  surgeons  considered  to  have  been  even  a  more  potent  cause  of  an- 
eurism of  the  aorta  than  either  syphilis  or  alcohol.  Violence,  again, 
leading  to  a  partial  rupture  of  the  arter}^  is  an  undoubted  cause  of  an- 
eurism. This  is  well  illustrated  by  an  experiment  of  Kicherand,  which 
I  have  often  repeated.  In  the  dead  subject,  after  the  rigor  mortis  has 
been  completely  overcome  b}^  passive  motion,  let  the  knee  be  forcibly 
overextended  till  the  ligaments  are  heard  to  crack.  The  two  inner  coats 
of  the  popliteal  artery  will  often  Ije  found  ruptured.  And  there  can  be 
no  doubt  that  something  of  the  kind  often  occurs  in  those  sprains  of  the 
knee  whicli  are  so  frequently  assigned  as  the  cause  of  popliteal  aneurism. 
It  is  a  known  fact  that  sprains  and  blows  are  frequently  followed  b}'  an- 
eurism of  all  kinds,  and  it  is  a  frequent  observation  that  sailors  are  liable 
to  axillary  and  sul)clavian  aneurism,  from  the  sprains  and  injuries  of  the 
upper  extremit}'  incidental  to  their  calling,  in  a  proportion  wliich  as 
much  exceeds  the  average  as  does  the  predisposition  of  soldiers  to  aortic 
aneurism.  Finally,  the  direct  wound  of  an  artery  leads  to  aneurism 
(which  on  tl)at  account  is  called  traumatic),  by  causing  an  extravasation 
of  blood  into  tiie  surrounding  tissues,  whicli  become  limited  and  encap- 
suled  by  the  areolar  meml)rane,  muscles,  etc.,  whicli  form  the  sac,  the 
coats  of  the  artery  being  traceable  only  a  very  little  distance  into  the 
moutli  of  the  sac  (Fig.  233).  It  i"  well  to  keep  these  facts  in  view  in 
examining  a  case  of  aneurism,  since  the  causes  vvliich  act  by  producing 
general  arterial  degeneration  otier  less  prospect  of  the  success  of  local 
measures  than  those  which  are  more  localized ;  while  the  purely  trau- 


'  If  by  "'cliffusr-d  "  aneurism  be  meant  an  uneurit^m  which  has  burst  and  poured 
out  its  c(int<'nt.s  into  the  neighboring  ])art«,  it  wmiid  .surely  be  better  to  put  this  into 
common  and  unmistakable  English  by  calling  it  a  ruptured  aneurism,  as  it  is. 

'  See  Moxon,  op.  cit. 


DIAGRAMS    or    VARIOUS    KINDS    OF    ANEURISM. 


525 


Fig.  231. 


Fig.  230. — True  aneurism  ;  the  sac  formed  by  all  the  coats. 

Fig.  231. — "  False  "  aneurism ;  the  sac  formed  by  the  outer  coat  only. 

Fig.  232.—"  Hernial "  aneurism ;  the  sac  formed  by  the  inner  coat  only. 

Fig.  233. 


Fig.  233.— Traumatic  aneurism  ;  the  sac  formed  by  the  tissues  around  the  vessel. 
Fig.  234. — Dissecting  aneurism. 
a,  the  internal  coat  of  the  artery  ;  6,  the  middle  coat ;  c,  the  external  coat ;  d,  the  cellular  tissue,  sheath, 
or  other  tissues  surrounding  the  artery. 


526 


DISEASES    OF    THE    ARTERIES. 


Fig.  235. 


matic  aneurism  may  be  treated,  if  it  seems  advisable,  as  a  wound  of  an 
artery,  with  the  same  prospect  of  finding  the  vessel  healthy  up  to  the 
mouth  of  the  sac. 

Clo^fiification. — The  old  classification  of  aneurism  was  founded  on  the 
composition  of  the  sac,  an  aneurism  in  which  the  sac  is  formed  of  all  the 
three  coats  I)eing  termed  true  (Fig.  230)  ;  one  in  which  the  external  coat 
only  is  involved,  /a/^-r  (Fig.  231);^  and  one  in  which  the  sac  is  formed  of 
the  surrounding  tissues,  diffused,''  or  conaecvtive  (Fig.  233). 

This  nomenclature  is  certainly  neither  felicitous  in  expression  nor  use- 
ful in  practice.  It  is  impossible  to  tell  without  dissection  what  the  com- 
position of  the  sac  may  be.  The  three  coats  of  the  artery  can  hardly 
ever  be  traced  over  the  whole  sac,  except  at  the  very  commencement  of 
the  formation  of  aneurism,  and  then  almost  exclusively  in  the  case  of  the 
aorta ;  so  that  many  pathologists  den}^  the  existence  of  "  true  "  aneurism ; 
yet  the  use  of  the  term  "false"  seems  to  imply  something  exceptional 

in  a  condition  which  is 
really  almost  universal. 
It  would  be  better  to  call 
all  arterial  aneurisms  in 
which  the  sac  is  formed 
wholl}'  or  chiefly  bv  the 
wall  of  the  vessel  irue^ 
and  those  in  which  it  is 
formed  wholly  or  almost 
wholly  by  the  surround- 
ing tissues  false ;  and 
many  authors  use  the 
terms  in  this  sense. 

Another  classification 
regards  the  shape  of  the 
tumor.  It  is  very  com- 
mon in  the  aorta,  and  not 
uncommon  in  other  arte- 
ries, to  find  the  whole 
tube  dilated  for  a  very 
considerable  extent  to 
twice  or  more  times  its 
natural  size  (Fig.  235). 
This  is  called  aneurismal 
dilatation.^  or  tubular  or 
fusiform  aneurism,  while 
the  aneurisms  which 
stand  out  from  one  part 
of  the  circumference  of  the  vessel  like  a  bud  attached  to  the  artery  by  a 
neck  are  called  sacculafed. 

A  still  more  practical  distinction  is,  according  to  their  apparent  cause, 
into  Hponlaneous  and  traumatic. 

'  A  variety  of  "  false  "  aneurism  has  been  described  which  is  termed  hernial  (Fig. 
23'2),  in  which  the  sac  is  supposed  to  be  fornifd  of  the  two  internal  coats,  protruded 
or  h('rniiit(!d  tliroutjli  a  deficiency  in  the  external  coat.  The  existence  of  this  form 
of  ancurisn)  as  a  spontaneous  formation  seems,  however,  to  be  (to  say  the  least)  doubt- 
ful, though  an  undoubted  instance  of  its  occurrence  has  b<!en  reported  in  an  artery 
whose  external  coat  had  been  shaved  in  an  amputation,  witliout  the  tube  of  the  ves- 
sel being  cut  into.     It  may  also  be  arlificiall}'  produced  in  animals. 

*  The  term  "  diffu.sed  false  aneurism  "  is,  however,  often  used,  in  the  other  sense 
spoken  of  above,  to  signify  a  ruptured  artery  or  aneurism. 


A  tubiihir  aneurism,  or  aneurismal  dilatation  of  the  innominate 
and  right  subclavian  artery,  extending  from  the  arch  of  the  aorta 
to  the  axillary  artery.  Its  distal  end  could  be  felt  as  a  round  pul- 
sating tumor  in  the  axilla,  a  shows  the  axillary  artery,  which 
itself  is  perfectly  natural ;  h,  the  right  carotid  ;  c,  the  left  carotid 
and  subclavian  ;  r/,  a  largo  branch  of  the  right  subclavian  (prolia- 
bly  the  internal  mammary,  which  is  hanging  down  and  touching 
the  arch  of  the  aorta).  The  arch  itself  is  irregularly  dilated,  but 
the  root  of  the  innominate  artery  is  little  more  than  the  natural 
size.  The  position  of  the  parts  has  been  reversed,  in  order  to  show 
the  aneurismal  cavity  irregularly  occupied  by  clot. — St.  George's 
Hospital  Jluseum,  Sur.  vi,  No.  204. 


CIRSOID    ANEURISM. 


)27 


DiKsecfwg  Aneurism. — All  this  refers  to  the  true  arterial  aneiirisin. 
There  are  other  conditions  which  are  also  called  aneurisms,  but  which 
have  onl}- a  remote  resemblance  to  the  genuine  aneurismal  tumors.  The 
inner  coats  of  the  aorta,  when  atheromatous  or  ossified,  may  crack  off  and 
allow  the  passage  of  the  blood  between  the  external  and  middle  coats, 
or,  as  Dr.  Peacock  thinks,  is  always  (and  as  is  certainly  most  commonly) 
the  case,  between  the  layers  of  the  middle  coat.  The  blood  dissects  off 
the  external  from  the  internal  part  of  the  wall  of  the  aorta,  and  has  been 
known  to  proceed  as  far  downwards  as  the  external  iliac  arter}-.  Ulti- 
mately it  usually  bursts  through  the  outer  coat  of  the  artery,  producing 
fatal  haemorrhage,  and  this  may  take  place  in  the  reverse  direction  to  that 
of  the  circulation,  so  that  many  such  cases  prove  fatal  by  rupture  into  the 
pericardium.  In  rarer  cases  the  blood  bursts  through  the  internal  criats, 
and  thus  makes  its  way  back  into  the  artery  again.  Such  cases  were 
described  in  old  patho- 
logical works  as  instances  ^'^-  -^*'- 
of  double  aorta.  The 
name  of  ^''  dii<sectiiig  an- 
eurism "  is  given  to  this 
condition.  In  rare  cases 
it  may  be  diagnosed.^  It 
admits  of  no  curative 
treatment.  As  it  has 
hitherto  only  been  met 
with  originating  in  the 
aorta,  it  falls  rather 
within  the  province  of 
the  physician,  and  I  shall 
say  no  more  about  it  here. 

Cirsoid  Aneurism. — 
Another  condition  some- 
what allied  to  aneurism 
is  that  which  is  called 
cirsoid  aneurism,  or  ar- 
terial varix^  in  which  a 
single  artery  becomes 
dilated  and  elongated, 
very  much  as  a  varicose 
vein  does ;  and  closely 
allied  to  this  (often,  in- 
deed, in  practice,  indis- 
tinguishable from  it)  is      ^      ,      ^,        ,    .,   ^      ,.    .      ,    ,,    t,       ..  tt 

.    ^  ...  ,         '     .         Copy  from  tlie  portrait  of  a  patient  under  Mr.  Preseott  Hewett's 

the  condition  denomi-  g^re  with  cirsoid  aneurism  of  the  scalp,  in  the  Museum  of  St. 
nated  aneurism    by  anas-    George's  Hospital— From  tlie  System  of  Surgery,  vol.  iii,  p.  534. 

tomosis,   in   which  there 

are  a  number  of  such  dilated  and  tortuous  arteries  packed  together.  In 
this  condition  the  capillaries  and  veins  become  also  implicated,  and  many 
of  the  dilated  pulsating  vessels  seen  in  such  tumors  and  which  appear  to 
be  arteries,  will  be  found  on  dissection  to  be  really  veins. 

Arterio-venous  Anezirism. — Then  there  are  vascular  tumors,  or  enlarge- 
ments, which  are  formed  by  the  communication  of  a  diseased  or  injured 
artery  with  a  vein,  arterio-venous  aneurism.  Of  these  there  are  two  kinds, 
sufficiently  distinct  from  each  other  in  well-marked  examples,  though  not 


1  See  a  case  by  Dr.  Swayne,  of  York,  in  Path.  Trans.,  vol.  vii,  p.  106. 


528  DISEASES    OF    THE    ARTERIES. 

always  distinguishable  when  deeply  seated.  In  the  first,  varicose  aneu- 
rism^ there  is  an  aneurismal  tumor  13'ing  between  and  communicating 
with  the  artery  on  one  side  and  the  vein  on  the  other,  so  that  the  two 
vessels  open  only  indirectly  into  each  other.  In  the  second,  aneurismal 
variu;  the  hole  in  the  artery  opens  directl}'  into  the  vein,  no  tumor  what- 
ever being  present.  The  veins  are  varicose  in  both.  They  generally 
pulsate  to  some  distance  in  the  aneurismal  varix,  and  may  do  so  in  the 
varicose  aneurism,  if  the  two  openings  of  the  sac  are  exactl}'  opposite  to 
each  other. 

The  symptoms  of  arterio-venous  aneurism  are  easily  distinguished  from 
those  of  common  aneurism.  When  there  is  a  tumor  (varicose  aneurism) 
it  will  be  found  to  have  not  only  a  pulsation  synchronous  with  the  arterial 
pulse,  but  also  a  continuous  thrill,  due  to  the  venous  stream  ;  and  the 
murmur  is  also  composed  of  an  intermittent  blowing,  arterial  sound,  and 
a  constant  rasping  or  thrilling  bruit  (compared  to  the  snarling  of  a  dog 
or  the  harsh  pronunciation  of  the  letter  R)  caused  by  the  meeting  of  the 
arterial  and  venous  streams.  In  an  aneurismal  varix  the  bruit  will  be 
somewhat  similar,  varying  in  tone,  however,  with  the  var^dng  condition 
of  the  orifice,  and  the  varicose  veins  will  pulsate.  There  is  also  com- 
monly an  increase  of  heat  in  the  skin,  and  the  hair  and  other  epidermal 
tissues  are  over-nourished. 

Treatment. — Cirsoid  aneurism  is  rarely  made  the  subject  of  any  treat- 
ment. If  it  be  necessary  to  undertake  its  cure,  the  ligature  of  the  trunk- 
artery  leading  to  it,  though  an  exceedingly  uncertain  measure,  is,  perhaps, 
the  best.  The  dilated  vessel  itself  is  too  much  altered  in  structure  to  bear 
the  ligature  with  safety  ;  and  coagulating  injections  are  verj'  dangerous. 
But  when  ligature  of  the  main  trunk  is  inapplicable  resort  must  be  had 
either  to  coagulating  injection  or  to  galvano-puncture ;  or  if  the  tumor 
is  not  too  large  it  may  be  extirpated.  Reference  may  be  made  to  what 
has  been  said  above  (p.  359)  about  the  treatment  of  aneurism  by  anasto- 
mosis, to  which  these  cirsoid  aneurisms  bear  a  veiy  great  resemblance. 

Arterio-venous  aneurism  is  very  commonly  the  result  of  a  wound,  and 
in  such  cases  the  vessels  will,  in  all  probability,  be  healthy,  if  the  disease 
is  not  of  ver}^  long  standing.  But  when  it  has  existed  for  a  long  time 
the  artery  becomes  so  dilated  and  thinned  above  the  orifice  of  communi- 
cation that  no  operation  on  it  could  have  an\'  chance  of  success.  When 
the  disease  is  recent  it  may  often  be  cured  by  pressure  simultaneously 
exercised  on  the  artery  and  on  the  orifice  of  communication.  This  is 
best  done  l)y  two  persons,  one  of  wliom  presses  lightly  on  the  point  at 
which  the  arterial  stream  enters  the  tumor  with  just  so  much  force  as  is 
necessar}'^  to  suspend  the  cooing  murmur;  the  other  compresser  holds  the 
artery  at  some  convenient  spot  above  the  tumor,  as  in  ordinary  aneurism. 
If  this  plan  fails  it  is  best,  in  recent  traumatic  cases,  to  lay  open  the  sac 
(having  compressed  the  artery  above)  and  tie  the  artery  above  and  below 
the  orifice.  The  veins  may  also  be  tied  if  it  seems  necessary.  The  artery 
has  also  been  tied  above  and  below  the  tumor  without  opening  the  sac, 
and  witli  success.'  The  main  artery  and  vein  have  also  both  been  tied, 
and  with  success.  Finally,  cases  have  been  treated  successfull}-  by  coagu- 
lating injections  and  galvano-puncture,  but  these  plans  are  less  certain 
than  surgical  operation,  and  I  believe  more  dangerous,  and  should  only 
be  used  in  exceptional  instances. 

'  By  Mr.  Spence.  See  a  lecture  on  Femoral  Aneurism,  in  the  Lancet,  Oct.  17th, 
1874.  Since  the  publicKtion  of  that  paper  Mr.  Annimdale  hu.s  recorded  a  case  in 
which  he  laid  open  an  arterio-venous  aneurism  in  the  thigh  and  tied  both  the  vein  and 
artery  with  success.     No  gangrene  occurred. 


SYMPTOMS  —  DIAGNOSIS.  529 

When  the  disease  does  not  eanse  much  inconvenience,  and  is  not 
rapidly  advancing,  it  is  questionable  whether  the  patient  ought  to  be 
advised  to  submit  to  any  dangerous  treatment ;  and  this  is  still  more  the 
case  the  more  nearly  the  disease  approaches  to  the  form  of  true  aneurismal 
varix,  i.  (?.,  the  less  proof  there  is  of  the  existence  of  a  distinct  tumor 
between  the  artery  and  vein. 

Si/wptoms. — The  symptoms  of  arterial  aneurism  are  as  follows  :  There 
is  a  pulsating  tumor  situated  in  the  course  of  the  artery,  and  incapable 
of  being  drawn  away  from  it;  the  pulsation  is  of  a  heaving  charncter, 
and  causes  an  expansion  of  the  tumor  in  all  directions,  laterally  as  well 
as  up  and  down.  It  is  usually  accompanied  by  a  hi-uit — a  blowing  or 
whistling  sound — synchronous  with  the  pulse.  Pi'essure  on  the  artery 
above  suspends  botii  pulsation  and  bruit ;  and  if  the  Itlood  in  the  aneurism 
is  entirely  fluid  the  tumor  can  now  be  almost  emptied  by  pressure.  The 
tumor  refills  in  a  certain  number  of  pulsations  on  the  withdrawal  of  the 
pressure.  In  some  cases  pressure  on  the  artery  below  will  cause  an 
increase  in  the  size  or  tension  of  the  sac.  The  pulse  in  the  artery  below 
is  generally  much  weakened,  and  there  are  various  symi)toms  due  to  the 
pressure  of  the  tumor  on  neighboring  organs,  and  depending,  therefore, 
on  its  anatomical  relations.  Thus  poi)liteal  aneurism  causes  pain  and 
numbness  in  the  course  of  the  internal  i)opliteal  nerve,  and  oedema  of  the 
leg  from  pressure  on  the  vein  ;  subclavian  and  axillary  aneurism  cause 
pain  in  the  brachial  plexus,  weakness  and  oedema  of  the  arm  ;  aortic 
aneurism  cough,  hoarseness,  pain  between  the  shoulders,  and  various 
symptoms  too  numerous  to  catalogue  ;  in  fact,  each  form  of  aneurism 
has  its  own  definite  symptoms,  due  not  to  its  nature  but  to  its  position. 

Diagno^ii^ — The  diagnosis  of  surgical  or  external  aneurism  is  usually 
but  not  always  easy,  that  of  thoracic  aneurism  often  very  dilFicult.'  The 
reason  is  that  in  thoracic  aneurisms  there  is  very  often  no  bruit,  and  the 
pulsation  may  be  imperceptible,  so  that  the  pressure  effects  furnish  the 
only  symptoms,  and  these  can  hardly  be  decisive  of  the  nature,  even  if 
they  can  prove  the  existence,  of  a  tumor.  Even  in  external  aneurism 
certain  sources  of  ambiguity  are  found.  A  tumor  of  a  solid  or  cystic 
consistence  may  lie  so  close  to  an  artery  as  to  derive  pulsation  from  the 
vessel.  A  familiar  instance  is  found  in  a  cyst  of  the  thyroid  body  which 
often  touches  the  carotid  or  innominate  arter}^,  or  a  cyst  or  enlarged  gland 
in  the  ham  which  may  press  upon  and  derive  pulsation  from  the  popliteal. 
But  such  tumors  have  never  the  definite  whirr  of  the  aneurismal  bruit, 
even  if  some  dull  "thud"  is  caused  by  the  pressure  they  exert  on  the 
artery.  It  will  be  found  that  a  similar  sound  can  be  produced  by  pressing 
the  stethoscope  on  any  large  accessible  artery.  And  they  never  have  the 
expansive  pulsation  of  aneurism — only  the  up  and  down  movement  com- 
municated to  them  from  the  underlying  pulsation.  But  the  strongest 
sign  of  all  is  that  they  can  usually  be  drawn  away  from  the  artery,  and 
then  no  longer  pulsate.  The  great  difficulty,  however,  is  to  distinguish 
between  aneurism  and  those  malignant  tumors  which  sometimes  spring 
from  the  bones,  and  contain  large  spaces  which  are  filled  with  blood,  and 
which  pulsate  from  the  great  size  of  the  vessels  opening  into  them.  It 
must  be  admitted  that  in  some  cases  the  diagnosis  is  hardl}^  possible, 
since  these  pulsating  tumors  occasionally  have  a  bruit,  lie  in  exactly  the 
situation  of  aneurism,  and  their  pulsation  of  course  disappears  on  com- 
pression of  the  trunk-vessel  which  feeds  them.  In  most  cases  of  pulsatile 
cancer,  however,  there  is  either  no  bruit  or  one  very  different  from  that 


1  This  is  still  more  the  case  with  intracranial  aneurisms,  but  these  hardly  form 
part  of  our  subject. 

34 


530 


DISEASES    OF    THE    ARTERIES. 


of  aneurism  ;  the  bone  may  be  felt  to  be  expanded  in  the  neighborhood 
of  the  tumor;  the  expansion  of  the  tumor  is  much  less  in  proportion  to 
its  size  than  in  aneurism  ;  and,  if  the  case  is  watched,  the  pulsation  ma}^ 
sometimes  be  found  not  to  be  constaut.  It  has  been  known  to  disappear 
for  a  time  and  return  again.  Sometimes  also  flakes  of  bone  ma}'  be  felt 
in  the  coverings  of  the  tumor.  Again,  there  has  often  been  found  to  be 
a  practical  ditliculty  in  distinguishing  between  those  blood-collections 
which  are  sometimes  (tliough,  as  I  contend,  improperly)  called  diffused 
false  aneurisms,  or  between  aneurisms  which  liave  lost  their  pulsation  b}' 
free  rupture  of  the  sac,  and  abscess.  The  chief  diaguostic  signs  are- the 
absence  of  inflammation  of  the  integuments,  the  weakness  of  the  pulse 
below  the  rupture,  possibly  coldness  of  the  parts  below,  and  in  some  cases 
the  presence  of  a  bruit  at  the  point  of  lesion  of  the  artery.  In  cases  of 
doubt  exploration  witli  a  grooved  needle  can  do  no  harm,  and  wall  settle 
the  question.' 

Relotion><  hetween  the  Sac  and  Artery. — The  relations  of  the  aneurismal 
sac  to  the  artery  are  a  matter  of  some  importance.  Very  often  a  single 
part  only  of  the  artery  has  given  way,  although  a  considerable  part  of 
the  vessel  is,  as  it  were,  buried  in  the  sac  (Fig.  237) ;  at  other  times,  even 


Fig.  237. 


Fig.  238. 


Fig.  237. — Showing  iin  aneurismal  sac,  in  wliieli  tlie  artery  has  given  way  at  a  single  point,  and 
where  tlie  artery  is  imbedded  for  some  distance  in  the  tissue  of  the  sac.  This  is  regarded  by  many 
surgeons  a.s  the  usual  condition  in  aneurisms  of  the  limbs. 

Fig.  238. — Showing  an  aneurism  in  wliich  the  whrile  circumference  of  the  artery  has  given  way  for 
some  distance, so  that  tlicre  are  two  communications  between  the  artery  and  the  sac, one  at  the  upper 
end  of  the  tumor,  tlie  other  near  the  middle,  from  which  the  lower  part  of  the  artery  springa.  This 
is  a  very  common  form  of  aneurism,  especially  in  the  interior  of  the  body,  and  represents  a  stage 
intermediate  between  the  former  figure  and  the  true  fusiform  aneurism,  sliown  in  Fig.  235. 


in  a  sacculated  aneurism,  tlie  whole  circumference  of  the  arteiy  has  given 
way,  and  there  are  two  op(Miings,  tnie  of  entrance  and  one  of  exit,  sepa- 
rated  by  a  considerable   interval  (Fig.  238).     This  is,  of  course,  always 

*  Sfe  a  paper  On  the  Diagno.sis  of  Aneurism,  in  St.  Georgo's  Hospital  Keports, 
vol.  vii. 


PROGRESS  OF  ANEURISM.  531 

the  case  in  a  fusiform  aneurism.  Tiie  walls  of  the  artery  are  by  no  means 
always  diseased  in  the  neighborhood  of  the  mouth  of  the  aneurism.  Still, 
it  remains  trne  that  this  jiart  of  the  artery  is,  in  a  spontaneous  aneurism, 
more  likely  to  be  found  diseased  than  any  other,  and  that  operations  on 
that  part  ought  therefore  to  be  avoided  if  possible. 

Pror/ress  of  Aiieurinm. — The  usual  progress  of  aneurism  is  to  the  rup- 
ture of  the  sac.  The  tumor  increases  gradually;  it  comes  into  contact 
with  neighboring  structures,  which  it  compresses  and  absorbs,  and  which 
in  their  turn  also  compress  and  cause  the  absorption  of  the  tissue  which 
forms  the  sac.  Thus,  in  thoracic  and  abdominal  aneurisms,  the  spinal 
column  is  al)sorbed  b}'  pressure  till  the  theca  is  often  exposed  ;  in  l)op- 
liteal  aneurism  the  femur  and  the  posterior  ligament  of  the  joint  are  worn 
away,  etc.  And  as  this  goes  on  the  sac  softens  and  its  tissue  is  replaced 
by  tlie  fasciae,  muscles,  or  bones  which  the  sac  has  met  with  in  its  prog- 
ress, until  it  gives  way  and  the  lilood  exudes.  This  sometimes  occurs  by 
a  sudden  rent,  the  symptoms  of  which,  if  it  takes  place  into  the  cellular 
spaces  of  a  limb  or  into  a  joint,  are  sufficiently  well  marked.  The  tumor 
suddenly  loses  its  pulsation  and  its  shape,  becoming  flattened  ;  a  sharp 
sensation  of  a  crack,  or  of  something  giving  way,  often  accompanies 
this;  the  limb  becomes  swollen  and  cold;  possibly  ecchymosis  may  be 
perceptible  beneath  the  surface.  If  nothing  is  done  gangrene  will  prob- 
ably ensue.  When  the  rupture  occurs  through  a  serous  surface  it  is  often 
by  a  sudden  crack,  accompanied  by  rapidly  fatal  hremorrhage.  On  mu- 
cous surfaces  the  bleeding  is  usually  gradual.^  Aneurisms  do  not  often 
burst  through  the  skin  ;  when  they  do  the  bleeding  is  generally,  but  not 
always,  fatal  at  once. 

Spontaneous;  cure,  however,  may  take  place,  and  this  in  several  ways. 
First,  tlie  aneurism  may  simply  lose  its  pulsation  gradually  as  its  sac  be- 
comes more  and  more  occupied  l)y  coagula,  fresh  laminae  forming  con- 
centrically till  the  whole  sac  is  filled  and  obliterated.  Secondly,  the  distal 
opening  of  the  aneurism,  or  tlie  distal  portion  of  the  artery,  may  become 
closed  by  an  embolic  clot,  and  this  clot  may  gradually  grow  into  the  sac 
by  fresh  accretion  till  it  is  filled  up.  Thirdly,  the  whole  sac  may  sup- 
purate, the  resulting  inflammation  may  seal  both  portions  of  the  artery, 
and  the  tumor  may  thus  be  extirpated,  a  mass  of  blood-clot,  mixed  with 
pus,  l)eing  evacuated  on  the  opening  of  the  abscess.  Fourthly,  it  is  re- 
garded as  possible  by  many  eminent  surgical  pathologists  that  the  tumor 
may  itself  compress  the  trunk  of  the  artery  above  it,  and  so  produce  a 
hindrance  to  the  circulation  through  the  sac  sufficient  to  permit  of  the 
entire  consolidation  of  the  blood  in  it. 

Finally,  it  may  be  said  that  some  aneurisms,  or  perhaps  aneurismal 
dilatations,  make  no  progress  whatever  for  an  indefinite  time.  It  is  com- 
mon to  find  a  dilatation  of  the  root  of  the  right  carotid  artery,  which 
seems  to  remain  in  a  stationary  condition  for  inany  years,  without  pro- 
ducing any  appreciable  inconvenience  to  the  patient,  except  a  loss  of  the 
power  of  active  exertion. 

Ti'eatmeyU. — The  treatment  of  aneurism  is  either  internal  (medical)  or 
external  (surgical).  The  internal  treatment  aims  at  producing  a  cure  as 
in  the  first  process  of  spontaneous  cure  above  described.  Its  main  object 
is  to  reduce  the  circulation  by  rest  and  low  diet,  and  to  keep  the  heart's 
action  at  a  uniform  level.''  The  rest  should  be  iperfect^  the  patient  being 
never  allowed  to  leave  his  bed  nor  to  assume  the  erect  or  even  the  sitting 
posture,  and  everything  about  the  bed  and  chamber  should  be  carefully 

1  See  Gairdner,  in  Med.-Chir.  Trans.,  vol.  xbi. 

2  See  Tufnell,  On  the  Successful  Treatment  of  Internal  Aneurism,  1864. 


532  DISEASES    OF    THE    ARTERIES. 

arranged  so  as  to  make  this  as  little  irksome  as  possible.  The  diet  should 
be  spare  in  quantity  but  nourisiiino-  in  quality  (say  6  to  8  ozs.  of  solid 
food,  of  which  meat  forms  a  good  part),  with  as  little  fluid  as  he  can  be 
persuaded  to  take.  A  little  wine  is  usually  desirable.  The  object  is  not, 
as  in  tlie  treatment  of  Valsalva,  l)y  repeated  bleedings,  to  reduce  the 
l)atient's  strengtli  or  exhaust  his  supply  of  blood,  but  to  keep  the  heart's 
action  perfectly  equal)le  and  somewhat  below  the  standard  of  healtii,  the 
pulse  being  between  GO  and  70,  and  never  varying,  as  far  as  tluit  is 
possible.  The  bowels  must  be  carefully  regulated  if  necessary  by  the 
gentlest  possible  laxatives,  no  purging  or  constipation  being  permitted, 
since  both  involve  disturbance.  If  it  be  necessary,  chloral  may  be  given 
to  procure  sleep,  or  small  doses  of  morphia  injected.  Under  this  plan 
pursued  for  several  months  much  benefit  may  be  obtained  in  the  majority 
of  cases  of  internal  aneurism,  and  a  few  complete  cures  may  be  hoped 
for.  As  to  medicines,  none  have  as  yet  been  proved  to  have  any  effect 
on  the  disease.  Much  benefit  has,  no  doubt,  in  many  cases  followed  the 
administration  of  iodide  of  potassium,  and  if  it  does  not  disagree  witli  the 
general  healtli  a  trial  may  be  given  to  it.  At  the  same  time  I  have  often 
administered  it  with  no  efl[ect  whatever,  and  in  cases  where  it  has  done 
good,  as  perfect  rest  has  also  been  employed,  it  is  impossible  to  say  how 
much  of  the  benefit  was  due  to  this.  The  iodide  may  be  given  in  five-grain 
doses  three  times  a  day,  gradually  increasing ;  and  if  the  heart's  action 
is  excited  a  small  quantity  (irijv-viij)  of  the  tincture  of  digitalis  or 
Fleming's  tincture  of  aconite  ("K''j-^')  "^^.V  be  conbined  with  it.  The 
acetate  of  lead  has  not  seemed  to  me  to  act  in  any  wa}'  beneficially. 

The  Old  Operation. — The  surgical  or  operative  methods  of  treating 
aneurism  are  very  various.  The  old  operation  (that  of  Antyllus)  is  an  imi- 
tation of  the  cure  by  suppuration.  It  consists  in  cutting  into  the  sac, 
turning  out  the  clots,  tying  the  artery  above  and  below  the  tumor,  and 
allowing  the  cavity  to  fill  up  by  granulation.  The  operation  is  usually 
difficult,  always  dangerous,  and  sometimes  impossible;  but  it  has  the 
merit  that  if  successful  it  is  certain  to  cure  the  disease,  whicii  is  not  the 
case  with  any  of  the  otliers.  Mr.  Syme  has  lately  done  much  to  reintro- 
duce this  operation  into  practice;  not  in  popliteal  aneurism,  in  which 
there  can  be  no  doulit  tliat  other  methods  are  preferable,  but  in  some  of 
the  other  forms — axillary,  gluteal,  iliac,  and  carotid.'  When  it  is  possi- 
ble a  tourniquet  should  he  applied,  and  then,  the  circulation  being  com- 
pletely commanded,  the  sac  may  be  freely  split  open  (by  a  crucial  incision, 
if  need  be),  so  that  its  interior  can  be  inspected  throughout  and  the 
opening  of  the  vessel  clearly  seen.  But  in  some  cases  (as  in  carotid 
aneurism)  this  cannot  be  done.  It  is  then  necessary,  in  order  to  avoid 
fatal  hfemorrhage,  to  make  an  opening  into  the  tumor  just  large  enough 
to  admit  the  finger,  and  enlarge  it  if  necessary  till  two  fingers  can  be  in- 
troduced, tlic  opening  being  all  the  wliile  plugged  by  the  finger.  Then 
the  surgeon  feels  around  the  interior  of  the  sac  till  he  gets  his  finger  on 
tiie  point  from  wlience  tiie  blood  is  issuing.  Keeping  this  steadily  com- 
manded, he  next  splits  u|)  the  sac  freely,  turns  out  all  the  clots,  and  by 
the  help  of  his  assistant  lays  bare  the  artery  above  the  opening  of  the 
aneurism,  and  ties  its  cardiac  part.  This  being  done,  he  withdraws  his 
finger,  to  make  sure  that  the  direct  circulation  is  controlled  ;  then  dis- 
sects out  the  distal  part  of  the  artery  and  ties  this  also,  in  order  to  bar 
the  reflux  stream. 

The  Hunlerian  operation  for  aneurism  consists  in  tying  the  trunk  of 


'  See  Syme,  Med.-Chir.  Trsms.,  vol.  xliii,  p.  1:57,  and  vol.  xlv,  p.  381. 


HUNTERS    OPERATION. 


533 


the  artery  at  a  variable  distance  above  the  aneurismal  sac.  French 
writers  nsnally  speak  of  this  as  the  method  of  Anel;  but  the  difference 
is,  tliat  in  Anel's  method  the  artery  is  tied  close  to  the  sac,  no  branch 
intervening,  while  in  Hunter's  it  is  tied  at  a  distance,  and  often  a  great 
distance  (as  when  the  external  iliac  is  tied  for  an  aneurism  of  the  super- 
ficial femoral),  so  that  in  the  former  no  branch  intervenes  between  the 
ligature  and  the  sac,  while  in  the  latter  often  many  considei'alile  branches 
arise  in  the  interval.  Anel's  method  selects  for  ligatun;  that  part  of  the 
artery  which  is  most  likely  to  be  diseased,  and  in  that  respect  has  no 
superiority  over  the  old  operation.  In  many  cases  it  would  be  hardly 
possible  to  carry  it  out  without  wounding  the  sac  (see  Fig.  237).  In 
fact,  it  is  only  a  part  of  the  old  operation,  and  the  latter  is  in  most  cir- 

FiG.  230.  Fig.  240.  Flu.  241. 


Fig.  239. — Anel's  operation. 

Fig.  240. — Hunter's  operation. 

Fig.  241. — A  preparation  showing  the  definitive  cure  of  aneurism.  The  aneurism  affected  the  pos- 
terior tit)ial  artery,  and  the  femoral  had  been  tied  some  months  before  death.  &  shows  the  posterior 
tibial  nerve  spread  out  over  the  tumor  c;  a,  the  artery,  wliich  appeared  to  be  closed  up  at  the  seat  of 
aneurism.— St.  George's  Hospital  Museum,  Ser.  vi.  No.  129. 

cumstances  equally  feasible,  more  certain  to  cure  the  disease,  and  there- 
fore preferable.  Hunter's  method  is  an  imitation  of  the  first  mode  of 
natural  cure.  It  does  not  (as  might  at  first  sight  be  thought)  altogether 
suspend  the  circulation  through  the  tumor,  except  for  a  very  short  time, 
but  greatly  diminishes  it.  The  collateral  circulation  brings  back  the 
blood  into  the  tumor  certainly  after  the  first  few  hours,  at  which  time 
there  is  often  enough  movement  of  fluid  in  the  sac  to  be  perceptible  to 
the  hand,  and  very  likely  even  sooner.  In  animals  it  has  been  proved  by 
experiment'  that  the  collateral  circulation  is  restored  in  a  very  few  min- 
utes, and  the  same  is  most  likely  the  case  in  the  human  suliject.  But 
this  sligiit  stream  of  blood,  instead  of  retarding  coagulation  in  the  sac, 
is  thought  by  many  surgeons  to  promote  it.  Thus  Broca  draws  a  dis- 
tinction between  the  clots  which  are  formed  by  the  coagulation  of  the 
blood  en  masne^  such  as  are  produced  after  death,  containing  all  the  solid 
elements  of  the  blood,  and  a  good  deal  of  serum  also,  and  which  he  calls 
passive  clots,  and  the  layers  of  coagulated  fibrin  mingled  only  with  more 


1  See  Syst.  of  Surg.,  2d  ed.,  vol.  iii,  p.  470. 


534  DISEASES    OF    THE    ARTERIES. 

or  less  of  blood-corpuscles  and  comparatively  destitute  of  fluid,  which  he 
calls  aclire  c/o/.s,  believing  that  tlie  former  are  rather  injurious  than  use- 
ful in  the  coagulation  of  an  aneurism,  as  irritating  to  the  sac  and  liable 
to  suppurate  ;  while  to  the  latter  he  attributes  the  active  process  of  filling 
up  the  cavity.  For  the  coagulation  of  the  blood  en  masse  no  circulation 
is  necessary,  but  for  the  production  of  laminated  fibrin  he  believes  that 
some  amount  of  circulation  is  at  least  very  advantageous,  if  not  neces- 
sary. This  theory,  however,  is  refuted  by  the  fact  that  when  the  circu- 
lation is  completel}'  commanded  for  a  few  hours  by  pressure  on  the  artery 
under  chloroform,  the  sac  often  becomes  filled  with  coagula  (which  must 
necessarily  be  of  the  kind  which  Broca  denominates  passive),  and  that 
tiiese  ver}'  often  become  gradually  more  and  more  solid  and  a  definite 
cure  results;  proving  that  circulation  is  not  essential  for  the  production 
of  laminated  fibrin,  and  that  soft  clots  are  not  a  hindrance  to  the  con- 
solidation of  the  tumor.  The  stress  of  the  circulation  being  removed 
from  the  aneurism  by  the  ligature  of  the  vessel,  the  sac  and  the  parts 
around  contract  upon  the  blood  ;  the  latter  becomes  gradually  more  and 
more  solid,  and  generally  no  more  pulsation  is  perceptible  in  the  tumor. 
By  the  time  the  ligature  has  come  away  (see  p.  115)  the  tumor  is  much 
reduced  in  size;  this  shrinking  goes  on  for  some  time,  and  the  tumor 
becomes  harder  as  it  becomes  smaller,  till  at  last  only  a  hard  kernel  is 
left,  and  sometimes  no  perceptible  enlargement  remains.  On  dissection 
the  sac  is  found  filled  with  laminsB  of  fibrin  much  resembling  the  coats  of 
an  onion,  entirely  discolored,  if  old;  if  tolerably  recent  the  outer  layers 
are  perfectly  butt-colored,  while  the  inner  retain  more  or  less  of  coloring 
matter.  The  arter^^  also  is  usually  obstructed  at  this  part.  If  no  con- 
siderable branch  comes  oft'  between  the  ligature  and  the  sac  (^.  f.,  if  the 
case  resembles  Anel's  operation  to  this  extent)  the  whole  artery  from  the 
ligature  to  the  tumor  is  obliterated,  and  a  single  arch  of  anastomosis 
carries  the  blood  into  the  artery  below  the  aneurism  ;  otherwise  there  are 
two  arches  of  anastomosis,  one  to  convey  the  blood  round  the  portion 
obliterated  by  the  ligature,  and  the  other  to  convey  the  blood  round  the 
obliterated  aneurismal  sac,  above  which  there  is  a  pervious  tract  of  artery 
(Fig.  242). 

The  main  dangers  which  attend  on  this  operation  are  those  which  have 
V)een  spoken  of  as  incidental  to  tlie  ligature  of  an  artery,  viz.,  gangrene 
and  secondary  haemorrhage  (see  pages  116-1 18) ;  but  we  ought  not  to  omit 
to  mention  that  the  operation  may  also  fail  in  one  of  two  ways.  The  more 
usual  is  the  suppuration  of  the  sac.  The  coagulation  remains  somewhat 
imperfect,  and  after  a  longer  or  shorter  time — for  this  is  very  variable — 
the  part  becomes  swollen,  red,  and  painful,  and  an  exploratory  puncture 
will  discovcfi"  i)us.  It  is  vvell  to  wait  till  the  matter  has  come  near  the  sur- 
face and  then  to  open  the  sac  pretty  freely.  Usually  the  artery  will  be  found 
to  be  closed;  and  if  the  patient  can  support  the  suppuration  the  cavit^"^ 
will  fill  up,  and  a  cure  will  result ;  but  if  on  opening  the  tumor  haemorrhage 
ensues,  or  if  there  be  bleeding  afterwards,  ami)utation  is  indicated. 

In  rarer  cases  the  ligature  does  not  suppress  the  pulsation,  or  after  it 
has  been  temporarily  suppressed  it  recurs.  It  is  not  very  uncommon  for 
a  little  pulsation  to  be  percei)tible  tor  a  short  time,  whicli  ultimately  dis- 
appears ;  but  in  the  cases  here  spoken  of,  as  a  result  of  too  free  anasto- 
mosis the  tumor  returns  to  exactly  its  former  condition  and  resumes  its 
growth.  It  now  becomes  necessary  to  undertake  its  treatment.  The  first 
indication  is  to  employ  genuflexion  or  pressure  both  directly  to  the  tumor 
and  to  the  artery  above.  This  failing,  the  surgeon  must  choose  between 
the  ligature  of  the  arter\-  lower  down  and  the  old  operation.     Both  plans 


TREATMENT    BY    PRESSURE. 


535 


have  been  successfully  adopted,  and  the  choice  would  depend  more  on  the 
individual   features  of  the  case  than 

1  •        •     1  HM  F"i-  242. 

on  any  general  principles.  I  here 
might,  of  course,  be  circumstances 
which  would  render  amputation  more 
advisable. 

Distal  Ligature. — The  distal  liga- 
ture after  the  methods  of  Brasdor  and 
Wardrop  is  a  method  of  treatment 
which  is  now  restricted  to  aneurism 
at  the  root  of  the  neck,  and  which 
will  be  discussed  on  a  subsequent 
page  in  treating  that  form  of  aneurism. 

Compression  Treatment. — Pressure 
on  the  artery  above  has  now  become  a 
recognized  method  of  treating  aneur- 
ism, and  on  the  whole  has  been  very 
successful.  There  are  many  ways  of 
doing  this,  amongst  which  I  have  no 
hesitation  in  sa_ying"  that  compression 
with  the  finger  is  far  the  best,  when  it 
can  be  carried  out.  But  it  must  be 
recollected  that  pressure  cannot  be  ex- 
pected to  succeed  unless  it  is  regular, 
efficient,  and  equable.  Irregular  pres- 
sure, which  allows  the  sac  to  lelill  fre- 
quently, cannot  but  aggravate  the  dis- 
ease by  perpetual  disturbances  both 
of  the  sac  and  its  contents,  as  well  as 
distress  and  pain  to  the  patient.  What- 
ever form  of  pressure,  therefore,  is 
selected,  care  should  be  taken  to  as- 
certain by  constant  supervision  that 
during  the  whole  of  its  application  no 
circulation  is  perceptible  through  the 

tumor.'       And    it    is    well    not    to    com-  a  preparation  showing  the  collateral  circula- 

mence    the    treatment    until,    by  a  few  tlon  after  the  cure  of  aneurism  by  the  ligature, 

days  of  complete    rest    and    low    diet,  The  external  iliac  artery  has  been  tied  for  the 

■'     .         1      .         I  cure  of    aneurism  of  the   superfacial    femoral. 

the  circulation  lias  been  brought  down  The  whole  length  of  the  external  iliac  is    ob- 

tO  the  level  of  health  or  below  it,  and  Uterated,  and  the  femoral  is  obliterated  at  the 

until,  as   Dr.  Carte  suggests,  a  weight  seat  of  aneurism,     a  points  to  the  internal  iliac, 

„     ,         ,  o  11        1-1          li            .^           •      Ti  the  branches  from   which  and  from   the  aorta 

of  about  8  lbs.  laid  on  the  artery  in  the  have  anastomosed  with  b  b,  the  two  branches  of 

groin     (taking     the    case    of    l)Opliteal  the  external  iUac,  as  well  as  with  those  of  the 

aneurism)   will    stop   the  circulation  in  pr<>funda,c,  and  thus  have  brought  the  blood  into 

.  1        .                      rill             -c    T     -i    1  the  common  femoral,  which  is  enormously  en- 

the  tumor.      1  hen,  if  digital  pressure   ,^,^3^  ,,  ,,  t„  ,^,^1  i„  ^^.^  .^e  common  iliac 

is  to  be  used,  a  staff  of  assistants  must    artery.     Again,  the  branches  from  the  profunda 

be  Organize(i,  who  are   to    take  charge    havecommunicated  with  the  superficial  femoral, 

c  ,1  .  •  •  111-  .1         which  is  pervious  from  a  point  immediately  be- 

of  the  artery  111  pairs,  one   10  dma:  the   ,     .,     '      .       «. ,.        ,  u     ^  ,Ar 

J  I  ^  a   "    ^    low  the  aneurism.   St.(jceorge'sHo.spital  Museum, 

arteiy  while  the  other  keeps  his  hand  ser.  vi.  No.  120.— From  the  Syst.  of  Surg. 


•  When  compression  was  first  introduced  into  general  use  surgeons  were  a  good 
deal  under  the  influence  of  the  theory  which  Broca  has  so  strongly  advociited,  and 
only  Slimed  at  reducing  not  stof)|)ing  tlie  circulation.  I  believe  1  am  correct  in  say- 
ing that  this  plan  is  given  up  even  in  France  since  the  great  success  which  has  been 
proved  to  attend  on  digital  pressure  in  the  practice  of  Vanzetti  and  others.  For 
digital  pressure  is  always  applied  so  as  to  stop  the  circulation  altogether. 


636  DISEASES    OF    THE    ARTERIES. 

on  the  tumor,  to  see  that  the  pressure  is  effectual.  Without  assistauce  a 
man  can  hardly  command  the  femoral  artery  completely  for  more  than  ten 
minutes,  but  the  compresser's  fingers  can  ])e  much  assisted  b}'  a  weight  or 
bag  of  shot  made  to  fall  upon  the  end  of  the  finger.'  In  this  way  it  is  said 
that  the  same  person  can  maintain  compression  for  an  hour.  In  changing 
the  coin|)resser  care  should  be  taken  that  the  artery  does  not  escape  even 
for  an  instant.  The  process  is  by  no  means  painful,  and  a  very  rapid 
cure  is  in  some  instances  obtained."  In  other  cases  the  pressure  must 
be  intermitted,  in  order  to  give  the  patient  needful  repose  during  the 
night,  and  resumed  uext  morning.  So  long  as  the  case  goes  on  well — 
i.  f\,  if  the  pulsation  and  size  of  the  tumor  are  obviously  diminishing — 
the  treatment  should  be  continued  ;  but  if  no  impression  whatever  is  made 
on  the  disease  I  do  not  think  it  is  wise  to  persevere  be3'ond  the  first  few 
days,  at  least  in  those  forms  of  aneurism  where  (as  in  the  popliteal)  the 
operation  of  ligature  is  easy  and  involves  comparativel}^  little  danger. 

In  cases  where  the  artery  lies  too  deep  for  digital  compression  it  may 
be  compressed  manually  by  means  of  a  pad  mounted  on  a  handle.  A 
very  useful  instrument  for  this  purpose  has  been  devised  by  my  friend, 
Mr.  Coles,  which  has  been  successfully  employed  in  the  compression  of 
the  carotid  arter\'.'  A  small  pad,  about  the  size  of  the  end  of  the  finger, 
is  mounted  on  a  rod  fixed  in  a  tubular  stem,  with  a  spring  so  that  the 
pad  does  not  exercise  completely  dead  pressure. 

Instrumental  compression  is  most  easily  made  by  means  of  a  weight 
suspended  from  a  frame,  svhich  can  be  improvised  out  of  any  materials 
that  happen  to  be  at  hand,  or  which  may  be  held  by  the  patient  or  an 
attendant.  The  end  of  the  weight  ought  not  to  be  much  larger  than  the 
finger,  in  order  to  avoid  as  far  as  may  be  the  simultaneous  compression 
of  the  vein  or  any  of  the  neighboring  parts.  But  in  this,  as  in  all  other 
forms  of  compression,  the  most  careful  and  continuous  supervision  is 
necessary.  It  is  obvious  that  any  sudden  movement  of  the  patient's 
body  u)ay  entirely  displace  the  whole  a[)paratus,  and  a  few  moments' 
negligence  may  undo  the  effect  of  hours  of  compression.  Still,  niany 
cases,  especially  of  femoral  and  popliteal  aneurism,  have  been  success- 
fully treated  in  this  way.  The  femoral  artery  in  the  groin  is  peculiarly 
well  situated  for  this  form  of  treatment. 

Numerous  more  elal)orate  instruments  have  been  devised  ;  modifica- 
tions of  the  Italian  or  horseshoe  tourniquet  (Signorini's),  which  com- 
presses the  artery  by  means  of  an  arm  carrying  a  pad,  and  supported  on 
a  plate  moulded  to  the  opposite  side  of  the  limb.  The  i)ad  is  movable, 
either  by  a  joint,  or  by  a  screw.  The  best  form,  I  think,  is  Carte's 
compressor,  in  which  the  arm  which  carries  the  pad  is  mounted  on  a 
universal  joint,  and  is  supported  i)y  stout  india-rubber  springs,  so  as  to 
l»e  somewhat  elastic  without  siiifting.  IJut  the  great  success  of  digital 
pressure  has  much  restricted  the  ai)plication  of  these  instruments,  and  I 
think  it  unnecessary  to  describe  or  figure  their  various  forms.  The 
reader  will  find  them  figured  in  Broca's  work  on  Aneurism,  or  in  the 
illustrated  catalogues  of  the  instrument  makers. 

^  Si'e  Holdfiri,  in  8t  BartliolDiTunv'.*  H()s|iital  Reports,  vol.  viii,  p.  140.  A  similar 
plan  lia.s  Ik-imi  fjroposcd  b}'  a  l"'ri'nch  .siiri^con.  In  a  oa.<e  recently  under  my  care  the 
conipre.-iscT.-i  found  relief  by  leanini^  the  opposite  elbow  on  the  compressitii^  fintjers. 

■•^  Till'  most  ra|)id  cures  are  one  of  tcnioral  aneurism,  undiT  tln^  care  of  Mr.  Darke 
of  Salisbury,  cured  in  1^  hours;  one  (pojiliteal),  und(!;'  Mr.  iJlackman,  in  three;  hours; 
and  om-  und(!r  Vanxetti's  care  in  2.]  hours.  On  an  average  it  is  said  that  cases  of 
poj)liteal  aneuri.>m  are  cured  by  digital  pressure  in  three  daj's,  and  by  instrumental 
in  fourteen. — Lancet,  May  8.  1875. 

^  Lancet,  June  14,  21,  1873. 


TREATMENT    BY    PRESSURE.  537 

The  advantasies  of  the  digital  over  the  instrumental  form  of  pressure 
are  that  it  involves  less  risk  of  compressing  the  vein  along  with  the 
artery,  a  drawback  which  is  inseparable  from  instrumental  compression  ; 
that  it  is  less  likely  to  ulcerate  the  skin  ;  that  tiie  minimum  of  pressure  nec- 
essary for  the  purpose  is  more  easily  ascertained ;  and  that  it  is  more  easy 
to  shift  the  point  of  its  application  to  one  at  a  short  distance,  so  as  to 
give  relief  to  the  skin  at  the  point  (irst  compressed,  yet  not  change  to  a 
different  part  of  the  artery.^ 

The  advantage  of  instrumental  over  digital  pressure  consists  in  its 
requiring  no  numerous  staff"  of  trained  assistants;  but  it  does  require  the 
constant  supervision  of  at  least  one  well-trained  and  competent  attend- 
ant, and  is  much  more  likely  to  succeed  when  that  attendant  is  the 
surgeon  himself.  It  very  often  fails  from  being  left  to  students,  nurses, 
etc.,  who  direct  the  pressure  wrongly  or  use  it  too  severely. 

The  cure  of  an  aneurism  liy  pressure  is  generally  preceded  by  enlarge- 
ment of  the  neighboring  collaterals,  arteries  being  felt  pulsating  in  situ- 
ations where  normally  no  artery  is  perceptible,  and  it  is  often  accom- 
panied by  very  severe  pain  in  the  part,^  which  sometimes  is  so  agonizing 
that  the  patient  declares  he  can  bear  the  pressure  no  longer,  and  desires 
that  an  operation  may  be  at  once  performed. 

"  Bapid  "  PreaHure. — Another  method  of  attempting  the  cure  of  aneur- 
ism by  pressure  is  by  what  is  called  "rapid"  pressure,  ?'. e.,  the  endeavor 
to  keep  the  circulation  entirely  stopped  for  as  long  a  time  as  may  be  neces- 
sary to  fill  the  sac  with  clot,  in  the  hope  that  definitive  coagulation  will 
follow  on  this.  Generall}'  speaking,  the  proceeding  is  too  painful  to  be 
endured  without  antesthesia,  and  for  this  puri)ose  a  patient  has  been  kept 
under  the  influence  of  chloroform  sufficiently  to  bear  the  pressure  for  as 
many  as  fifty-two  hours,'^  being  allowed  to  recover  consciousness  at  inter- 
vals just  enough  to  allow  him  to  swallow.  The  plan  has  hitherto  been 
carried  out  chiefly  in  aneurisms  of  the  abdomen  and  thigh,  by  compres- 
sion of  the  aorta  or  one  of  the  iliac  arteries.  Where  the  vessels  are 
more  accessible  to  pressure,  orwiiere  their  ligature  does  not  involve  very 
great  danger,  it  seems  very  doubtful  wliether  it  is  justifiable  to  resort  to 
it.  The  pressure  has  in  all  known  cases  been  applied  by  some  form  of 
tourniquet.  Further  particulars  will  be  found  under  the  head  of  Abdom- 
inal Aneurism. 

Flexion  of  the  limb  has  often  proved  successful  in  the  treatment  of 
poi)liteal  aneurism.  It  has  been  used  also  with  success,  I  believe,  in  the 
treatment  of  aneurism  at  the  bend  of  the  elbow,  and  has  been  tried  in 
femoral  aneurism,  but,  as  far  as  I  can  ascertain,  with  no  definite  results.* 

1  Mr.  Walker,  of  Liverpool,  insists,  and  I  think  with  some  reason,  on  what  he 
calls  "  the  one  artery  system  "  of  pressure.  That  is  to  say,  for  instance,  in  popliteal 
aneurism  the  pressure  is  always  to  be  applied  either  to  the  coniinim  or  to  tlie  super- 
ficial femoral.  In  changing  from  the  one  to  the  other  the  system  of  collateral  vessels 
is  also  changed,  and  the  course  of  the  cure  interrupted.  In  tlie  instrumental  form  of 
pressure  it  is  almost  always  necessary  to  shift  the  pad  a  considerable  distance ;  not  so 
in  the  digital. — tSee  Walker,  in  Liverpool  Med.  and  Surg.  Reports,  vol.  v,  and  Lancet, 
May  8,  1875.  p.  (i39. 

2  See  Mr.  Cam[)bell  DeMorgan's  case,  related  in  theSyst.  of  Surg.,  2d  ed.,  vol.  iii, 
p.  445. 

3  Mr.  Holt's  case,  in  Clin.  Soc.  Trans  ,  vol.  vii,  p.  56. 

■*  A  case  of  Dr.  Gordon  Buck  is  always  quoted  in  the  books  as  a  successful  adapta- 
tion of  fli'xion  to  femoial  aneui'ism.  A  reference  to  the  original  (Amer.  .Jour.  Med. 
Sc,  1870,  p.  69)  will  show  that  the  case  was  merely  one  of  temporary  return  of  pulsa- 
tion after  cure  by  compression,  and  that  the  effect  of  the  flexion  was  to  exercise  direct 
pressure  on  the  sac.     It  bore  very  little  resemblance  to  a  recent  case  of  aneurism. 


538  DISEASES    OF    THE    ARTERIES. 

Genuflexion  acts  by  retarding  the  circulation  much  as  compression 
of  the  arterj'  does,  and  also,  as  I  believe,  by  displacement  of  clot  and  by 
direct  pressure  on  the  parts,  including,  perhaps,  the  artery  above  the 
tumor,  as  in  our  fourth  mode  of  spontaneous  cure  (p.  531).  It  need  not 
be  enforced  to  an  extent  which  is  either  painful  to  the  patient  or  likely  to 
injure  the  tumor,  and  if  not  speedily  successful  should  not  be  long  per- 
sisted in.  The  simplest  cases  are  the  best  for  it.  More  will  be  said  on 
this  subject  under  the  head  of  Popliteal  Aneurism. 

3IanipuIafio)}  of  the  tumor  was  introduced  into  practice  by  Sir  W. 
Fergusson.  in  order  to  imitate  the  second  mode  of  spontaneous  cure 
above  described.  The  object  of  the  manipulation  is  to  press  the  two  walls 
of  the  aneurism  together,  and  so  far  to  displace  some  of  the  coagula  which 
are  contained  in  it  that  they  ma}'  either  be  carried  into  the  distal  mouth 
of  the  aneurism  or  at  least  project  into  the  blood-stream  and  form  the 
starting-point  of  renewed  coagulation.  It  has  been  employed  with  success 
in  popliteal,  femoral,  carotid,  and  subclavian  aneurisms,  and  is  an  undoubt- 
edly justifiable  measure  in  tumors  which  cannot  be  operated  on  without 
ver}'  great  danger,  which  are  not  near  to  bursting,  and  in  which  there  is 
evidence  of  the  formation  of  blood-clot. 

Coagiilatmg  Injections. — The  injection  of  coagulating  fluids  (generally 
the  perchloride  of  iron,  about  25  per  cent,  of  the  salt)  has  been  occasion- 
ally used  with  success ;  but  it  can  only  be  rarelj'^  useful  in  arterial  aneurism, 
since  in  order  to  be  employed  with  safety  it  requires  that  the  circulation 
should  be  commanded  above  the  tumor,  i.  e.,  that  the  case  should  be 
amenable  to  ligature  or  pressure,  which  therefore  are  generally  indicated, 
as  the  injection  is  neither  free  from  danger  nor  by  any  means  certain  to 
cure  the  disease. 

Galvano-puncture. — Electricit}'  may  also  be  employed  to  coagulate  the 
blood  in  the  sac.  A  weak  stream  of  galvanic  electricity  passed  through 
the  blood  will  be  found  to  decompose  it,  hydrogen  being  disengaged  at 
the  negative  and  oxygen  at  the  positive  pole,  and  in  this  way  coagulation 
may  be  commenced,  which  under  favorable  circumstances  will  go  on  till 
the  sac  is  completely  filled  ;  but  the  method  is  a  very  uncertain  one,  and 
is  liable  to  failure  from  the  melting  down  of  the  soft  clot  which  may  have 
been  formed,  or  it  may  prove  fatal  by  setting  up  inflammation  of  the  sac, 
or  bj'  causing  sloughing  around  the  needle  punctures,  followed  by  haemor- 
rhage. 

Introduction  of  Foreign  Bodies. — Finally,  it  has  been  proposed  and 
attempted  to  produce  coagulation  in  the  sac  by  the  introduction  of  foreign 
bodies  into  the  blood  which  is  circulating  through  it — much  in  the  same 
wa}'  as  the  fibrin  is  whipped  out  of  blood  in  a  basin  by  a  bunch  of  twigs. 
Mr.  Moore'  originated  this  method  of  treatment,  by  introducing  a  large 
quantity  of  iron  wire  into  the  sac  of  an  aortic  aneurism.  Considerable 
coagulation  was  produced,  but  the  wire  caused  fatal  inflammation  of  the 
sac-wall.  Di'.  Muriay  of  Newcastle  tried  carbolized  catgut,  but  without 
result.  Ilecently  horsehair  has  been  used,  by  Dr.  I^evis  of  Philadelphia, 
in  a  case  of  sul)claviaM  aneurism,  and  by  Mr.  I>ryant  iu  one  of  popliteal 
aneurism,  and  also  with  the  elfect  of  producing  a  good  deal  of  coagula- 
tion.'^ Both  cases,  which  were  of  a  ver}-  unfavorable  nature,  ended 
fatally;  iMit  it  does  not  appear  that  the  foreign  body  caused  any  injury  to 
the  sac  or  other  parts  in  either,  and  the  expeiinient  may  be  worth  repeat- 
ing iu  a  case  uliich  is  not  auienal)le  to  more  hopeful  measures.  But  treat- 
ment which  acts  only  on  the   blood    in  tiic   sac  holds   out  comparatively 


'  Mod.-Chir.  Trjins.,  vol.  xlvii,  p.  129. 

'  The  preparation  from  Mr.  Bryant's  case  is  in  the  Museum  of  Guy's  Hospital. 


INNOMINATE    ANEURISM.  539 

little  hope  of  success.  The  really  successful  methods  of  treatment — rest, 
ligature,  and  pressure — are  assisted  in  their  operation  by  the  reaction  of 
the  tissues  around  and  of  the  sac  itself.  The  weak  point  in  the  treatment 
by  manipulation,  coagulatiuii;  injections,  galvano-puncture,  and  the  intro- 
duction of  foreign  bodies  is,  that  these  metliods  either  tend  to  injure  or 
to  produce  inflammation  of  tlie  sac-wall. 

A  short  exposition  of  the  chief  kinds  of  surgical  aneurism  is  necessary 
here,  to  which  I  shall  append  a  description  of  the  operation  of  tying  each 
artery. 

Thoracic  Aneurit^m. — Aneurism  of  the  arch  of  the  aorta  can  only  very 
rarely  be  made  the  subject  of  surgical  treatment,  but  the  surgeon  should 
be  acquainted  with  its  main  features,  in  order  to  diagnose  it  from  other 
diseases,  as  well  as  to  distinguish  those  rare  cases  in  whicli  operative 
treatment  may  be  justifiable.  Bruit  is  very  frequently' absent  in  thoracic 
aneurisms,  which  are  often  of  the  tubular  variety,  or  open  into  the  artery 
b}'  a  wide,  unobstructed  orifice.^  The  pulsation  also  is  often  imperceptible, 
so  long  as  the  thoracic  i)arietes  remain  intact,  and  it  may  be  simuhited  by 
pulsation  communicated  by  the  heart  to  a  cancerous  or  otlier  tumor.^ 
Consequently  the  diagnosis  often  rests  more  on  the  indirect  than  the 
direct  symptoms.  These  are  usuallj"  pain  between  the  shoulders  from 
pressure  on  the  spine,  ringing  cough  from  pressure  on  the  trachea,  spas- 
modic d3'spna?a,  either  from  pressure  on  tlie  recurrent  nerve  or  on  the 
windpipe  itself,  dyspnoea,  haemoptysis,  and  inequality  of  the  pulse  in  the 
wrists  and  sometimes  also  in  the  carotids.  Very  commonly  one  of  the 
large  branches  given  off' by  the  arcli  is  so  obstructed  that  no  i)ulse  can  be 
felt  in  its  branches. 

Thoracic  aneurism  is,  as  a  rule,  best  treated  b}'  the  internal  or  medical 
treatment  descril)ed  on  p.  531.  Under  this  plan  of  treatment  almost  every 
case  of  thoracic  aneurism,  and  many  cases  of  aneurisms  of  the  limbs,  will 
rapidly  improve  ;  and  in  some  rare  cases  even  of  aortic  aneurism  a  com- 
plete cure  may  possibly  be  obtained.  Tlie  only  surgical  measures  which 
are  admissible  in  aortic  aneurism  are  either  galvano-puncture  or  the  liga- 
ture of  the  carotid  on  Brasdor's  method.  The  former  is,  as  far  as  our 
present  knowledge  extends,  an  uncertain  and  a  dangerous  measure,  which, 
however,  has  yielded  some  good  results  in  the  skilful  hands  of  Signor 
Ciniselli  and  others.  The  latter  seems  to  me  to  be  useful  or  justifiable 
only  in  aneurisms  believed  to  implicate  the  transverse  position  of  the  arch 
and  to  be  extending  along  the  course  of  the  carotid  into  the  neck,  in 
which  case  the  corresponding  artery  (generall}'  the  left  carotid)  may  be 
tied,  and  this  has  been  done  by  Mr.  C.  Heath  in  one  well-known  case  with 
very  considerable  benefit.  The  patient,  an  agricultural  laborer,  under  Dr. 
Cockle's  care,  is  now  alive,  and  remained  in  good  health  for  about  four 
years  after  the  operation,  earning  his  bread  by  fieldwork.  Latterly  the 
tumor  has  begun  to  grow  again.' 

Innominate  Aneurism. — Aneurism  of  the  innominate  artery  is  difficult 
to  diagnose  from  aortic  aneurism,  and  many  cases,  under  the  care  of  the 
best  surgeons,  are  on  record,  in  which  supposed  innominate  aneurisms 
have  on  dissection  turned  out  to  have  been  purely  aortic.    It  forms  a  pul- 

i  On  the  other  htrnd,  I  have  known  the  bruit  so  loud  as  to  bo  heard,  all  over  the 
room. 

'■*  See  a  case  reported  by  me  in  the  Path.  Tran.s.,  vol.  ix,  p.  29*. 

3  On  thesubject  of  thoracic  aneurism  1  would  refer  the  reader  for  details  and  dis- 
cussions, for  wiiich  I  can  tind  no  space  here,  to  a  series- of  liectures-  pubiish«d.  in  the 
Lancet  for  June  and  July,  1872. 


640  DISEASES    OF    THE    ARTERIES. 

satiiio-  tumor  near  the  right  sternoclavicular  articulation,  pushing  the 
upper  part  of  the  sternum  forwards,  often  dislocating  the  end  of  the  clavi- 
cle or  eroding  it,  and  usually  first  presenting  in  tlie  interval  between  the 
tendinous  and  muscular  origins  of  the  sternomastoid.  More  or  less  dysp- 
noea may  be  present  from  pressure  on  the  trachea,  and  the  pulse  in  the 
riglit  wrist  is  generally  mucli  feebler  than  in  the  left.  The  other  symp- 
toms will  vary  with  tlie  size  of  the  tumor. 

In  innominate  as  in  aortic  aneurism  it  is  desirable  to  avoid  sui'gical 
measures  if  possible,  since  no  operation  can  be  practiced  without  very 
great  danger,  and  the  i)rospect  of  success  or  even  of  benefit  is  very  slight. 
But  if  tlie  tumor  be  extending,  in  spite  of  the  treatment  by  rest,  and  es- 
pecially if  it  be  extending  along  the  trachea,  as  evidenced  by  its  growth 
and  by  the  increase  of  dyspnoea,  it  is,  in  my  opinion,  quite  justifiable 
either  to  try  galvano-puncture,  or  to  tie  the  right  carotid  on  Brasdor's 
method,  or  even,  perhaps,  to  tie  the  subclavian  artery  as  well.^ 

Cay^otid  Aneurism. — Aneurism  of  the  cai'otid  artery  is  generally  situ- 
ated at  the  bifurcation  of  the  common  carotid.  It  ma}',  however,  affect 
the  common  trunk  lower  down,  or  one  of  the  secondary  carotids,  gener- 
ally' the  internal.  The  diagnosis  is  usually  easy,  but  the  lower  down  the 
tumor  extends  the  greater  is  the  difhculty  in  distinguishing  it  from  aortic 
aneurism  ;-  and  cases  have  been  recorded  here,  as  in  other  regions  of  the 
body,  where  eitlier  an  abscess  pressing  on  the  artery,  and  receiving  pul- 
sation from  it,  has  been  mistaken  for  an  aneurism,  or,  vice  verm,  an  an- 
eurism has  been  mistaken  for  an  abscess  ;  but  I  do  not  know  that  the 
danger  of  mistakes  is  greater  here  than  elsewhere.'' 

Brasdor^s  and  Wardroj)^s  Operations. — An  aneurism  of  the  common 
carotid  low  down  in  the  neck,  or  an  aneurism  of  the  intrathoracic  part 
of  the  left  carotid  (if  the  latter  affection  ever  occurs,  of  wiiich,  as  far  as 
I  know,  no  instance  exists  at  present),  ma}^  be  treated  with  good  pros- 
pect of  success  by  Brasdor's  operation  ;  and  it  is  to  these  aneurisms,  as 
Hodgson  and  Wardrop  have  clearly  shown,  that  Brasdor's  operation  is 
in  strictness  applicable;  and  a  good  augur}' of  its  probable  success  in 
sucli  cases  is  given  by  the  fact — which  Wardrop  noticed  vvitli  surprise  in 
a  case  in  which  he  had  tied  the  arter}^  beyond  the  aneurism — that  the 

^  As  I  have  myself  tied  the  subclaviiin  (third  part)  and  the  carotid  simultaneously 
in  a  case  of  innominatt;  aneurism,  I  need  hardly  say  that  I  think  the  distal  operation 
justifiable  in  appropriate  cases  of  this  atiection.  But  I  must  say  that  the  study  of 
ray  own  case  and  of  the  published  records  of  the  others  has  led  me  to  the  decided 
conviction  that  the  benelii  which  has  been  obtsiined  in  some  of  them  has  been  due 
usually  to  the  licjature  of  tlic  carotid  b}-  which  the  carotid  or  tracheal  portion  of  the 
sac  has  been  obliterated  ;  and  I  should  be  disposed  in  any  future  cases  to  commence 
with  the  less  severe;  measure  of  tying  the  rigiit  carotid.  It  must  be  remcunbered  that 
the  lari^e  branches  from  the;  first  part  of  the  subclavian  must  carry  on  the  collateral 
circulation  after  the  third  part  of  that  artcM-y  has  been  tied  ;  and  for  this  purpose  the 
circulation  must  go  on  through  the  sac  into  the  first  part  of  tlu;  subclavian  artery, 
and  probably  with  increased  force,  after  the  operation,  so  that  the  entire  obliteration 
of  the  sac  by  ihi-  disial  ligature  seems  impossible!  unless  the  first  part  of  the  subcla- 
vian could  be  secured  inside  its  large  branches,  which  ufi  to  the  present  timci  has  b(;en 
found  incompatible  with  the  patient's  recovery,  even  without  the  complication  of 
ligature  (if  tlie  right  carotid.  Still  Mr.  Kearn's  I'asc,  where;  a  prae-tical  cure  c(;rtainly 
resulted  (a  channel  about  the;  .-ize  of  the  originsii  artery  being  maintained  through 
the  clot  which  filled  the  aneurism),  is  an  encouragement  for  tying  the  two  arteries 
either  simultaneously  or,  perhaps  better,  with  an  interval,  as  in  that  case. 

2  fSee  the  well-known  case  under  Sir  A.  ('ooper's  care  in  Allan  Hums,  On  the  Sur- 
gical Anatomy  of  the;  Head  and  Neck,  p.  00  et  seq. 

3  Traumatic  aneurism  of  the  vertebral  artery  has  also  been  mistaken  for  carotid 
aneurism.     On  this  subject  see  a  lecture  published  in  the  Lancet,  July  26th,  1873. 


LIGATURE    OF    CAROTID. 


541 


tumor  collapses  immediately  the  artery  is  tied,  instead  of  increasing  in 
tension  and  pulsation,  as  it  would  do  if  the  stream  of  blood  pumped  in 
from  tlie  heart  were  not  derived  down  the  collaterals,  which  at  once  begin 


Fig.  243. 


Fig.  244. 


Fin.  24.3  shows  Wardrop's  operation,  /.  e.,  the  ligature  of  the  carotid  artery  for  aneurism  of  the 
innominate.  Wardrop's  idea  seems  to  have  been  that  as  the  quantity  of  lilood  conveyed  by  the  carotid, 
that  by  the  branches  of  the  first  part  of  the  subclavian,  and  that  by  tlie  third  part  of  that  artery,  may 
be  taken  to  be  about  equal,  he  could  deprive  the  sac  of  one-third  of  its  blood  by  tying  the  carotid,  and 
of  two-thirds  l:)y  tying  the  third  part  of  the  subclavian  also.  He  had  not  allowed  for  the  increase  of 
the  collateral  circulation. 

Fig.  244  shows  Brasdor's  operation  as  applied  to  an  aneurism  limited  to  the  trunk  of  the  carotid,  the 
only  situation  in  which  this  operation  can  in  strictness  be  applied. 

I  have  shown  reasons  for  believing  that  when  these  operations  succeed  they  do  so,  not  so  much  by 
retarding  the  blood-flow  through  the  tumor  as  by  the  extension  of  coagulation  from  the  tied  artery 
into  the  aneurismal  sac. 

to  enlavge.  It  is  possible  that  some  aneurisms  seated  low  down  on  the 
carotid  might  even  be  cured  by  distal  compression,  but  no  case  is  at 
present  recorded. 

Aneurisms  seated  near  the  bifurcation  or  in  one  of  the  secondary  caro- 
tids or  their  branches  may  be  treated  either  by  the  old  operation,  by  the 
Hunterian  ligature,  or  by  compression.  The  first  method  has  been  de- 
scribed above.  Compression  of  the  common  carotid  is  not  an  easy  thing 
either  to  perform  or  to  endure;  nevertheless  at  least  five  successful  cases 
have  been  published.^  It  may  be  effected  either  by  the  finger,  by  an  ap- 
paratus with  a  movable  arm  carrying  a  small  pad,  or  by  Coles's  com- 
pressor. The  point  against  which  it  is  most  easily  compressed  is  the 
anterior  tubercle  of  the  transverse  process  of  the  fifth  cervical  vertebra, 
which  lies  about  two  inches  al)0ve  the  clavicle,  and  is  called  sometimes 
"  Chassaignac's  tubercle,"  since  that  surgeon  first  drew  attention  to  the 
comparative  ease  with  which  the  carotid  could  be  compressed  there. 

Ligatiu-e  of  the  Common  Carotid. — The  common  carotid  maj'  he  tied 
in  any  part  from  the  root  of  the  neck  to  the  bifurcation,  and  either  of 
the  secondary  carotids  are  accessible  as  high  as  the  parotid  gland.  The 
"lieu  d'election  "  for  the  ligature  of  the  common  trunk  is  just  above 
where  it  is  crossed  by  the  omohyoid  muscle,  i.  e.,  at  tlie  level  of  the  cri- 
coid cartilage.     An  incision  is  made  with  its  centre  at  this  level, '^  and  in 


1  See  Lancet,  June  21,  1873. 

2  In  the  chapter  on  Operative  Surgery  diagrams  will  be  found  showing  the  external 
incisions  in  all  the  ordinary  operations  on  the  arteries. 


542 


DISEASES    OF    THE    ARTERIES. 


the  course  of  the  vessel  (?".  f.,  in  a  line  from  the  sternoclavicnlar  articu- 
lation to  the  point  midwa}'  between  the  angle  of  the  jaw  and  mastoid 
process),  its  length  being  proportioned  to  the  size  of  the  neck.  After 
the  skin,  platysma,  and  deep  fascia  have  been  divided  the  edge  of  the 
sternomastoid  is  seen,  and  the  upper  belly  of  the  omohyoid  may  be 
noticed  passing  upwards  and  inwards.  Then  the  operator  searches  for 
the  sheath  of  the  vessels,  lying  close  on  the  trachea,  and  often  having 

the   deseendens  noni  nerve 
Fig.  245.  in     front     of     it.       Having 

opened  the  sheath,  the  pul- 
sation and  the  color  of  the 
arter}^  will  be  recognized. 
Then  it  is  to  be  cautiously 
separated  with  the  director 
and  the  point  of  the  knife 
from  the  sheath  and  the 
vein,  for  a  ver}^  short  dis- 
tance, so  as  to  allow  the 
needle  to  be  got  round  it. 
Compression  of  the  bare 
artery  between  the  finger 
and  the  needle  will  stop  the 
pulsation  in  the  tumor,  or, 
if  the  operation  be  on  the 
distal  side  of  the  aneurism, 
will  stop  the  pulse  in  the 
temporal  artery ;  and  this 
experiment  should  never  be 
neglected,  for  very  good  sur- 
geons have  been  so  deceived 

LigErtureof  the  common  carotid  artery.    The  edge  of  the  ^.V   pi'lsation    COmmunicated 

Bternomastoid  muscle  is  seen  with  a  double  hlunt  hook  passed  tO  a  piece  of  faScia  as  tO  tie 

under  it.    b  shows  the  carotid  artery,  with  a  ligature  passed  it  instead  of  the  VeSSCl. 
round  it.    The  sheath  is  shown  opened,  and  on  the  sheath  Thp  lowpr  mrf  of  thp  Cir- 

may  be  seen  the  deseendens  noni  nerve.    Crossing  the  sheath  .  ,    .  '  *,         ,  '  , 

is  the  omohyoid  muscle,  a.    The  opening  in  the  sheath  is  ^tld    IS    morC    deeply  Seated, 

represented   larger  than   it  would   be  made  in  practice,  in  and    in    tying   it    it    is    better 

order  to  show  the  jugular  vein  external  to  the  artery,  and  ^q     divide      tllC      stcrnomas- 

ihe  pneumogastric  nerve  between  the  two  vessels  and  poste-  ,     ._,     f       i        p,ir>no-h     fr>     a^r 

rior  to  them.    In  practice,  however,  the  nerve  ought  never  ^^'^     neciy     eiiuiij^ii     lu     ex- 

to  be  exposed  ;  and  the  jugular  vein,  unless  it  is  distended,  is  pOSC    fairly    the    Sternohyoid 

■ueuaiiy  not  brought  into  view.  and  Sternothyroid   muscles. 

These  muscles  should  tlien 
be  carefully  divided  on  a  director,  when  the  sheath  will  be  exposed.  In 
tying  the  carotid  the  jugular  vein  and  pneumogastric  nerve  are  not  usu- 
ally seen,  l)ut  eitlier  of  them  may  be,  especially  the  vein,  which  is  some- 
times swollen  and  laps  over  the  artery,  so  as  to  give  some  trouble.  At 
the  root  of  the  neck,  on  the  riglit  side,  the  vein  is  separated  from  the 
artery  by  an  interval,  while  on  the  left  side  it  somewhat  overlaps  the 
artery.  The  slieath  of  the  vessels  near  the  root  of  the  neck  is  usually 
covered  \ry  several  veins  descending  from  the  thyroid  body,  whicii  in- 
creases the  difficulty  of  the  operation.  The  ligature  should  alwa3's  be 
passed  from  without  inwards. 

Ligature  of  the  common  carotid  has  hitherto  proved  fatal  in  about  40 
per  cent,  of  the  cases  operated  on.  Dr.  Pilz  has  tabulated  (iOO  miscel- 
laneous cases  in  the  9th  vol.  of  Langenbeck's  Jrchives,  with  259  deaths. 
But  the  danger  seems  to  depend  more  on  the  patient's  general  condition 


LIGATURE    OF    LINGUAL    AND    THYROID.  543 

than  on  the  intrinsic,  severity  of  the  operation,  the  great  mortality  being 
in  cases  where  the  artery  has  been  tied  for  hjiemorrhage.  In  ordinary 
cases  the  death  rate  is  estimated  at  abont  one-tliird.' 

Ligature  of  the  External  Carotid. — Ligature  of  the  internal  carotid  is 
not  an  operation  witli  which  I  have  any  acquaintance,  except  as  a  dis- 
secting-room exercise;  but  the  external  carotid  has  often  been  tied,Mn 
the  following  manner :  Make  an  incision  downwards,  from  a  little  external 
to  the  angle  of  the  jaw  to  near  the  anterior  edge  of  the  sternomastoid, 
from  one-third  to  half  an  inch  below  the  upper  border  of  tiie  thyroid  car- 
tilage, dissect  away  some  cervical  glands  and  the  venous  branches  con- 
nected chiefly  vvith  the  facial  and  lingual  veins,  which  lie  over  the  artery. 
The  glands  should  not  be  torn  away  or  lifted,  for  fear  of  tearing  tiie  veins, 
to  which  the}'  adhere  closely,  but  freely  incised,  and  the  veins  tied  and 
divided  if  necessary.  Then  look  for  the  hypoglossal  nerve,  which  crosses 
the  artery  perpendicularly,  and  will  serve  as  a  guide  to  the  vessel  lying 
immediatel}'  beneath.  There  is  usually  about  half  an  inch  of  the  trunk 
available  for  the  purpose  of  placing  the  ligature,  between  the  origin  of 
the  superior  thyroid,  which  is  generally  close  to  the  bifurcation,  and  that 
of  the  lingual,  facial,  and  occipital  above.  The  identity  of  the  vessel  may 
be  known  by  its  relation  to  tlie  iiypoglossal  nerve,  the  presence  of  a 
collateral  (the  superior  thyroid),  when  it  happens  to  come  into  view,  and 
the  fact  that  pressure  on  the  exposed  vessel  commands  the  pulse  in  the 
temporal,^ 

Ligature  of  the  Lingual  and  Thyroid  Arteries. — Some  of  the  branches 
of  the  external  carotid  have  been  tied.  The  lingual  is  the  one  most  fre- 
quently operated  upon,  and  mainly  on  account  of  hemorrhage  from  cancer 
of  the  tongue.  An  incision  is  made  having  its  centre  opposite  the  great 
cornu  of  the  liyoid  bone,  and  either  horizontal  or  downwards  and  for- 
wards, at  an  angle  of  45^.  The  superficial  parts  and  the  deep  fascia 
having  been  divided,  the  operator  seeks  for  the  ninth  nerve,  which  runs 
superficial  to  the  hj'oglossas  muscle,  while  the  artery  crosses  beneath  it 
to  pass  under  that  muscle.  One  plan  is  to  draw  the  nerve  aside  and  tie 
the  vessel  as  it  plunges  under  the  muscle  ;  the  other  is  to  divide  the  fibres 
of  the  hyoglossus  from  the  bone  and  look  for  the  artery,  lying  parallel  to 
the  upper  border  of  the  hyoid  bone.  It  must  be  remembered  that  the 
artery  varies  in  its  origin,  and  in  its  course  external  to  the  cornu  of  tiie 
hj^oid  bone,  so  that  it  is  sometimes  very  difficult  to  find  it  in  the  first 
portion  of  its  course. 

As  to  tiie  other  arteries  in  the  neck  I  may  quote  the  following  direc- 
tions : 

"  For  the  superior  thyroid  an  incision  is  to  be  made,  two  inches  long, 
parallel  to  the  inner  margin  of  the  sternomastoid,  its  centre  correspond- 
ing to  the  great  cornu  of  the  thyroid  cartilage.  This  brings  into  view  the 
omohyoid  muscle  and  the  sheath  inclosing  the  jugular  vein  and  common 
carotid;  the  fibrous  lamellae  which  cover  the  artery  having  been  torn 
away  with  a  director,  the  superior  thyroid  may  be  found  running  down- 
wards between  the  vessels  and  the  tliyroid  gland ;  or,  if  tlie  facial  is 
the  arteiy  sought  for,  it  can  be  found  by  the  same  incision,  the  search 
being  conducted  upwards  towards  tlie  jaw,  where  the  arteiy  is  found 
between  the  great  vessels  and  the  submaxillary  gland. 

"  The  inferior  thyroid  is  to  be  sought  by  an  incision  similar  to  that  for 


1  Syst.  of  Surg.,  vol.  iii,  p.  589. 

'^  M.  Guyon  quotes  twenty-four  cases  in  the  6th  vol.  of  the   Mem    de  la  Soc.  de 
Chir.  de  Paris. 

3  Syst.  of  Surg.,  vol.  iii,  p.  592,  2d  ed. 


544  DISEASES    OF    THE     ARTERIES. 

the  carotid  in  the  lower  part  of  the  neck.  It  is  usually  concealed  by  the 
upper  part  of  the  omohyoid  muscle.  This  muscle  must  therefore  l)e  de- 
pressed or  divided,  and  tlie  artery  sought  for  between  the  trachea  or 
a^sophagus  and  the  trunk  of  the  carotid.  The  recurrent  nerve  and  the 
descendens  noni  will  be  endangered  in  this  operation.'" 

Orbital  aneui-ism  is  a  rare  disease,  i.  ^.,  pulsating  tumor  in  the  orbit  is 
rare,  and  true  aneurism  is  still  rarer.  The  case  which  first  attracted  the 
notice  of  the  profession  was  published  by  Mr.  Travel's'  as  one  of  aneurism 
by  anastomosis,  but  it  is  now  conceded  on  all  hands  that  most  of  the 
cases  of  pulsating  tumor  in  the  orbit  are  certainly  not  of  this  nature, 
altiiough  we  may  still  admit  the  occasional  occurrence  of  aneurism  by 
anastomosis  here,  distinguished  by  its  appropriate  symptoms.^  But  the 
objections  to  regarding  the  ordinary  cases  of  pulsating  tumor  in  the 
orbit  as  aneurisms  by  anastomosis  are  irresistible.  Mr.  Nunneley,  in 
two  most  interesting  papers  on  pulsating  tumors  in  the  orbit,*  succeeds, 
I  think,  in  proving  this  point,  since  "  aneurism  by  anastomosis  involves 
all  the  neighboring  vessels,  arteries,  and  veins  in  active  disease;  aneurism 
of  the  orbit  is  generally  limited  to  a  single  part,  or  if  the  neighl)oring 
vessels  are  dilated  they  seem  only  enlarged  from  obstruction — ligature 
of  the  trunk  of  a  vessel  leading  to  an  undoubted  aneurism  by  anasto- 
mosis is  an  extremely  unsuccessful  operation  ;  in  aneurism  of  the  orbit, 
a  very  successful  one — finally,  the  cases  dissected  have  turned  out  to  be 
common  aneurism." 

But  that  some  of  these  tumors  are  not  arterial  aneurisms  seems  clear 
enough,  from  a  tract  published  by  M.  Delens^  recounting  two  cases 
under  tiie  care  of  Nelaton,  in  both  of  which  the  disease' was  found  to 
consist  in  a  communication  between  the  internal  carotid  arter^^  and  the 
venous  channel  in  the  cavernous  sinus  ;  and  again,  Mr.  Bowman's  case 
(published  in  Streatfield's  Ophthalmic  Beports^  April,  1859)  shows  that 
all  the  ordinary  symptoms  of  what  is  called  "orbital  aneurism  "  may  be 
caused  by  coagulation  of  blood  in  the  venous  sinus  pressing  on  the  carotid 
arter}'  and  occasioning  protrusion  of  the  eyeball. 

The  s3'mptoms  of  "orbital  aneurism  "  (so-called)  are  protrusion  of  the 
eyeball,  eversion  of  tlie  lids,  loss  of  vision,  and  pulsation  ;  sometimes  in 
the  form  of  definite  rounded  tumor  above  the  eyeball,  sometimes  as  a 
general  pulsation  perceptible  throughout  the  orbit. 

In  cases  which  have  been  followed  to  their  conclusion  uninfluenced  by 
treatment,  it  has  been  found  that  the  tumor  will  sometimes  subside  en- 
tirely without  any  permanent  mischief,''  or  in  some  cases  with  loss  of 
vision  in  consequence  of  the  long  exposure  of  the  protruded  eyeball;' 
and  this  is  in  itself  a  strong  presumption  against  the  presence  in  such 
instances  of  arterial  aneurism,  and  a  strong  argument  against  the  too 
early  resort  to  any  serious  surgical  operation. 

Tlie  aj^jiearances  on  dissection  have  also  been  very  various.  In  some 
cases  it  is  said  that  an  ordinary  encysted  aneurism  of  the  ophthalmic  artery 
has  been  found,"  whether  in  tlie  orbit  or  in  the  sella  turcica."     In  other 

1  Syst.  of  Sure;.,  vol.  iii,  p.  594,  2d  ed. 

2  Mcd.-Chir.  Trans.,  vol.  ii.     See  also  anolhor  case,  by  Mr.  Dalrymple,  in  vol.  vi. 

3  S<^e  Hayncs  Walton,  Suru'.  Di.«.  of  the  Eyo,  2d  cd.,  1861,  p    230. 
■*  Med.-Cliir.  Trans.,  vols,  xlii  and  xlvlii. 

*  De  la  Communication  di-  la  Carotido  internn  etdu  Sinus  Cavornoux,  Paris,  1870. 
8  Erichsen,  Scinnce  and  Art  of  Sur<;jcry,  vol.  ii,  p.  28.      Holmes,  Amer.  Jour,  of 

Mod    Science,  .July,  1804,  p.  44. 

'  Franco,  Guy's  IIosp.  Reports,  Ser.  iii,  vol.  1,  p.  58,  1855. 

*  Guthrie's  case,  quoted  by  Nunneh^y. 

s  Nunneley,  Med.-Chir.  Trans.,  vol.  xlviii,  p.  29. 


SUBCLAVIAN    ANEURISM.  545 

cases,  as  in  tliose  reported  by  Pr.  Delens  from  Nelaton's  practice  {op. 
nupr.  cit.)  there  has  been  a  communication  between  the  internal  carotid 
and  the  venous  channel  of  the  cavernous  sinus  (arterio-venous  aneurism), 
and  in  tliese  the  pulsating  tumor  over  the  eyeball  has  been  proved  to 
have  been  formed  b}^  a  dilating  and  pulsating  vein  ;  in  others,  again, 
nothing  bevond  a  collection  of  blood-clot  (thrombosis)  in  the  sinus  press- 
ing on  the  artery  (as  in  Bowman's  case). 

For  these  reasons  surgeons  are  now  less  quick  than  they  used  to  be  to 
resort  to  the  ligature  of  the  carotid  artery  in  such  cases.  It  is  better  at 
first  to  watch  the  case  ;  and  if  no  great  inconvenience  is  caused  by  the 
disease  it  is  very  doubttul  whether  any  treatment  is  necessary  ;  other- 
wise digital  pressure  on  the  carotid  artery  as  long  and  as  frequently  as 
the  patient  can  tolerate  it  is  advisable.  If,  in  si)ite  of  this,  the  symp- 
toms are  advancing,  the  choice  lies  between  the  injection  of  perchloride 
of  iron  and  the  ligature  of  the  carotid.' 

Subclavian  aneurism  is  a  very  formidable  and  fatal  disease  ;  like  all 
other  aneurisms  near  the  heart,  it  is  usually  fatal  if  left  to  itself,  while 
surgical  treatment  generally  only  hastens  death.  The  only  really  suc- 
cessful methods  of  treatment  in  aneurism  are  those  in  which  the  surgeon 
deals,  not  with  the  blood  or  the  contents  of  the  sac  only,  but  also  with 
the  sac  and  the  tissues  which  surround  it ;  by  taking  away  the  eccentric 
pressure  of  the  blood  on  the  walls  of  the  sac,  the  latter  are  allowed  to 
react  on  the  contained  blood,  and  this  is  a  powerful  aid  in  the  cure  of 
the  disease.  On  the  other  hand,  a  softened,  inflamed,  or  ruptured  sac  is 
usually  the  precursor  of  death  when  the  tumor  is  near  the  heart.  Now, 
in  aneurism  of  the  first  or  second  part  of  the  subclavian  artery  the  liga- 
ture can  onl}'  be  applied  to  the  innominate  arter^',  and  in  aneurism  of  the 
third  part  of  the  right  subclavian  to  the  first  part  of  the  same  vessel; 
and  both  operations  have  proved  uniformly  fatal,  except  in  one  case,  in 
which  the  innominate  and  subsequentl}^  the  vertebral  artery  were  tied  by 
Dr.  Sm3"th,  of  New  Orleans,  and  the  patient  survived  after  several  sex  ere 
attacks  of  secondary  haemorrhage.  Galvano-puncture  may  be  tried,  but 
its  eflfect  is  so  commonly  to  set  up  inflammation  of  the  sac  that  it  must 
always  be  doubtful  whether  it  is  not  more  dangerous  than  abandoning 
the  case  to  nature.  The  "  manipulation  "  of  the  tumor  remains  as  the 
only  active  surgical  measure  ;  and  this,  though  perfectly  justifiable,  and 
indeed  indicated,  when  the  sac  contains  a  good  deal  of  clot  in  one  part, 
but  is  growing  in  another,  must  be  allowed  to  be  a  desperate  measure. 
In  cases  which  are  not  growing  perhaps  gentle  direct  pressure  may  grad- 
ually eflTect  a  cure.'"'  In  some  cases,  where  aneurism  afl'ects  the  end  of  the 
subclavian,  and  the  artery  rises  high  in  the  neck,  it  may  be  possible  to 
make  compression,  either  digital  or  instrumental,  on  the  artery  above,  as 
in  Mr.  Poland's  case.^  If  there  is  gangrene  or  a  threatening  of  gangrene 
ami)utation  at  the  shoulder-joint  is  indicated.  The  great  branches  of  the 
subclavian  having  been  removed,  the  aneurism  may  cease  to  grow.  In 
Mr.  Poland's  paper  a  case  of  this  nature  under  Mr.  Spence's  care  is  related. 

Ligature  of  (he  Innominate. — When  the  surgeon  has  made  up  his  mind 
to  risk  the  ligature  of  the  innominate  arter^',  or  of  the  first  part  of  the  right 


1  The  whole  question  of  the  pathology  and  treatment  of  pulsating  tumors  in  the 
orbit  has  been  elaborately  discussed  by  Mr.  Eivington  in  a  paper  which  will  be  found 
in  Med  -Chir.  Trans.,  vol    Iviii. 

■^  A  case  under  Mr.  Corner's  care  is  related  by  Mr.  Poland  (op.  infr.  cit  )  as  one  of 
cure  by  direct  pressure  ;  where,  however,  it  seems  to  me  that  the  recovery  was  spon- 
taneous. 

3  Med. -Chir.  Trans.,  vol.  Hi,  p.  277. 

35 


546  DISEASES    OF    THE    ARTERIES. 

subclavian,'  his  best  plan  is  to  obtain  free  space  externally  y^y  a  Y-shaped 
incision  made  along  the  inner  margin  of  the  sternomastoid  and  the  upper 
border  of  the  clavicle.  The  sternomastoid  having  been  cut  awa}^  freely 
from  the  clavicle,  is  turned  aside,  and  the  sternoh^'oid  and  sternothyroid 
divided.  Now  the  carotid  sheath  is  fairly  exposed.  If  the  innominate 
is  to  be  secured,  the  surgeon  follows  the  carotid  down  to  its  bifurcation 
and  passes  his  finger  into  the  thorax  along  the  artery,  which  is  now  the 
innominate.  This  manoeuvre  may  be  somewhat  facilitated  by  drawing 
the  head  strongly  backwards.  The  needle  must  then  be  passed  around 
the  vessel  from  without  inwards,  as  low  down — ^.  e.,  as  near  the  aorta — 
as  can  be  reached,  great  care  being  exercised  to  avoid  puncturing  or 
contusing  the  right  innominate  vein.  A  needle  with  a  sharper  curve 
than  ordinary  may  be  employed,  or  some  special  contrivance,  provided 
with  a  catch  for  drawing  up  the  ligature. 

If  the  surgeon  intends  to  tie  the  first  part  of  the  right  subclavian,  this 
can  only  be  done  just  external  to  the  point  where  the  pneumogastric 
nerve  crosses  it.  On  the  right  side  a  triangular  interspace  is  left  between 
the  carotid  artery  and  the  jugular  vein,  and  here  the  nerve  is  seen  cross- 
ing the  artery.  As  the  recurrent  laryngeal  runs  inwards  round  the  ves- 
sel, and  as  the  phrenic  nerve  crosses  the  artery  close  to  its  termination, 
either  of  these  important  nerves  will  probablj'  be  injured;  but  sympa- 
thetic filaments  must  almost  necessarily  be  interfered  with,  while  the 
proximity  of  the  large  branches  of  the  artery  almost  necessitates  sec- 
ondary haemorrhage  (of  which  the  great  majority  of  those  operated  on 
have  died);  and  the  risk  of  wounding  the  large  veins  of  the  pleura  has 
also  to  be  considered.     This  operation  has  never,  as  yet,  been  successful. 

Axillary  aneurisvi  is  a  more  common  aflTection  than  subclavian,  the 
free  movement  of  the  joint,  near  which  the  artery  passes,  rendering  it 
liable  to  slight  injuries,  like  the  popliteal,  though  in  a  lesser  degree  ;  so 
that  these  aneurisms  are  frequently  found  to  follow  upon  sprains  or  con- 
tusions. Total  rupture  of  the  axillarj'  artery  has  been  known  to  be  pro- 
duced by  the  efforts  to  reduce  a  dislocation  of  the  shoulder-joint.'' 

There  is  usually  little  or  no  difficulty  in  the  diagnosis,  but  the  treat- 
ment is  only  too  frequently  unsuccessful.  Three  principal  measures  have 
to  be  considered:  1.  The  ligature  of  the  subclavian  artery  was  long  the 
only  resource  in  this  form  of  aneurism,  and  it  still  remains  the  most  easy 
of  application  ;  but  it  is  doubtful  whether  it  is  tlie  safest,  since  the  mor- 
tality has  been  very  great.  2.  Mr.  Syme'*  speaks  strongl}'  in  favor  of  the 
old  operation;  and  in  cases  of  rupture  of  the  axillary  artery,  where  no 
sac  has  formed,  this  is  no  doubt  the  best  course  to  pursue.  The  sub- 
clavian artery  must  be  commanded  by  the  fingers  of  an  assistant,  for 
which  purpose  an  incision  may  be  made  in  the  usual  situation  for  the 
ligature  of  that  vessel,  and  the  artery  be  held  firmly  against  the  rib. 
Then  the  blood-tumor  is  to  be  opened  in  its  whole  extent,  the  clots  re- 
moved, and  ])oth  ends  of  the  lacerated  vessel  tied.  The  same  course 
may  very  projjerly  be  followed  in  a  traumatic  aneurism,  particularly  if  the 
tumor  has  so  far  elevated  the  clavicle  as  to  make  the  operation  of  tying 

1  The  left  suDclavian  has  been  tied  in  its  first  part  behind  the  apex  of  the  left  lung 
by  Dr.  J.  K.  llodejers,  of  New  York,  but  the  oporation  is  so  difficult  that  most  surgi- 
cal writers  liave  sfKikon  of  it  as  inipriictifiiblf^  ;  and  it  is  known  that  Sir  A.  Coopur, 
having  attempted  it,  was  obliged  to  desist,  b(^lieving  tliat  lio  had  injurcid  the  thoracic 
duct.  It  is  hardly  worth  while  to  spend  time  in  describing  an  operation  which  will 
probably  not  be  repeated. 

2  See  Callender,  in  St.  Bartholomew's  Ho.sjiital  Reports,  vol.  ii,  p.  9G. 

3  Med.-Cliir.  Trans  ,  vol.  xliii,  p.  137. 


LIGATURE    OF    SUBCLAVIAN    ARTERY. 


547 


Fig.  246. 


the  subclavian  difficult  and  dangerous ;  but,  as  I  have  shown  in  another 
place,  the  relations  of  the  sac  to  the  artery  and  to  the  nerves  of  the  plexus 
are  ver}'  variable,  and  the  surgeon  may  easily  meet  with  very  great  diffi- 
culties. 3.  Compression  has  been  successfully  applied  to  the  third  part 
of  the  subclavian  artery;'  and  though  the  difficulty  of  doing  this  is  in 
some  cases  so  great  as  to  make  it  well-nigh  impossible  for  the  surgeon  to 
do  it,  or  for  the  patient  to  endure  it,  yet  in  others  it  will  be  found  quite 
easy.  These  differences  depend,  of  course,  on  the  varying  height  to 
which  the  artery  rises  in  the  neck,  the  varying  level  at  wliich  the  clavicle 
is  found,-'  and  the  varying  thickness  of  the  neck.  In  any  case  in  which 
it  seems  at  all  feasible  to  make  compression,  and  where  the  rapid  growth 
of  the  tumor  does  not  contrain- 
dicate  the  attempt,  I  think  the 
surgeon  is  bound  to  try  this 
method  of  treatment  before  re- 
sorting to  the  ligature.  Cole's 
compressor,  an  apparatus  con- 
structed for  the  purpose,  or 
the  finger,  may  be  used,  ac- 
cording to  the  depth  of  the 
vessel. 

Ligature  of  the  Subclavian 
Artery. — The  subclavian  artery 
may  be  tied  in  the  third  part  of 
its  course  under  ordinary  cir- 
cumstances with  no  great  diffi- 
culty, though  in  complicated 
cases  few  operations  are  more 
embarrassing.  The  patient's 
head  is  to  be  turned  to  the  op- 
posite side — the  affected  shoul- 
der is  drawn  downwards  by  an 
assistant  as  far  as  possible. 
The  operator  draws  the  skin  of 
the  neck  down  over  the  chest 
with  the  fingers  of  his  left  hand, 
and  makes  an  incision  on  to 
the  clavicle  for  about  its  mid- 
dle third.  The  skin  is  then  I'e- 
leased,  and  the  incision  lies 
about  a  finger's  breadth  above 
the  bone.  In  this  way  the  sur- 
geon avoids  all  risk  of  wound- 
ing the  external  jugular  vein 
as  it  dips  under  the  clavicle. 
This  vessel  is  next  defined  and 
drawn  aside  ;  or,  if  there  is  any 
difficult}'  in  getting  it  out  of  the 
way,  it  is  divided  between  two 
ligatures.     The  deep  fascia  is 


Ligature  of  the  subclavian  artery.  At  the  inner  an- 
gle of  the  external  incision  the  root  of  the  external 
jugular  vein  is  seen,  and  its  course  above  is  indicated 
through  the  skin.  Some  fibres  of  the  sternomastoid 
muscle  would  also  probably  be  seen  in  this  situation. 
Deeper  down  is  seen  the  scalenus  anticus  muscle  going 
into  the  first  rib,  and  the  artery  emerging  from  behind 
it,  with  the  nerves  of  the  brachial  plexus  above  and 
behind  the  vessel.  Above  these  is  seen  the  posterior 
belly  of  the  omohyoid.  The  outer  angle  of  the  incision 
reaches  to  the  trapezius  muscle. 


1  Lancet,  Sept.  27,  1873,  p.  445. 

2  It  may  be  worth  while  to  notice  that  some  surgeons  believe  with  jV[r.  Spence  that 
the  clavicle  is  not  merely  pushed  up  passively  by  the  size  of  the  tumor  in  the  axilla, 
but  that  its  elevation  is  also,  and  perhaps  chiefly,  an  active  one,  due  to  irritation  of 
the  nerves,  causing  the  muscles  to  contract  and  draw  the  scapula  and  clavicle  upwards. 


548  DISEASES    OF    THE    ARTERIES. 

now  opened  to  the  extent  of  the  skin-wound,  and  the  celhilar  tissue  of 
the  subclavian  triangle  scratched  through  with  the  point  of  the  director 
till  the  margin  of  the  scalenus  anticus  muscle  is  plainly  seen.  In  doing 
this  the  omohyoid  muscle  may  be  exposed,  and  possibly  the  transver- 
salis  colli  artery  may  be  met  with.  The  surgeon  now  traces  the  scalenus 
anticus  muscle  down  to  its  insertion  into  the  first  rib,  and  he  will  then 
find  the  arter}'  lyiiig"  close  beneath  his  finger,  emerging  from  behind  the 
muscle,  immediately  behind  the  scalene  tubercle.  The  nervous  cord 
formed  Iw  the  eighth  cervical  and  first  dorsal  nerves  lies  close  above  and 
behind  the  artery,  and  great  care  must  be  taken  not  to  mistake  it  for  the 
vessel,  which  may  easily  be  done,  if  from  an}'^  cause  the  pulsation  is  not 
plainly  perceptible  in  the  arter}^,  or  the  parts  cannot  be  brought  into  view. 
The  needle  is  passed  around  the  vessel  either  from  above  or  below,  as  is 
most  convenient,  and  when  this  has  been  done  it  should  be  carefully  as- 
certained, first,  that  only  one  structure  is  embraced  b}^  the  needle,  and 
second,  that  pressure  on  that  structure  commands  the  pulsation. 

Sometimes  when  the  aneurism  extends  too  far  up  the  vessel  to  allow  of 
the  third  part  of  the  artery  being  safely  tied,  the  second  part  has  been 
secured.  The  operation  is  essentially  the  same,  only  a  freer  incision  is 
desirable,  which  is  obtained  by  notching  the  inner  end  of  the  skin-cut 
upwards,  and  by  dividing  the  fibres  of  the  sternomastoid  as  far  as  may  be 
necessar}^  to  bring  tlie  scalenus  anticus  into  view.  When  this  has  been 
done  the  fibres  of  that  muscle  are  to  be  divided  transversely  on  a  direc- 
tor, with  all  possible  care,  to  avoid  injuring  the  phrenic  nerve,  and  thus 
the  artery  is  exposed.  The  surgeon  must  remember  that  on  the  right  side 
the  superior  intercostal  usually  comes  off  from  this  part  of  the  artery,  so 
that  it  is  very  undesirable  to  tie  the  second  part  of  the  right  artery  ;  but 
if  circumstances  have  rendered  it  inevitable  he  should  try  and  include 
the  branch  also  in  the  ligature.  The  greatest  care  should  be  taken  not 
to  wound  the  pleura,  which  lies  close  below. 

Ligature  of  the  sul)clavian  artery  is  a  very  formidable  operation,  about 
45  per  cent,  of  the  cases  operated  on  having  proved  fatal.^ 

Aneurism  below  the  Axilla.-— Spontaneous  aneurisms  below  the  axilla 
are  extremely  rare,  though  they  are  not  unknown  even  in  arteries  so 
small  as  those  of  the  hand  ;  but  I  do  not  think  it  would  answer  any  good 
purpose  to  speak  in  detail  here  of  such  rare  cases.  The  main  point  to 
remember  is,  that  spontaneous  aneurism  of  these  small  vessels  is  verj- 
commonly  associated  with  disease  of  the  heart  or  general  arterial  degen- 
eration, and  ought  not  to  be  too  actively  treated. 

Tiic  arteries  of  the  up|)er  extremity  are,  however,  usually  tied  for 
wound,  either  at  the  part  wounded,  or,  in  the  case  of  wounds  of  the  palm, 
at  a  higher  spot. 

Li<jature  of  the  Axillary. — The  axillary  is  very  rarely  tied  in  the  pres- 
ent day  as  a  formal  operation.  In  tiie  dissecting-room  it  may  be  reached 
in  any  part  of  its  course  eithei'  by  a  free  division  of  the  i)ectoralis  major 
(the  jirecise  line  for  which  matters  little,  i)ut  which  is  generally  effected 
by  an  incision  convex  inwards  from  the  coracoid  process  to  the  edge  of 
the  anterior  Hap  of  the  axilla),  or  the  first  part  of  the  artery  may  be  ex- 
posed by  cutting  asunder  the  clavicular  and  sternal  portions  of  the  pec- 
toralis  maj(;r  and  drawing  them  away  fi'om  each  otiier  with  strong  double 
hooks,  wthout  dividing  an}-  muscular  fibres.     In  the  living  subject,  how- 

'  "Of  94  cases  when"  thisiirtfry  has  boon  tied  for  aneurism  in  tlie  axilla  51  have 
recovered  and  43  have  died." — Lancet,  Sept.  27,  1873,  p.  444. 


LIGATURE    OF    ULNAR. 


549 


ever,  it  would  be  much  better  to  follow  Guthrie's  advice,  by  cutting  freely 
through  the  anterior  flap  of  the  axilla  and  tracing  the  artery  upwards  to 
the  point  where  the  ligature  is  to  be  applied.  Tlie  vein  lies  to  the  front 
and  inner  side  of  the  artery,  and  the  varying  position  of  the  median  nerve 
must  be  recollected. 

Ligature  of  the  Brachial. — The  brachial  is  generally  tied  about  its 
centre  by  an  incision  along  the  edge 
of  the  biceps,  or,  if  that  edge  cannot 
be  seen,  in  a  line  drawn  from  the 
middle  point  between  the  flaps  of  the 
axilla  above  to  the  middle  of  the 
bend  of  the  elbow  below.  Possibly 
the  basilic  vein  or  the  internal  cu- 
taneous nerve  may  be  seen  in  the 
first  incision,  and  if  so,  should  be 
avoided.  The  deep  fascia  being 
opened,  the  edge  of  the  biceps  will 
be  exposed,  and  if  the  muscle  is 
large  is  to  be  drawn  aside.  Then  the 
median  nerve  generally  comes  into 
view,^  and  must  be  gently  displaced, 
and  the  artery  picked  up  between 
its  venre  comites.  When  the  nerve 
crosses  behind  tlie  artery  the  vessels  will,  of  course,  come  into  view  at  once. 

Ligature  of  the  Ulnar. — The  ulnar  may  be  tied  at  the  upper  part  of  the 
forearm,  but  this  is  very  rarely  necessary.  Here  it  lies  under  the  mass 
of  muscles  which  arise  from  the  inner  cond3'le  (except  the  flexor  carpi 
ulnaris),  and  is  crossed  by  tlie  median  nerve.  The  line  of  the  vessel  is 
from  the  middle  of  the  bend  of  the  elbow  to  the  outer  side  of  the  pisiform 

Fig.  248. 


Ligature  of  the  brachial  artery.  The  edge  of  the 
biceps  is  seen.  The  median  nerve  is  shown  in 
front  of  the  artery.  There  are  vense  comites  on 
either  side,  which  are  not  shown.  At  the  inner 
side  and  behind  are  seen  the  basilic  vein  and  in- 
ternal cutaneous  nerve,  but  these  structures  are 
not  generally  exposed  in  the  operation. 


Ligature  of  the  ulnar  and  radial  arteries.  The  upper  figure  illustrates  the  ligature  of  the  ulnar.  The 
upper  double  hook  draws  aside  the  tissues,  exposing  the  tendon  of  the  Fl.  carpi  ulnaris.  Tlie  lower 
exposes  the  ulnar  tendon  of  the  Fl.  subl.  digitorum.  The  artery  is  seen  with  its  nerve  on  the  ulnar 
side,  and  the  vense  comites  on  either  side  of  it. 

The  lower  figure  illustrates  the  ligature  of  the  radial.  The  lower  double  hook  exposes  the  tendon  of 
the  supinator  longus,  the  upper  that  of  the  Fl.  carpi  radialis.  Between  them  is  seen  the  artery,  having 
its  vente  comites  on  the  two  sides.  Mem. — In  practice  there  is  no  necessity  for  exposing  the  tendons  in 
this  way. 

bone.  There  are  two  ways  of  exposing  it — either  from  above  or  below. 
In  the  former,  an  incision  having  been  made  over  the  course  of  the 
artery,  the  bicipital  fascia  is  freely  divided — the  median  nerve  sought, 
the  pronator  teres  freely  cut  through,  and  the  vessel  found  below  it.  In 
the  latter  the  ulnar  nerve  is  sought  under  the  radial  border  of  the  flexor 
carpi  ulnaris,  and  traced  till  it  is  found  joining  its  artery,  which  is  then 
followed  upwards,  the  muscles  being  successively  divided  till  the  point  is 
reached  where  it  is  to  be  tied. 


1  This  nerve  crosses  behind  the  artery  about  once  in  every  four  cases. 


550  DISEASES    OF    THE    ARTERIES. 

Far  more  commonly  the  artery  is  souijht  just  above  the  wrist,  between 
the  tendon  of  the  flexor  earj)!  nlnaris  and  the  ulnar  tendon  of  the  flexor 
subliniis  digitornm.  It  is  covered  here,  not  only  by  the  common  deep 
fascia,  but  also  by  a  si)ecial  and  strong  tiiongh  thin  aponeurosis.  This 
having  been  divided,  the  artery  will  be  found  between  its  veins,  and  with 
the  nerve  on  the  inner  side. 

Liyalure  of  (he  Eadial. — Similarly  the  radial  may  be  tied  in  the  upper 
third  of  its  course,  but  this  is  rarely  necessary.  It  involves,  however, 
no  division  of  the  muscles.  An  incision  being  made  along  the  belly  of 
the  supinator  longus,  the  arter}'  and  venre  comites  come  into  view  between 
that  nuiscle  and  the  pronator  teres.  The  nerve  is  not  here  in  contact  with 
the  vessel. 

The  common  situation,  however,  for  the  ligature  of  the  radial  also  is 
just  above  the  wrist,  where  it  may  easily  be  found  by  dividing  the  deep 
fascia  along  the  inner  border  of  the  flexor  carpi  radialis  between  that 
tendon  and  the  supinator  longus.  When  the  fascia  is  freely  divided  the 
artery  and  its  veins  come  into  view.  Here  also  the  nerve  is  not  in  con- 
tact Avith  the  vessels. 

Abdominal  aneurism  affects  either  the  abdominal  aorta  or  one  of  the 
smaller  arteries.  Its  diagnosis  is  not  always  easy.  In  the  first  place,  the 
abdominal  aorta  itself  sometimes  pulsates  so  powerfully  as  to  simulate 
aneurism,  when  no  aneurism  exists.  This  is  most  common  in  young 
women,  and  is  sometimes  called  "hysterical  pulsation,"  but  is  also  not 
unusual  in  nervous  men  of  relaxed  fibre.  It  may  be  known  from  aneurism 
by  the  alisence  of  any  true  aneurismal  bruit  (though  some  sound  can 
often  l)e  elicited  by  pressure  with  the  stethoscope,  and  sometimes  in  the 
vein  as  well  as  the  artery),  by  the  fact  that  the  pulsation  can  be  stopped 
by  firm  pressure  with  a  single  finger,  if  the  patient  can  tolerate  it;  and 
above  all,  by  watching  the  case,  when  it  will  be  seen  to  remain  in  the 
same  condition  for  an  indefinite  period.  Again,  cancer  connected  with 
the  bones  of  the  spine  or  pelvis,  and  sometimes  cancer  of  the  lumbar 
glands  or  even  of  the  kidney,  may  pulsate,  and  thus  simulate  aneurism  — 
as  to  which  the  reader  must  be  referred  to  what  has  been  said  above 
(page  529).^  And,  on  the  other  hand,  abdominal  aneurisms  sometimes 
do  not  pulsate,  and  then  their  diagnosis  becomes  exceedingly  obscure. 

When  the  diagnosis  of  aneurism  is  established  it  is  not  always  easy  to 
specify  the  artery  affected;  but  this  is  perhaps  of  minor  importance. 
Aneni'ism  of  tiie  abdominal  aorta  produces  [)ain  in  the  back  from  pressure 
on  the  spine,  weakness' and  pain  in  motion  from  the  same  cause,  loss  of 
nutrition,  possil)ly  from  pressure  on  the  thoracic  duct  or  some  of  the 
lacteals,  and  vomiting  or  other  distnrl)ance  of  digestion  from  pressure 
on  tlie  stomach,  intestines,  or  liver.  It  threatens  death  by  rupture  into 
the  peritoneal  cavity  or  into  the  cellular  tissue.  Aneurisms  of  the 
branches  of  the  aorta  (celiac  axis,  superior  mesenteric,  etc.)  produce 
much  the  same  symptoms,  and  are  distinguished  from  the  aortic  aneu- 
risms chiefly  V)y  their  position,  and  those  of  the  superior  mesenteric  by 
their  mobility,  which  is  sometimes  very  great,  as  well  as  by  the  way  in 
which  the  bruit  can  sometimes  be  traced  upwards  into  the  aorta.''  Aneu- 
rism of  the  common  iliac  is  rare,  but  when  it  occurs  it  can  generally  be 
known  l)v  its  situation,  and  by  the  definite  limitation  of  the  symptoms 
to  one  side  of  the  body.     Wlien  the  external  iliac  artery'  is  affected  there 


1  Also  to  a  paper  in  St.  Geor^o's  Hospital  Reports,  vol.  vii,  p.  173 
*  See  a  case  under  Mr.  Pollock'.s  care,  reported  in  the  Clin.  Soc.   Trans.,  vol.  vii, 
p.  58. 


LIGATURE    OF    THE    ABDOMINAL    AORTA.  551 

is  not  usually  any  difficnlty  in  determining  the  fact,  though  it  may  not 
be  easy  to  decide  how  high  the  tumor  extends. 

The  treatment  of  aneurism  of  the  abdominal  aorta  must  as  a  general 
rule  be  restricted  to  rest  and  medical  measures  only  ;  but  some  of  the 
aneurisms  which  affect  the  lowest  part  of  the  vessel  may  be  under  the 
influence  of  pressure  applied  to  tlie  artery  as  it  lies  on  the  spine  just 
above  the  origin  of  the  inferior  mesenteric.  Some  surgeons  believe  in 
the  possibility  of  compressing  even  a  higher  part  of  the  artery  tlian  this, 
where  it  lies  between  the  pillars  of  the  diaphragm.  This  bold  attempt 
was  first  made,  and  with  success,  by  Dr.  Murray  of  Newcastle,  in  the 
year  1864."  His  patient  was  cured  temporarily,  but  a  higlier  part  of  the 
aorta  became  aneurismal,  and  he  died  six  years  after.  Post-mortem  ex- 
amination proved  that  the  aneurism  had  really  affected  the  lowest  part 
of  the  aorta  itself.  Several  other  abdominal  aneurisms  have  been  cured 
by  pressure  under  chloroform,  and  in  some  of  them  the  aorta  is  believed 
to  have  been  the  artery  affected,  though  in  no  other,  as  far  as  I  know, 
has  definite  anatomical  proof  of  tiie  fact  been  obtained.  And  the  opera- 
tion is  now  a  recognized  surgical  proceeding  very  far  superior  to  the 
ligature  of  the  aorta  (which  has  proved  uniformly  fatal),  or  even  to  that 
of  the  common  iliac,  from  which  only  one-fourth  of  the  [)atients  have  re- 
covered. It  has,  however,  its  own  dangers,  and  they  are  by  no  means 
small.  These  dangers  arise  from  the  protracted  anaesthesia,  and  from 
the  risk  of  contusing  the  viscera  (the  intestines,  the  mesentery,  the 
pancreas,  and  the  kidney  have  all  been  found  to  have  beeu  injured),  or 
of  embarrassing  tlie  action  of  the  heart  or  injuring  the  great  sympathetic 
ganglia  and  nerves.  Several  deaths  have  occurred  from  these  causes, 
and  in  several  cases  the  compression  has  failed  to  effect  a  cure  ;  but  it  is 
a  most  valuable  remedy,  and  has  often  also  been  used  in  the  treatment 
of  aneurism  of  the  external  iliac,  the  common  iliac  being  then  usually 
selected  for  pressure.  Tlie  patient's  bowels  ought  to  be  well  unloaded, 
and  the  parietes  of  the  belly  relaxed  by  bending  the  body.  He  should 
be  placed  fully  under  the  anaesthetic,  and  the  tourniquet  should  then  be 
screwed  down.  If  the  aorta  is  to  be  compressed,  the  (nilsation  in  the 
aneurism  and  in  both  femorals  must  be  completely  abolished,  if  the  com- 
mon or  external  iliac,  one  femoral  only.  It  is  well  to  maintain  the  tem- 
perature of  the  limbs  by  swathing  in  wool.  Some  surgeons  apply  distal 
pressure  also  below  the  aneurism,  but  its  benefit  is  doubtful.  The  pulse 
and  respiration  should  be  carefully  observed  by  the  chloroformist,  while 
the  surgeon  and  liis  assistants  manipulate  the  tourniquet  and  attend  to 
tlie  pulsation.  The  anaesthesia  need  not  be  at  all  deep,  and  has  been 
continued  for  many  hours  in  some  cases  without  serious  danger. 

Ligature  of  the  Abdominal  Aorta  and  of  the  Iliac  Arteries. — Wliether 
the  abdominal  aorta  should  ever  again  be  tied  is  a  matter  of  opinion. 
My  own  is  that,  as  the  operation  has  been  practiced  at  least  eight  times, 
and  never  with  success,  the  patient  has  a  better  prospect  from  rest  and 
medical  treatment ;  but  the  operation  on  the  common  iliac  is  undoul^tedly 
justifiable.  There  are  two  different  ways  of  performing  it.  In  one  of 
these — Sir  P.  Crampton's  method^ — the  artery  is  sought  from  behind  by 
an  incision  made  "  from  the  end  of  the  last  rib  obliquely  forwards  and 
downwards  to  the  crista  ilii,  and  then  curved  forwards  above  and  parallel 
to  the  crest  of  the  ilium,  terminating  at  the  anterior  superior  spine.  The 
muscles  and  fascia  trans versalis  were  cut  through  at  the  l)Ottom  of  the 
incision  till  the  subperitoneal  interval  was  reached,  and  then — the  perito- 

1  Med.-Chir.  Trans.,  vol.  xlvii,  p.  187.    See  also  Lancet,  Feb.  8,  1873. 

2  Med.-Chir.  Trans.,  vol.  xvi,  p.  102. 


552 


DISEASES    OF    THE    ARTERIES. 


ueum  being-  held  back  by  the  front  of  the  finger — a  probe-pointed  bistoury 
was  run  along  the  back  of  the  finger,  and  so,  by  repeated  strokes  of  the 
bistoury,  the  muscles  were  divided  to  the  extent  of  the  external  wound. 
Sutiicient  room  was  tlnis  obtained  to  pass  in  the  whole  hand  and  raise 
the  peritoneum  and  intestines  from  tlie  fascia  iliaca.  The  parts  were 
then  plainly  visil)le,  and  the  vessel  easily  secured." 

The  other  method  of  securing  tlie  common  iliac  artery  is  from  the  front, 
and  this  operation  is  essentially  the  same,  whether  the  operator  wishes  to 
secure  the  aorta,  the  common,  the  internal,  or  the  upper  part  of  the  ex- 
ternal iliac  artery.  An  incision  is  made  through  the  abdominal  parietes, 
the  extent  of  which  varies  according  to  the  height  which  the  operator 
wishes  to  attain.  It  commences  lielow,  just  external  to  the  internal 
abdominal  ring,  runs  outwards  somewhat  parallel  to  Poupart's  ligament, 
and  then  curves  inwards  towards  the  umliilicus.  If  the  common  iliac  or 
the  aorta  is  to  be  tied  the  incision  should  not  be  less  than  six  inches  in 
length.  The  three  abdominal  muscles  having  been  divided,  and  the  fascia 
transversalis  incised  along  the  whole  extent  of  the  wound,  the  peritoneum, 
containing  the  intestines,  is  to  be  gently  separated  from  the  abdominal 
wall  until  the  iliac  vesssls  are  found.  They  must  then  be  traced  upwards 
as  far  as  necessar}-,  their  relations  being  attentively  borne  in  mind.  If 
the  aorta  is  to  be  secured,  the  main  point  is  to  separate  it  from  the 
cellular  tissue  which  forms  its  sheath,  and  from  the  vena  cava,  without 
any  injury  to  the  latter  or  to  the  parts  in  front,  in  which  the  great  lym- 
phatic vessels  and  the  commencement  of  the  receptaculum  chyli  might  be 
wounded.  Tlie  right  common  iliac  artery  is  in  relation  with  three  veins, — 
the  vena  cava  lies  on  the  right  side  of  its  upper  part,  the  right  common 
iliac  vein  on  its  right  side  below,  and  the  left  common  iliac  crosses 
behind  it  to  join  its  fellow  of  the  opposite  side.  The  left  common  iliac 
vein  lies  behind  and  internal  to  its  artery.  The  ureter  crosses  over  the 
bifurcation  of  the  common  iliac,  or  the  upper  part  of  the  external  iliac 
artery,  and  the  spermatic  vessels  pursue  their  course  upwards  in  front 
of  the  external  iliac  artery  ;  but  both  these  structures  are  generally  so 

adherent  to  the  perito- 
neum that  in  raising  that 
membrane  the  surgeon 
pushes  them  away  from 
the  artery.  The  external 
iliac  vein  lies  on  the  inner 
side  of  the  artery,  inclin- 
ing on  the  left  side  more 
to  its  deep  surface,  and 
in  tying  the  external  iliac 
the  genito-crural  nerve, 
which  runs  down  on  its 
surface,  should  be  looked 
for  and  avoided.  In  ty- 
ing the  lower  end  of  the 
external  iliac  artery  less 
extensive  incisions  are 
required.  Mr.  Aberne- 
thy,  in  his  original  ope- 
ration (the  first  in  which 
this   artery    was    tied)/ 


Fig.  249. 


Li(,'ature  of  the  external  iliac  artery.  The  assistant'.s  hand  is 
.shown,  pushing  back  the  intestines,  covered  with  peritoneum. 
The  two  ends  of  the  ligature  arc  seen  pa.ssing  in  between  the 
artery,  which  is  external,  and  the  vein  on  the  inner  side,  a  large 
part  of  the  sheath  having  been  cut  away  to  show  the  vessels. 
Towards  the  internal  ring  will  be  seen  the  while  end  of  the  vas 
deferens  dipping  into  the  pelvis,  and  the  spermatic  vessels  lying 
on  the  peritoneum. 


'  See  a  lecture  in  the   Lancet,  Aug.  29,  1874,  for  a  summary  account  of  the  early 
operations  on  this  artery. 


GLUTEAL    ANEURISM.  553 

made  the  incision  upwards  and  inwards  from  the  centre  of  Poupart's 
ligament  along  the  course  of  the  artery.  But  this  operation  has  now 
fallen  out  of  use.  The  oltjection  to  it  is  that  it  gives  little  room,  and  is 
not  available,  if  the  operator  finds  it  necessary  to  go  higher  than  he  at 
first  intended.  Tlie  lower  part  of  the  external  iliac  artery  can,  however, 
be  easily  reached  by  an  incision  parallel  to  and  a  little  above  the  outer 
half  of  Poupart's  ligament,  by  just  pushing  up  the  lower  part  of  the 
peritoneum,  and  this  is  the  plan  now  in  common  use.  If  more  room  is 
required  it  can  be  easily  got  by  extending  the  outer  end  of  the  incision 
upwards  and  inwards.  The  peritoneum  and  intestines  having  been 
gently  pressed  to  the  other  side  till  the  finger  is  about  to  pass  into  the 
true  pelvis,  the  artery  will  be  met  with  lying  on  the  brim  of  that  cavity. 
It  must  be  carefully  separated  from  its  vein,  and  the  ligature  passed  from 
within  outwards,  care  being  taken  not  to  include  the  genito-crural  nerve. 
The  internal  iliac  is  found  either  by  tracing  the  common  iliac  down- 
wards, or  the  external  ui)wards,  till  tlie  bifurcation  is  reached,  and  then 
passing  the  finger  down  the  artery  into  the  pelvis,  and  scratching  it  clean 
with  the  finger-nail  and  director,  so  as  to  get  the  ligature  round  it  about 
an  inch  from  its  origin  if  necessary.  The  great  depth  of  the  vessel  ren- 
ders a  very  free  incision  necessary,  and  there  is  often  much  difficulty  in 
getting  the  ligature  round  the  artery,  though  Mr.  Syme's  case  shows  that 
this  may  be  done  with  the  ordinary  aneurism  needle/ 

Gluteal  aneurism  is  a  rare  disease,  and  one  with  which,  therefore,  no 
surgeon  is  sufficiently  familiar  to  speak  with  much  decision  as  to  its  treat- 
ment. It  is  very  commonly  traumatic,  either  from  direct  perforation  of 
the  artery  by  a  stab  or  from  an  injury  in  which  the  vessel  is  contused 
against  the  bone.  The  artery  affected  may  be  either  the  gluteal  or  sciatic, 
or  even  the  internal  pudic,  as  it  crosses  the  spine  of  the  ischium,  as  in  a 
preparation  of  John  Hunter's  in  the  College  of  Surgeons'  Museum.  In 
wounds  the  smaller  arteries,  branches  of  the  gluteal  or  sciatic,  may  be 
implicated.  The  symptoms  are  not  always  obvious.  In  traumatic  aneu- 
rism (so-called)  there  may  have  been  no  sac,  or  in  this,  as  well  as  in 
spontaneous  aneurism,  the  sac  may  have  given  way,  and  so  there  may  be 
no  pulsation  ;^  and  many  such  tumors  have  been  opened  by  mistake  for 
abscess,  usually  with  a  fatal  result.  Such  a  disaster  would  probably  be 
avoided  by  auscultation,  for  it  is  certain  that  in  many,  if  not  all,  such 
cases  a  bruit  would  be  audible.  Gluteal  aneurism  is  not  necessarily  fatal. 
Indubitable  cases  of  spontaneous  cure  are  recorded,  and  in  other  cases  the 
disease  has  long  remained  stationary.  But  when  the  pressure  of  the  tu- 
mor on  the  nerves  causes  much  distress,  or  when  the  size  of  the  aneurism 
is  increasing,  and  it  threatens  soon  to  burst,  surgical  treatment  is  neces- 
sary ;  but  it  is  not  easy  in  the  present  state  of  our  knowledge  to  say  what 
is  on  the  whole  the  most  promising  method  of  treatment.  In  recent 
wound,  and  in  those  cases  of  traumatic  aneurism  which  most  nearly  ap- 
proach to  the  character  of  recent  wounds,  the  best  plan  is  to  la\'  the  sac 
freely  open  and  tie  the  artery.  Haemorrhage  may  be  controlled  during 
this  operation  either  by  plugging  the  sac  with  the  fingers  on  Mr.  Syme's 
plan  or  by  pressure  on  the  aorta  by  Lister's  tourniquet.  Many  cases,  I 
have  no  doubt,  might  be  cured  by  compression  of  the  aorta  or  common 
iliac  under  chloroform.     Some  have  been  treated  successfull}'  with  coag- 

1  Syme,  Observations  in  Clinical  Surgery,  p.  168. 

2  The  student  must  always  remember  that  the  pulsation  of  an  aneurism  depends  on 
the  reaction  of  the  sac  upon  the  blood  which  distends  it,  so  that  a  free  rupture  of  the 
sac  involves  loss  of  pulsation. 


554  DISEASES    OF    THE    ARTERIES. 

ulating  injection,'  and  galvano-puncture  ma}' very  fairly  be  tried  in  these 
cases,  or  manipulation.  In  cases  where  tlie  opening  in  the  artery  is  situ- 
ated inside  the  pelvis — a  fact  which  can  often  be  ascertained  by  exami- 
nation from  the  rectum,  and  which  is  extremely  probable  in  spontaneous 
aneurism — the  surgeon  will  probably  think  it  better,  on  the  failure  of 
compression,  to  resort  to  the  ligature  of  the  internal  iliac  artery,  an  opera- 
tion, however,  which  is  so  very  fatal,  from  its  anatomical  difficulties,  as 
well  as  from  the  risk  of  finding  the  artery  diseased,  that  it  should  be 
avoided  as  much  as  possible. 

For  many  details  on  the  diagnosis  and  treatment  of  gluteal  aneurism, 
for  wiiich  my  present  work  affords  no  space,  I  would  refer  to  a  lecture 
published  in  the  Lancet^  i\.\\y  11,  1874. 

Femoral  Anpurism. — Aneurism  of  the  femoi-al  artery  is  met  with  either 
in  the  groin  affecting  the  common  femoral  (inguinal  aneurism),  or  in  the 
lower  part  of  Scarpa's  triangle,  affecting  the  superficial  femoral,  and  often 
spreading  down  into  the  popliteal  space,  femoro-popliteal  aneurism,  or  in 
some  intermediate  situation  ;  and  here  the  common  or  the  superficial 
femoral  may  be  implicated,  according  to  the  level  at  which  the  profunda 
arises,  which  in  the  living  subject  can  hardly  be  determined,'^  or  the  pro- 
funda itself,^  or  even  one  of  the  secondary  branches,  as  the  external  cir- 
cumflex,* may  be  the  seat  of  the  aneurism. 

As  a  rule,  aneurisms  in  the  thigh,  when  they  occur  in  a  tolerably  healthy 
subject,  and  the  sac  is  perfect,  are  best  treated  b_y  pressure  on  the  femoral 
in  the  groin.  This  pressure  is,  I  tliink,  equally  indicated  in  aneurism  of 
the  common  and  superficial  femoral,  or  in  the  rare  cases  where  the  pro- 
funda or  other  smaller  branches  are  affected.  For  although  in  aneurism 
situated  low  down  in  the  thigh  it  might  on  other  grounds  seem  desirable 
to  put  pressure  on  the  superficial  or  on  the  lower  part  of  the  common 
femoral,  yet  these  arteries  are  so  much  more  deeply  placed,  and  their 
compression  is  so  much  more  painful,  that  in  practice  it  is  found  much 
easier  to  cure  the  disease  by  pressure  in  the  groin.  Digital  pressure  is, 
I  have  no  douljt,  far  superior  to  any  other  form  in  this  situation,  though 
the  artery  is  so  easily  compressed  tliat  any  other  form  of  pressure  can  be 
used ;  and  cases  have  been  treated  successfully  by  the  pressure  of  a 
weight,  suspended  from  a  frame  or  cradle,  or  by  various  forms  of  tour- 
niquet. 

In  ilio-femoral  aneurism  it  may  be  necessary  to  make  instrumental  pres- 
sure under  chloroform  on  the  aorta  or  common  iliac,  as  above  described, 
and  in  some  cases  of  aneurism  which  are  eitlier  entirely  femoral  or  only 
affect  the  very  end  of  the  external  iliac  artery,  the  latter  vessel  might  be 
compressed,  though  as  a  general  rule,  it  would  be  more  jirudent  to  select 
the  higher  artery,  so  as  to  avoid  all  risk  of  compressing  the  aneurismal 
tumor,  which  might  easily  occasion  inflammation  and  rupture  of  the  sac. 

1  Conipre.ssion  of  the  iiorta  would,  of  course,  bo  employed  during  the  injection  of 
the  contculatini:  fluid. 

^  I  would  refer  to  u  ea^e  described  1)v  Mr.  Pre.«eott  Hewett  (Mod. -Chir.  Trans.,  vol. 
xxix.  p.  75),  und(!r  Sir  B.  lirodit^'s  care,  in  which  the  external  iliac  artery  was  tied, 
and  which  is  ilijured  on  p.  ").'?5.  Before  dissection  this  was  believed  to  be  an  aneurism 
of  the  common  ftjmoral.  Afti-r  death  it  was  found  that  tiie  profunda  came  off  rather 
hiiih.  and  that  the  aneurism  really  sprang  from  the  commencement  of  the  superticial 
femoral. 

'  Several  instances  of  aneurisms  of  the  profunda  may  be  found  quoted  in  a  lecture 
published  in  the  Lancet,  Oct.  17,  1874,  under  the  care  of  Erichsen,  Cock,  and  P.  H. 
'Wats(m. 

*  An  aneurism  occurring  spontaneously  in  the  external  circumflex  artery  is  re- 
corded by  M.  Letenneur,  of  Nantes,  in  the  Bulletin  de  la  Soc.  dc  Chir.,  185G. 


SUPERFICIAL,    FEMORAL    ARTERY. 


555 


For  cases  of  ilio-femoral  aneurism  cured  by  rapid  compression  under 
chloroform  see  Lancet^  Oct.  10,  1874. 

When  pressure  has  failed  the  resort  to  the  ligature  should  not  in  my 
opinion,  be  long  delayed.  If  the  common  femoral  be  affected  the  external 
iliac  artery  must  be  tied,  and  in  ilio-femoral  aneurism  the  surgeon  may 
even  find  himself  obliged  to  operate  on  the  common  iliac. 

Ligature  of  Common  Femoral. — In  aneurism  implicating  the  lower 
part  of  the  common  or  the  superficial  femoral  or  profunda  arteries,  the 
question  lias  arisen  whether  the  common  femoral  artery  might  not  be  se- 
cured. The  general  rule  has  been  tiiat  if  the  aneurism  extends  too  high 
up  to  enable  the  surgeon  to  secure  the  superficial  femoral  arterj'  the  ex- 
ternal iliac  should  be  tied,  since  it  was  taught  that  the  ligature  of  the 
common  femoral  in  the  groin,  though  a  very  easy  was  a  peculiarly  fatal 
operation — so  much  so  that  some  good  surgeons  have  gone  so  far  as  to 
say  that  the  operation  ought  to  be  banished  from  practice.^  But  I  can- 
not discover  on  what  data  this  opinion  is  founded.  The  Irish  surgeons, 
following  on  the   example  of  the 

elder   Porter,  have  practiced  this  '         fig.  200. 

operation  tolerably  often,  and  their 
experience  of  it  has  been  pretty 
satisfactory;^  and  Dr.  Mott  also 
highly  recommends  it,  and  says  he 
has  often  performed  it  with  suc- 
cess.^ My  own  impression  is  that 
the  operation  is  less  dangerous 
than  the  ligature  of  the  external 
iliac  artery,  though  much  more  so 
tiian  that  of  the  superficial  femoral. 
A  longitudinal  or  oblique  incision 
is  made  over  the  course  of  the  ar- 
tery; any  glands  which  lie  in  front 
of  the  sheath  are  to  be  drawn  aside, 
as  well  as  the  crural  branch  of  the 
genito-crural,  or  a  branch  of  the 
anterior  crural  nerve,  which  may 
come  into  view ;  and  the  sheath 
being  opened  about  an  inch  belovv 
Poupart's  ligament,  the  ligature  is      ,■    *.        <■  *i  «  •  w  *      .     *        n^ 

'■  .     '^  '  o  Ligature  of  the  superficial  femoral  artery.    Two 

to  be  Cari'ied  round  the  artery  from     double  hooks  are  shown,  one  of  which  draws  the 
the  inner  side.  edgeofthesartoriusmuscleoutwardsordowuwards, 

the  other  exposes  the  fibres  of  the  abductor  longus 
running  in  the  opposite  direction.  A  large  piece 
has  been  cut  out  of  the  sheath,  to  show  the  artery 
with  the  ligature  round  it,  and  internal  to  and  below 
intended  when  t3'ing  "  tlie  femoral  it  the  vein,  indistinctly  seen.  A  nerve  is  seen  on  the 
artery"  is  spoken  of)  is  the  most  outer  and  front  aspectof  the  sheath,  a  branch  of  the 
„        ..•;  11^  u  i.  anterior  crural.    This  is  sometimes  the  saphenous, 

lamiliar,  and    by  tar  the    most    sue-    at  others,  where  the  artery  is  exposed  a  little  higher, 
Cessful,  of  all  the  operations  on  the     one  of  the  cutaneous  nerves. 

1  Erichsen,  Sc.  and  Art.  of  Surg.,  5th  ed.,  voL  ii,  p.  110.  Mr.  Erichsen,  however, 
in  his  last  edition,  though  he  does  not  approve  of  the  operation,  speaks  of  it  in  terms 
of  much  less  sweeping  condemnation. 

2  Out  of  nine  cases  three  died — one  from  haemorrhage  previous  to  operation  (this 
case  should  be  omitted  from  the  list),  one  with  diseased  arteries  from  secondarj^  haem- 
orrhage, and  another  in  whom  there  was  a  high  bifurcation  and  the  ligature  was 
placed  close  below  the  profunda,  also  of  secondary  hiemorrhage.  The  last  is  the  only- 
case  which  can  really  be  said  to  have  died  in  consequence  of  the  operation. 

2  See  also  other  cases  quoted  in  the  Lancet  for  Aug.  29,  1874. 


Superficial  Femoral  Artery. — 
The  ligature  of  the  superficial  femo- 
ral (which  is  the  operation  usually 


556  DISEASES    OF    THE    ARTERIES. 

arteries.  The  spot  which  is  selected  for  tying  the  vessel  is  jnst  above 
the  margin  of  the  sartorius,  at  the  apex  of  Scarpa's  triangle,  i.  e.,  at  the 
junction  of  the  upper  and  middle  third  of  the  thigh.  If  from  oedema  or 
other  causes,  the  edge  of  the  sartorius  cannot  be  made  out,  a  line  from 
the  middle  of  the  groin  to  the  front  of  the  inner  condyle  will  mark  the 
course  of  the  vessel.  The  skin  and  fascioe  having  been  divided  to  the 
extent  which  the  size  of  the  patient  requires  (three  inches  may  be  taken 
as  a  moderate  incision),  the  edge  of  the  sartorius  is  sought  for,  and  the 
muscle  having  been  drawn  a  little  downwards,  the  sheath  is  found,  with 
a  small  nerve  usually  lying  on  it — a  branch  ^rom  the  anterior  crural. 
The  long  saphenous  nerve  generall}'  does  not  join  the  artery  till  lower 
down.  The  sheath  is  to  be  carefully  opened  over  the  front  of  the  arter}'. 
When  the  white  coat  of  the  vessel  is  fully  brought  into  view  it  should  be 
gently  scratched  clean  with  the  point  of  the  director,  and  the  aneurism 
needle  passed  very  gently  round  it  from  the  inner  side.  Great  care 
should  be  used  neither  to  expose  the  artery  to  an  unnecessar}'  extent  nor 
to  contuse  the  vein.  In  fact,  it  is  more  satisfactory  never  to  have  touched 
or  seen  the  vein. 

The  anomalies  in  the  course  of  the  artery  are  so  ver}'  rare  that  it  is 
hardly  worth  while  to  do  more  than  just  to  mention  that  in  one  case  Sir 
C.  Bell  found  that  the  femoral  artery  had  a  large  "  vas  aberrans,"  which, 
given  off  from  a  higher  source,  joined  the  main  trunk  above  the  aneuris- 
mal  tumor,  and  carried  on  the  circulation  in  it  after  the  arter}'  had  been 
tied,  and  that  cases  have  been  dissected  in  which  the  sciatic  artery  fur- 
nishes a  large  branch — "  femoro-popliteal  " — which  runs  down  the  back  of 
the  limb  into  the  popliteal  space,  while  the  superficial  femoral  arter}'  is 
deficient,  or  is  represented  only  by  a  small  branch  which  terminates  as 
the  anastomotica  magna.^ 

The  femoral  artery  may  also  be  tied  in  Hunter's  canal,  as  Hunter  origi- 
nall}^  did.  This,  however,  can  only  be  done  in  popliteal  aneurism,  not  in 
femoral,  and  is  only  done  then  after  the  failure  of  the  operation  in  Scarpa's 
triangle.  A  much  freer  incision  must  be  made  in  the  line  above  indi- 
cated from  the  apex  of  Scarpa's  triangle  downwards.  The  sartorius  mus- 
cle having  been  exposed,  and  recognized  by  the  direction  in  which  its 
fibres  run,  its  upper  edge  must  be  drawn  downwards,  if  the  opei*ator 
wishes  to  reach  the  artery  in  the  upper  part  of  the  canal ;  or  contrariwise, 
the  muscle  must  be  drawn  upwards,  if  the  vessel  is  to  be  secured  near  the 
opening  in  the  adductor  magnus.  Then,  the  anterior  wall  of  the  canal 
having  lieen  laid  open,  the  artery  is  sought  with  the  long  saphenous  nerve 
lying  usually  in  front  of  it  and  within  the  sheath.  This  should  be  care- 
fully avoided  as  vvell  as  the  vein. 

Popliteal  aneurism  is  the  form  by  far  the  most  familiar  to  surgeons ; 
and  it  is  satisfactory  to  know  that  the  treatment  of  this  disease,  which 
was  so  formidable  in  the  times  before  Hunter  that  Mr.  Pott  expressed,  in 
the  most  decided  terms,  his  [n'eference  for  amputation  over  the  treatment 
then  in  vogue,  has  now  become  so  manageable  that  out  of  212  cases  ad- 
mitted into  various  metrojiolitan  and  provincial  hospitals,  chiefly  during 
the  ten  years  18(51-70,  and  reported  to  me  from  those  hospitals,  166  were 
cured  entirely  and  permanently  by  ligature  or  pressure  (and  a  few  by 
less  common  means),  12  were  cured  after  amputation,  in  four  the  disease 
was  not  cured,  and  29  died.'^  This  is  a  list  formed  entirely  of  unselected 
and  coramon  cases  just  as  they  presented  themselves  at  the  various  hos- 

'  Dr.  Hilton  Fagge,  in  Guy's  Hospital  Reports,  3d  ser.,  vol.  x,  1864. 
*  Lancet,  May  1,  1875. 


POPLITEAL    ANEURISM.  557 

pitals,  containing,  of  course,  a  percentage  of  complicated  and  advanced 
cases  which  were,  probal)ly,  in  themselves  incurable.  The  cases  were 
under  the  care  of  surgeons  of  very  various  degrees  of  experience  and 
operative  skill.  In  fact,  it  seems  to  me  to  represent  in  all  ways  the 
average  of  success  and  failure  which  the  surgeons  of  the  present  day  have 
met  with  in  the  treatment  of  popliteal  aneurism.  And  this  average  of 
success,  large  as  it  is,  will,  there  is  no  doubt,  be  largely  increased  by  the 
improved  methods  of  compression  recently  introduced,  and  by  the 
increasing  intelligence  of  the  laboring  population,  and  their  diminished 
fear  of  surgical  treatment,  leading  them  to  apply  earlier  for  advice. 

Again,  I  think  that  I  have  shown  (in  the  lectures  above  referred  to) 
that  the  mortality  after  the  Hunterian  operation  on  the  femoral  artery 
has  been  greatly  diminished,  as  has  also  been  the  prevalence  of  gangrene, 
secondary  luiemorrhage.  and  other  untoward,  but  not  necessarily  fatal, 
complications,  in  modern  practice,  in  all  probability  as  a  consequence  of 
the  more  careful  method  of  operating,  and  simpler  treatment  after  opera- 
tion, which  distinguish  modern  surgery  ;  so  that  the  mortality  which  in 
188  published  cases  tabulated  by  Norris  ^  was  24.46  per  cent,  was  only 
14.94  i)er  cent,  in  87  similar'^  (pul)lished  and  unpublished)  cases  contained 
in  the  list  above  referred  to.  These  facts,  which  I  think  can  hardly  be 
gainsaid,  are  most  encouraging  to  a  surgeon  in  undertaking  the  care  of  a 
case  of  popliteal  aneurism.  There  remains  the  question,  what  class  of 
cases  are  adapted  for  the  ligature,  what  for  compression,  and  wliat  for 
flexion  ?  And  after  compression  or  flexion  has  been  attempted,  how  long 
should  the  attempt  be  persisted  in,  if  not  at  once  successful? 

I  may,  perhaps,  add  that,  though  cases  are  on  record  in  which  cure  has 
been  obtained  by  some  of  the  less  usual  proceedings — such  as  manipula- 
tion, coagulating  injections,  etc. — it  seems  to  me,  speaking  generally,  that 
such  proceedings  are  so  far  more  dangerous  and  so  far  less  likely  to  suc- 
ceed than  the  known  and  familiar  resources  of  surgery-,  ligature  and  pres- 
sure, that  I  think  it  useless  to  spend  time  on  their  discussion  here. 

In  discussing  the  treatment  of  popliteal  aneurism  it  is  well  to  study 
the  symptoms  and  the  anatomy  of  various  specimens  of  it.  The  first  thing 
that  strikes  us  is  the  differences  in  the  relation  of  the  sac  to  the  artery. 
Some  aneurisms  grow  from  the  anterior  face  of  the  vessel  towards  the 
knee-joint.  These  are  marked  by  a  distinct  line  of  pulsation  in  the  course 
of  the  artery  lying  over  and  distinguished  from  the  general  pulsation  of 
the  tumor,  and  l)y  the  readiness  with  which  the  joint  becomes  inflamed. 
The  more  common  form  (as  it  seems)  grows  from  the  back,  or  partly  from 
the  side,  of  the  artery,  and  is  marked  by  the  absence  of  any  such  distinct 
line  of  pulsation,  and  by  tlie  early  implication  of  the  nerve,  leading  to 
pain  shooting  down  the  limb,  and  by  pressure  on  the  vein,  causing  (jedema 
and  weight  of  tlie  leg  and  foot. 

My  own  impression  is  that  aneurisms  on  the  anterior  face  of  the  artery 
are  rarely  cured  by  any  measure  short  of  the  ligature  ;  and  even  the  latter 
often  fails  and  amputation  becomes  necessary.^ 

Again,  the  progress  of  the  case  has  a  most  important  influence  on  the 
treatment  to  be  adopted.  In  an  aneurism  which  is  extending  rapidl}^, 
and  of  which  the  sac  is,  therefore,  thin  and  probably  imperfect  in  parts, 
it  seems  more  prudent  to  resort  to  the  ligature  at  once;  and  generally  in 

1  Si>e  Norri.s's  Contributions  to  Sursrery. 

2  B_v  similar  cmscs  1  mean  cases  in  which  the  femoral  artery  was  tied,  as  in  those 
tabulated  \>y  Norris,  without  the  previous  use  of  compression. 

'  See  two  ca>es  r(  hUed  by  Tufnellon  Aneurism,  pp.  120-130;  and  see  also  a  lecture 
in  the  Lancet,  Dec.  12,  1874. 


658  DISEASES    OF    THE    ARTERIES. 

all  the  severer  cases,  and  in  those  where  the  tnmor  has  already  burst,  hut 
where  the  surgeon  does  not  think  it  necessary  to  amputate  at  once,  the 
ligature  is  probably  the  safest  course.' 

Genufie.rion. — Flexion  is  indicated  in  small  aneurisms,  situated  on  the 
posterior  or  lateral  aspect  of  the  artery,  in  which  the  pulsation  and  bruit 
are  susj)ended  by  bending  the  knee.  It  need  not  be  extreme  nor  painful, 
nor  need  tiie  limb  be  bandaged  or  confined  in  any  way,  at  least  in  many 
cases.  Voluntary  flexion,  in  which  the  patient  is  allowed  to  change  the 
position  of  the  limb  slightly,  will  succeed  in  many  cases,  and  will  be  tol- 
erated where  forced  flexion  would  produce  pain  and  would  be  given  up. 
Besides,  forced  flexion  has  been  known  to  produce  rupture  of  the  sac, 
which  voluntary  flexion  hardly  could  do.  Flexion  seems  to  act  partly  bj' 
retarding  the  blood-stream,  partly  by  direct  pressure  and  probable  dis- 
placement of  clot.  It  may  easily  be  combined  with  digital  or  instrumental 
pressure. 

When  pressure  or  flexion,  either  alone  or  in  combination,  are  to  suc- 
ceed, a  perceptible  amelioration  of  the  symptoms  is  generally  noticed  at 
once,  i.  e.,  in  the  course  of  the  first  two  or  three  days.  If  this  is  not  the 
case  it  becomes  a  very  important  question  how  long  the  attempt  should' 
be  continued.  Relying  on  the  doctrine  that  if  pressure  failed  to  cure  the 
aneurism  it  would  produce,  at  any  rate,  some  benefit  by  causing  dilatation 
of  the  anastomosing  vessels,  and  thus  diminishing  the  risk  of  gangrene, 
and  influenced  also  by  the  published  statistics  of  ligature  of  the  femoral 
artery — which,  I  think,  I  have  shown  to  be  more  unfavorable  than  the  re- 
sults of  modern  practice  justify — many  surgeons  were  in  favor  of  persever- 
ing with  pressure  for  a  very  considerable  length  of  time,  and  it  is  not  to  be 
denied  that  in  many  cases  a  cure  has  been  so  obtained,'^  but  at  the  expense 
of  an  amount  of  suffering  to  which  few  persons  would  willingly  submit 
unless  in  order  to  avoid  some  very  great  danger.  And,  as  it  seems,  it  is 
very  problematical  whether  the  danger  is  not  the  other  way.  Certainly 
the  mortality  after  ligature  of  tlie  femoral  artery  appears  not  to  be  di- 
minislied,  but,  on  the  contrary,  increased,  by  the  previous  unsuccessful 
trial  of  compression  f  and,  on  the  whole,  I  have  been  led  to  the  conclu- 
sion that  if  no  considerable  improvement  has  been  effected  by  the  blood- 
less methods  in  the  first  week,  it  is  better  to  give  up  the  attempt,  allow 
the  patient  a  few  days  to  recover  from  the  distress  which  the  compression 
has  general!}'  caused,  and  then  tie  the  artery. 

In  making  compression  I  have  myself  no  doubt  whatever  of  the  supe- 
riority of  the  digital  over  all  other  forms  of  pressure,  if  carefully  employed  ; 
and  I  think  the  observation  of  Mr,  Walker  an  important  one,  that  the 
pressure  should  not  be  varied  from  the  common  to  the  superficial  femoral 
and  vice  vernd^  but  should  be  applied  to  the  same  vessel  througliout  ("the 
one-artery  system,"  as  he  calls  it),  so  that  the  same  collaterals  should  al- 
ways be  called  upon. 

Ligature  of  Tibial  Arteries. — Aneurism  occurs  below  the  popliteal 
space,  but  aluiost  always  from  traumatic  causes,  or  in  cases  of  extensive 
disease  of  the  heart  and  arteries.     Traumatic  aneurisms  of  small  arteries 

1  Cases  of  successful  h'gature  after  the  rupture  of  the  tineurism  may  be  found  re- 
corded in  the  IJrit.  Med.  .Jour  ,  1809,  p.  47!)  (where  tlie  tmcurism  had  burst  into  the 
knee-joint)  ;  and  one  in  the  Lancet,  1851,  vol.  ii,  p.  30,  wlierc  the  aneurism  (femoral) 
bad  burst  throui;li  the  skin. 

2  See  a  remarUuble  instance  of  resolute  persistence  on  the  ])art  of  the  surgeon  and 
of  the  i)atient  for  a  space  of  half  a  year,  after  which  a  cure  was  at  length  obtained, 
recorded  by  Mr.  Walker  of  I^iverpool.  — Liverpool  Hospital  Reports,  vol.  v. 

3  Lancet,  May  1,  1875. 


LIGATURE    OF    TIBIAL    ARTERIES. 


559 


are  best  treated  as  recent  wounds ;  and  in  the  present  day  the  nse  of 
Esmarch's  bandage  enables  the  surgeon  to  exclude  the  blood  completely 
from  the  tumor,  while  he  dissects  out  the  vessels  and  ties  them  as  easily 
as  on  the  dead  subject.  Aneurisms  the  result  of  cardiac  or  general 
arterial  disease  are  best  let  alone  or  treated  by  the  mildest  forms  of  com- 
pression. They  are  usually  not  in  themselves  very  dangerous,  and  the 
patient's  life  cannot  in  any  case  be  a  long  one.  For  these  reasons  opera- 
tions on  the  tibial  arteries,  other  than  their  direct  ligature  for  wound,  are 
amongst  the  rarest  operations  in  surgery.  In  some  very  rare  cases,  how- 
ever, one  of  the  tibial  arteries  has  been  wounded  from  the  other  side  of 
the  leg  by  a  stab  through  the  interosseous  membrane,  and  then  it  has 
been  necessary  to  cut  down  formally  on  the  arterj'  according  to  the  rules 
of  the  dissecting-room. 

The  posterior  tibial  can  be  secured  near  the  ankle  with  facility,  as  it  lies 
between  the  tendons  of  the  tibialis  posticus  and  flexor  longus  digitorum 
in  its  inner,  and  that  of  the  flexor  longus  poUicis  at  its  outer  side.  All 
that  is  necessary  is  to  make  an  incision  half-way  between  the  internal 
malleolus  and  the  heel  and  dissect  the  pai'ts. 

To  secure  the  vessel  higher  up  two  different  plans  are  adopted.  Mr. 
Guthrie's  has  the  advantage  of  enabling  the  surgeon  to  secure  the  peroneal 
artery,  if  his  diagnosis  should  prove  at  fault  and  the  wound  or  other  lesion 
should  implicate  that  vessel  and  not  the  tibial.  A  vertical  incision  is  made 
in  the  centre  of  the  calf  about  six  inches  long,  through  the  gastrocnemius 


Fig.  251. 


Fig.  252. 


Fig.  251.— Ligature  of  posterior  tibial  artery.  The  posterior  liook  draws  aside  tlie  deep  mass  of  mus- 
cles and  the  intermuscular  fascia.  The  vessels  and  posterior  tibial  nerve  are  seen  lying  on  the  tibialis 
posticus. 

Fig.  252.~Ligature  of  anterior  tibial  artery.  The  vessels  are  seen  with  the  nerve  lying  in  front  and 
to  the  outer  side. 


and  soleus  muscles,  the  deep  or  intermuscular  fascia  freely  divided,  and 
the  vessel  sought  immediately  beneath  this  fascia,  superficial  to  the 
tibialis  posticus  muscle. 

The  old  method  of  tying  the  posterior  tibial  is  to  make  an  incision 
parallel  to  the  posterior  border  of  the  tibia,  and  about  a  finger's  breadth 


560  DISEASES    OF    VEINS. 

behind  it  tlirongh  the  skin,  superficial  and  deep  fascia,  exposing  the 
tibial  origin  of  the  soleus  muscle.  This  is  then  cut  from  the  bone,  the 
intermuscular  fascia  opened,  the  arter>'  found,  with  a  vein  on  either  side 
of  it,  and  the  nerve  probably  superficial  to  it,  separated  from  these  struc- 
tures, and  tied. 

Tlie  anterior  tibial  artery  will  be  found  in  any  part  of  its  course  by  an 
incision  in  a  line  drawn  from  the  head  of  the  fibula  to  the  central  point 
between  the  two  malleoli.  At  the  upper  part  of  the  leg  it  lies  very 
deeply,  at  the  outer  edge  of  the  tibialis  anticus  muscle,  in  a  septum  of 
the  fascia,  which  shows  as  a  white  line,  separating  that  muscle  from  the 
extensor  long.  dig.  above  and  the  ext.  prop,  pollicis  in  the  middle  of  the 
leg.  Success  in  this  operation  depends  on  hitting  the  edge  of  the  tibialis 
anticus,  for  which  pui'pose  the  surest  way  is  to  get  the  patient  to  put  it 
into  action  before  he  is  put  under  anaesthesia  and  mark  it  out,  and  to  make 
the  incision  very  freely,  and  carefully  search  for  the  white  line  before  open- 
ing the  fascia.  The  artery  has  venai  comites  on  either  side,  and  the  nerve 
superficial  to  it. 


CHAPTER  XXIX. 

DISEASES  OF  THE  VEINS  AND  ABSOKBENTS. 

Phlebitis  and  Thrombosis. — The  leading  symptoms  of  phlebitis,  or  in- 
flammation of  veins,  is  the  occurrence  of  coagulation  in  them,  as  evidenced 
by  hardness  along  the  course  of  the  vein.  In  true  infiammation  this  is 
accompanied  by  pain  and  ledness,  and  some  amount  of  general  fever. 
The  mere  coagulation  of  the  blood  in  the  veins  by  no  means  implies  any 
inflammation,  or  any  general  aflection  of  the  system,  or  even  any  altera- 
tion in  the  tissues  of  tiie  vein  itself.  Such  passive  coagulation  of  the 
blood  in  tlie  veins  used  to  lie  denominated  "adhesive  phlebitis,"  on  the 
theory  that  the  cause  of  the  coagulation  was  tlfusiou  of  lymph  from  the 
lining  n)embrane  of  the  vein  ;  but  it  has  been  satisfactorily  shown,  both 
by  clinical  and  anatomical  observation,  that  in  many  of  these  cases  there 
is  no  evidence  of  any  inflammation  whatever;  and  the  direct  experiments 
of  Guthrie,  Travers,  H.  Lee,  and  Calleiider,  in  our  own  country,  besides 
foreign  observers,  have  shown  that  the  lining  memlirane  of  the  veins  does 
not  secrete  lymph.  Consefpiently  the  condition  known  to  the  older  pa- 
thologists as  "adhesive  phleltitis"  is  now  usually  designated  more  cor- 
rectly as  "thrombosis."  It  proceeds  from  a  variety  of  causes, — from 
pressure  or  obstruction  to  the  return  of  blood,  from  diminished  power  of 
the  circulation,  from  varicosity  of  the  veins,  from  the  extension  into 
them  of  chits  forming  nearer  the  heart,  and  from  conditions  of  the  blood 
itself  wliicii  are  not  as  yet  perfectly  understood.  Thus,  in  the  thrombo- 
sis wiiich  occurs  in  the  veins  of  the  lower  extremity  alter  parturition, 
and  to  which  the  name  of  "  phlegmasia  dolens"  is  applied,  the  coagula- 
tion which  has  necessarily  taken  place  in  the  uterine  sinuses  extends 
down  the  iliac,  femoral,  and  other  veins.     In  fractures  where  a  vein  has 


PHLEBITIS.  561 

been  contused  or  torn  the  coagulation  so  produced  often  extends  into  the 
lower  veins  and  impedes  the  union  of  the  fracture/     And  sometimes  we 
see  cases  in  which,  with  no  definite  local  exciting  cause  (though  commonly 
in  some  condition  of  general  disease),  the  veins  become  blocked,  often  to 
a  very  great  extent.     The  same  passive  coagulation  or  thrombosis  occa- 
sionally, though  rarely,  happens  in  the  pulmonar}'  arteries,  and  is  a  rec- 
ognized cause  of  sudden  death, ^  and  there  can  be  no  doubt  that  similar 
passive  coagulation  of  blood  in  the  cavities  of  the  heart  occasionally  pro- 
duces death.     The  first  symptoms  of  thrombosis  are  a  sense  of  uneasi- 
ness and  an  aching  pain  in  the  part  affected,  followed  by  some  difficulty 
in  moving  the  limb.     On  examination  a  hard  cord  is  felt  in  the  place  of 
the  vein  aflTected,  which  is  somewhat  tender  on  being  handled,  and  there 
is  general  swelling  and  oedema  of  the  limb.     The  affected  vein  is  some- 
times though  not  always  surrounded    by  inflamed  cellular  tissue.     If 
there  is  an  opportunity  of  examining  the  vein  it  will  be  found  filled  with 
coagula,  which   are  more  or  less   adherent  to   its   inner  surface.     The 
coagula  are  of  a  variable  or  mottled  color,  almost  black  in  some  places, 
in  others   nearly  decolorized,  and  generally  the    decolorized  parts    are 
firmly  connected  to  the  lining  membrane,  while  the  central  portion  of  the 
clot  is,  on  the  contrary,  often  broken  down  into  a  creamy  fluid,  looking 
like  a  mixture  of  blood  and  pus.     In  some  cases,  even  when  the  obstruc- 
tion of  veins  is  great,  no  constitutional  disturbance  can  be  traced.    There 
is  no  feverish  excitement,  no  change  in  the  normal  temperature  or  pulse, 
and  the  affection  subsides  spontaneously  as  it  arose — the  vessels  regain- 
ing their  natural  appearance,  and  the  functions  of  the  limb  being  com- 
pletely restored.     But  this  is  not  always  the  case.     Whether  along  with 
or,  as  seems  more  probable,  in  consequence  of  the  coagulation,^  the  walls 
of  the  vein  and  the  cellular  tissue  which  support  it  become  inflamed,  and 
this  inflammation  is  often  accompanied  with  severe  pain  and  with  much 
constitutional  disturbance,  and  the  serious  symptoms  may  ensue  which 
are  described  as  acute  or  suppurative  phlebitis,  and  which  are  often  de- 
veloped by  severe  injuries,  such  as  amputation  or  excision,  when  the  cav- 
ities of  large  veins  have  been  laid  open,  and  especially  those  veins  which, 
being  contained  in  bony  canals,  are  incapable  of  closure,  and  thus  of  im- 
mediate union. 

The  anatomical  characters  of  phlebitis  are  perceived  partly  on  the  cel- 
lular tissue  which  supports  the  vein,  partly  in  the  coats  of  the  vessel 
itself,  and  partly  in  its  contents.  The  disease  consists — in  some  measure 
at  least — of  diffuse  inflammation  spreading  along  the  cellular  membrane 
in  which  the  vein  lies.  Hence  the  redness,  hardness,  and  oedema  which 
are  seen  during  life  in  the  course  of  the  affected  vessel.  Although  this 
inflammation  most  commonly  extends  in  the  course  of  the  circulation, 
cases  are  not  wanting  in  which  it  spreads  towards  the  distal  veins.  In 
this  inflammation  the  outer  or  cellular  coat  of  the  vein  participates.  Co- 
incidently  with  this  the  tissues  of  the  vessel  itself  become  altered.  "  The 
circular  fibrous  coat  becomes  injected  and  thickened  by  deposit ;  the 
inner  coat  loses  its  natural  transparencj-,  and  becomes  wrinkled  and  even 

1  See  Callander,  Med.-Chir.  Trans.,  vol.  li. 

2  The  reader  will  find  a  very  interesting  account  of  these  cases  of  thrombosis  in 
the  superficial  veins,  the  cerebral  sinuses,  the  cavities  of  the  heart,  and  the  pulmo- 
nary arteries,  in  a  paper  On  the  Coagulation  of  the  Blood  in  the  Venous  System 
during  Life,  by  Dr.  Humphry,  republished  in  1859  from  the  British  Medical  Journal. 

3  "  Coagulation  of  the  blood  in  a  vein,"  says  Mr.  Lee,  "  may  be  either  a  primary 
or  secondary  aifection  :  it  may  be  either  the  cause  or  efi"ect  of  the  inflammation  of 
the  coats  of  the  vein." — Practical  Pathology,  3d  ed.,  vol.  i,  p.  24. 

30 


562  DISEASES    OF    VEINS. 

fissured.  It  is  of  a  dull,  opaque,  dirty-white  color,  staiued  more  or  less 
bj'  the  contents  of  the  vein  ;  exudation  often  occurs  between  the  inner 
and  outer  coats,  and  the  different  layers  of  the  former  then  become  dis- 
integrated, or  the  lining  membrane  may  be  cast  oft"  in  large  portions  into 
the  interior  of  the  vessel.  All  the  coats  of  the  vein  may,  under  these  cir- 
cumstances, be  easil}'  detached  from  each  other,  or  may  be  separated  by 
serous,  fibrinous,  or  puriform  exudation.  When  these  form  under  the 
lining  membrane  they  may  be  seen  as  patches  of  various  sizes  and 
shapes  through  the  transparent  structure,  so  long  as  this  retains  its  in- 
tegrity. Afterwards  the}'  may  be  poured,  together  with  the  fragments 
of  the  disintegrated  membrane,  into  the  cavity  of  the  vessel.  The  in- 
flammatory exudation  between  the  diff'erent  coats  of  the  A'ein  destroys  its 
natural  pliabilit}',  so  that  when  divided  it  will  remain  open  like  an  artery." 
(Lee,  op.  cit.,  p.  25.)  So  much  for  the  anatomical  changes  in  the  vein 
itself.  Along  with  this  there  are  changes  in  the  blood  contained  in  it. 
We  have  seen  that  the  blood  may  clot  in  the  veins  without  any  previous 
inflammatory  symptoms  or  appearances,  and  sometimes  without  any  sub- 
sequent bad  consequences  (thrombosis),  but  we  have  also  seen  that  this 
obstruction  of  the  vein  may,  on  the  other  hand,  prove  the  starting-point 
of  inflammation  of  its  tissue.  Coagulation  may  also  follow  on  injury  to 
the  vein,  or  on  the  passage  into  its  cavity  of  any  irritating  or  decompos- 
ing matter.  In  such  cases  the  coagulation  is  to  be  regarded  as  salutary — 
a  barrier  thrown  up  against  the  passage  of  the  products  of  inflammation 
or  decomposition  into  the  mass  of  the  circulating  blood.  Should  this 
barrier  hold,  the  inflammation  will  be  limited  to  the  part  first  affected, 
the  general  symptoms  which  may  have  been  excited  will  subside,  and 
the  patient  recover.  But  the  coagulum  often  breaks  down  and  softens 
into  a  creamy  puriform  fluid,  resembling  sanious  pus  to  the  naked  eye, 
but  only  showing  under  the  microscope  granular  matter  and  disintegrated 
blood  cells ;  and  when  this  matter  passes  into  the  general  current  of  the 
blood  it  will  spread  the  inflammation  of  the  vein  to  an  indefinite  extent, 
and  will  produce  the  general  symptoms  and  signs  of  septicfemia  or  pytemia. 
And,  lastly,  as  clotting  in  a  vein  and  the  decomposition. of  the  clots  some- 
times excites  the  general  symptoms  of  pyaemia,  so  conversely  the  passage 
of  putrid  matter  into  the  blood — septicaemia — often  is  the  cause  of  clot- 
ting and  of  decomposition  of  clot  in  the  remote  veins.  As  Mr.  Lee 
phrases  it,  "the  decomposition,  originating  in  a  local  action,  may  infect 
the  general  mass  of  the  blood  and  rapidly  kill  the  patient,  without  the 
occurrence  of  any  blood-clotting;  or  coagula  may  form  in  the  vessels, 
disintegrate  and  decompose,  and  become  conveyed  to  other  parts.  In 
the  last  instance  the  phoiomena  of  thrombosis  and  afterwards  of  embo- 
lism become  superadded  to  the  original  septicaemia"  (op.  cit.,  p.  58). 

Various  Kinda  of  Phlebilis. — The  kinds  of  thrombosis  and  phlebitis, 
ranked  according  to  their  causes,  are  enumerated  by  Paget  as:  (1)  The 
traumatic,  including  those  due  to  distension  ;  (2)  those  occurring  in  ex- 
haustion, during  or  after  either  acute  or  chronic  diseases;  (3)  those  due 
to  extension  of  inflannnation,  or  of  blood-clotting  from  nlcers,  morbid 
growths,  or  gangrenous  or  acutely  inflauied  parts  ; '  (4)  those  of  the  so- 
called  idiopathic  or  rheumatic  form  ;  (5)  the  pyiemial  ;  (6)  the  puerperal 
(among  which  it  is  probable  that  examples  of  all  kinds,  only  modified  by 
the  puerperal  state,  are  grouped) ;  and  (7)  the  gouty .'^ 

1  Sec  Fig.  181,  p.  427. 

2  Clin.  Lect.,  p.  293.  Sir  J.  Paget'.s  cssny  gives  an  interesting  sketch  of  gouty 
phlebitis,  distiiigiiii<lied  chiefly  by  its  .symmetry,  apparent  metastases,  and  frequent 
recurrence.  Mr.  Prescott  Hewett  ha;-  also  described  the  same  form  of  phlebitis  in 
Clin.  Soc.  Trans.,  vol.  vi. 


VARICOSE    VEINS.  563 

The  symptoms  above  stated  will  suffice  for  the  diagnosis  of  phlebitis 
whenever  the  vein  is  superficial  ;  in  fact,  the  only  disease  with  which  it 
could  be  confounded  is  inflamed  absorbents,  but  the  latter  is  not  accom- 
panied by  the  oedema  of  phlebitis  :  the  red  inflamed  streaks  are  much 
narrovver,  and  there  is  always,  if  enlargement,  at  any  rate  tenderness  of 
the  glands  above. 

Treatment. — The  treatment  of  phlebitis  must  in  general  be  merely  ex- 
pectant, any  concomitant  constitutional  or  general  disorder  being,  of 
course,  treated  according  to  its  own  indications.  Strict  rest  must  be 
enjoined  ;  the  part  must  be  put  in  such  a  position  as  will  favor  the  return 
of  blood ;  warm  lotions  are  generally  grateful,  and  possibly  may  be  use- 
ful in  favoring  the  distension  of  the  cellular  tissue  and  avoiding  tension. 
If  there  is  much  diflTuse  inflammation  around  the  affected  vein  incisions 
will  be  necessary.  The  administration  of  mercury  and  free  leeching 
around  the  inflamed  vein  used  to  be  much  practiced,  but  their  generally 
weakening  effect  is  more  deleterious  than  is  counterbalanced  by  any  local 
benefit  they  produce.  Pain  must  be  soothed  by  opium,  and  in  rheumatic 
and  gouty  cases  alkalies  will  be  indicated. 

Finally,  there  may  be  cases  where  the  surgeon  may  think  it  justifiable 
to  hinder  the  progress  of  the  inflammation  and  defend  the  patient  from 
the  danger  of  the  passage  of  the  decomposing  clot  into  the  mass  of  the 
blood  by  putting  two  needles  beneath  the  vein  and  dividing  it  in  the 
interval,  a  practice  of  which  Mr.  Lee  has  given  some  interesting  examples, 
apparently  successful,  though  of  course  it  will  be  only  rarely  that  such  a 
complication  to  an  already  dangerous  malady  will  be  considered  appro- 
priate, and  frequent  failure  in  checking  the  course  of  the  disease  must 
be  anticipated. 

Varicose  Veins. — Varicosity  or  dilatation  of  veins  is  an  exceedingly 
familiar  affection  as  seen  in  the  veins  of  the  lower  limb.  It  very  com- 
monly affects  the  veins  of  the  spermatic  cord,  forming  the  disease  known 
as  varicocele.  Many  piles  consist  wholly  or  in  part  of  varicose  haemor- 
rhoidal  veins,  and  other  superficial  and  deep  veins  are  occasionally  found 
to  be  varicose.  Dilated,  tortuous,  and  varicose  veins  are  also  not  unfre- 
quently  found  ramifying  under  the  skin  and  forming  a  collateral  circula- 
tion in  cases  where  an}'  large  trunk-vein  is  obliterated.  Thus,  when  the 
vena  cava  inferior  has  been  plugged,  large  veins  are  developed  under  the 
skin  of  the  abdomen,  which  bring  the  blood  from  some  of  the  radicles  of 
the  obstructed  vein  into  those  of  the  superior  vena  cava,  while  the  azygos 
circulation  is  no  doubt  also  enlarged  to  convey  the  remainder. 

The  diseases  caused  by  varicosity  of  special  A'eins,  and  admitting  of 
sui-gical  treatment,  will  be  found  described  in  other  chapters,  as  Vari- 
cocele and  Hemorrhoids.  We  will  deal  here  with  varix  of  the  lower  ex- 
tremity. 

This  may  arise  from  any  cause  which  throws  too  great  or  too  con- 
tinuous a  strain  on  the  veins,  or  which  obstructs  the  return  of  blood  from 
them.  Thus,  long-continued  standing,  especially  in  a  heated  atmosphere 
(as  is  done  by  soldiers,  cooks,  washerwomen),  the  presence  of  garters, 
ill-fitting  trusses,  tumors,  collections  of  fseces  in  the  sigmoid  flexure,  the 
gravid  uterus,  want  of  support  to  the  veins  from  relaxation  of  the  tissues 
which  should  support  them,  are  I'ecognized  causes  of  varix ;  and  much 
may  therefore  be  done  in  an  early  stage  of  the  disease  to  mitigate  or 
even  to  cure  it  by  a  removal  of  its  cause. 

The  first  effect  of  long-continued  pressure  on  a  vein  is,  of  course,  its 
dilatation.     This  dilatation,  when  not  carried  too  far,  or  continued  too 


564  DISEASES    OF    VEINS. 

long,  is  susceptible  of  complete  recovery  b}^  the  natural  elasticit}'  of  the 
tissues  which  form  and  those  which  support  the  vein.  But  if  it  be  car- 
ried too  far  the  vein  becomes  permanently  dilated,  the  valves  cease  to 
be  adequate  to  close  its  tube,  and  the  pressure  is  therefore  transmitted 
to  a  lower  part  of  the  trunk,  which  thereby  becomes  similarly  affected, 
and  so  a  long  tract  of  the  vein  becomes  permanently  varicose.  But 
there  are  other  cases  in  which  the  dilatation  affects  only  a  small  extent 
of  the  whole  vein,  and  even  some  very  rare  ones  in  which  only  a  portion 
of  the  calibre  is  dilated  into  a  circumscribed  tumor  exactly  resembling 
an  aneurism.'  Further  changes  follow  on  this  dilatation  of  the  vein.  In 
the  first  instance  the  coats  of  the  veins  are  probably  rendered  thinner  by 
their  distension,  and  there  are  cases  in  which  they  remain  thinner,  and 
some  in  which  they  give  waj'^  altogether ;  and  the  skin  over  them  being 
also  absorbed  by  the  pressure  of  the  varix,  external  haemorrhage  results. 
In  other  cases  the  dilatation  produced  b}'^  the  pressure  causes  thickening 
of  the  varicose  vein.  The  skin  ia  often  greatl}'  affected  in  this  disease. 
The  obstacle  to  the  return  of  the  blood  causes  congestion,  followed  often 
by  low  inflammation  and  ulceration.  Hence  varicose  veins  are  the  most 
prolific  of  all  the  causes  of  ulcer  of  the  leg. 

The  superficial  veins  are  chiefly  affected,  but  it  has  been  satisfactorily 
proved  that  the  deep  veins  are  not  exempt,  though  the  firm  support  which 
the}'  receive  from  the  muscles  and  fascise  amongst  which  they  lie  prevents 
their  attaining  the  size  which  the  superficial  veins  do.  This  enlargement 
of  the  deep  veins  is  testified  by  a  general  increase  in  the  size  of  the  limb, 
independent  of  the  swelling  of  tlie  superficial  vessels,  and  by  the  sense 
of  weight  and  aching  on  hanging  it  down.  And  the  occurrence  of  vari- 
cosity in  the  deep  veins  (though  doubted  by  Mr.  Callender)  has  been- 
directly  affirmed  by  Verneuil,  who  has  put  up  some  preparations  in  the 
Musee  Dupuytren  to  show  it.^ 

Treatment. — The  treatment  of  varicose  veins  must  be  either  palliative 
or  radical.  It  has  been  pointed  out  above  that  in  an  early  stage  of  the 
disease  complete  recovery  may  follow  on  the  I'emoval  of  the  cause,  the 
strengthening  of  the  general  health,  so  as  to  improve  the  tone  of  the  tis- 
sues, and  the  unloading  of  the  aflTected  veins  by  rest  in  the  raised  posture. 
And  even  when  the  veins  have  been  for  some  time  varicose,  if  the  disease 
has  not  progressed  very  far,  rest  in  the  raised  position  for  a  considerable 
time — sa}'  a  month — and  the  application  of  firm  but  soft  bandages,  will 
often  produce  the  complete  disappearance  of  the  enlargement  and  relieve 
the  symptoms.  Still  it  is  prudent  to  enforce  the  wearing  of  a  well-fitting 
bandage  or  elastic  stocking  for  a  long  while,  and  particularly  during  any 
strong  exercise.  When  the  enlargement  has  lasted  long,  and  the  veins 
have  become  much  thickened,  complete  recovery  cannot  be  expected,  but 
much  improvement  may  be  procured  by  proper  and  well-fitting  bandages 
and  stockings. 

Tlie  cases  in  which  operative  interference  is  desirable  are  not  numer- 
ous, for  it  has  been  abundantly  shown  that  if  one  varicose  cluster  is  cured 
another  will  often,  if  not  always,  form,''  and  also  that  very  much  improve- 

1  There  is  a  propanition  of  this  in  the  Museum  of  St.  Goorjjje's  Hospital. 

^  A  recent  writer  (Giacomini — see  Lund.  Med.  f'ecord,  March  4,  1874)  even  goes 
so  far  as  to  say  that  varico.'sity  of  tlie  siifjerlieial  veins  is  always  secondary  to  a  vari- 
co.se  slate  of  those  deeper  vein.s  (inter-  and  intra-musciilar)  which  establish  a  communi- 
cation between  the  trunk  veins  accompanying  the  arteries  and  the  subcutaneous 
vessels — the  radicles  of  the  sa[)henous. 

3  Sir  B.  IJrodie  says:  "  I  always  observed  that  if  I  cured  one  cluster  two  smaller 
ones  appeared,  one  on  each  side,  and  that  ultinmtely  I  left  the  patient  no  better  than 
I  found  him  " — Works,  vol.  iii,  p.  264. 


OTHER    AFFECTIONS    OF    VEINS.  565 

ment  may  be  obtained  by  rest  and  appropriate  treatment,  even  in  the 
worst  cases,  so  much  as  usually  to  allow  complete  relief  to  the  symptoms, 
by  proper  apparatus.  Now,  as  the  same  apparatus  will  be  required  even 
after  the  most  successful  operation,  it  may  fairly  be  argued  that  the  pain 
and  risk  of  the  latter  have  been  superfluous.  I  admit  this  to  some  extent. 
Still  the  operation  is  very  much  less  formidable  than  that  for  varicocele, 
and  it  certainly  gives  speedy  and  effectual,  though  possibly  only  tempo- 
rary, relief  in  many  cases  where  there  has  been  great  pain,  or  where  the 
patient  has  been  much  troubled  with  ulceration  or  inflammation  of  the 
skin.  There  are  very  numerous  operations  in  use  for  varicose  veins,  but 
I  will  only  describe  that  which  my  colleague,  Mr.  H.  Lee,  has  introduced 
at  St.  George's  Hospital,  which  is  very  easy,  very  efflcient,  and  after 
which  I  have  not  as  yet  seen  any  serious  accident.  The  vein  is  divided 
subcutaneously,  while  it  is  compressed  above  and  below  the  point  of 
division  long  enough  to  insure  its  obliteration,  but  not  long  enough  to 
allow  any  ulceration  of  the  vein.  Hence  there  is  no  way  left  by  which 
any  of  the  products  of  putrefaction  or  decomposition  (should  any  such 
products  form  in  the  subcutaneous  puncture)  can  pass  into  the  cavity  of 
the  vein. 

Two  pins  are  to  be  passed  under  the  vein,  at  a  distance  of  about  an 
inch  from  each  other ;  and  in  doing  so  great  care  must  be  taken  to  lift 
the  vein  well  up,  and  pass  the  pin  below  the  vein  and  not  through  it. 
Compression  is  then  made  by  twisting  a  figure  of  8  ligature  round  the 
pins  or  by  a  piece  of  india-rubber,  through  which  the  pin  is  thrust  before 
it  is  introduced,  and  which  is  then  drawn  over  its  point.  Then  a  thin 
knife,  a  little  longer  and  stronger  in  the  blade  than  a  tendon  knife,  is 
passed  under  the  vein,  and  the  latter  completely  divided  without  cutting 
the  skin.^  Two  or  three  circular  pieces  of  plaster,  encircling  the  whole 
leg,  are  then  firmly  applied  over  the  puncture  and  the  divided  ends  of 
the  vein,  and  the  patient  is  kept  in  bed,  with  the  limb  raised,  for  a  week 
or  ten  days.  The  pins  are  removed  at  a  time  varying  from  two  to  five 
days.  The  former  time  is  quite  enough  when  all  goes  well  and  there  is 
no  excess  of  action  round  the  subcutaneous  wound  ;  but  if  this  should 
take  place  the  surgeon  may  think  it  safer  to  keep  up  compression  longer. 
The  plaster  need  not  be  nioved,  unless  suppuration  is  found  to  be  going 
on.  After  the  above  time  a  bandage  may  be  carefully  applied,  and  the 
patient  allowed  to  move  about  a  little  in  the  house.  Then  a  well-fitting 
elastic  stocking  should  be  worn.  If  there  is  an  ulcer  the  patient  should 
be  kept  in  bed  till  it  heals. 

Other  Affections  of  Veins. — There  are  a  few  other  affections  of  veins 
which,  however,  are  more  pathological  products  than  surgical  diseases. 
Thus,  from  degeneration  of  clots  small  chalky-  concretions,  called  "  phle- 
bolithes,"  are  found  in  the  cavity  of  veins,  and  such  concretions  may  not 
uncommonly  be  recognized  during  life  in  the  spermatic  veins.  I  am  not 
aware  that  they  ever  produce  any  symptoms  or  require  removal. 

The  veins  are  peculiarly  liable  to  hypertrophy  and  atrophy,  according 
as  the  variations  of  the  circulation  throw  the  blood  into  anastomosing 
channels  or  the  removal  of  parts  deprives  the  veins  of  their  chief  function. 

1  Sir  B.  Brodie  introduced  the  practice  of  dividing^  the  veins  subcutaneously.  Mr. 
Lee  added  the  temporary  compression  above  and  below,  which  so  greatly  tends  to 
the  patient's  safety. 

2  They  consist,  according  to  an  analysis  made  for  Mr.  Callender  by  Dr.  Frankland, 
of  phosphate  of  lime,  with  some  sulphate  of  potash  and  sulphate  of  lime,  intermixed 
with  protein  substances  from  the  blood. 


566  DISEASES    OF    ABSORBENTS. 

Calcareous  degeneration  of  veins  is  also  spoken  of,  but  it  seems  doubt- 
ful whether  it  is  not  usually'  a  peculiar  arrangement  of  phlebolithes.  No 
disease  is  known  in  veins  corresponding  to  the  atheroma  of  arteries. 

Malignant  tumors  frequently  grow  into  veins ;  and  every  museum  con- 
tains specimens  of  cancer  protruding  into  the  cavity  of  some  large  vein. 

Parasitic  animals  may  be  found  in  the  venous  blood,  as  in  the  endemic 
ha?maturia  of  the  Cape  of  Good  Hope.^ 

DISEASES   OF   THE   ABSORBENTS. 

Lymphatic  Fishda. — The  absorbent  vessels  are,  though  very  rarely, 
the  seat  of  fistulous  openings,  through  which  their  secretion  is  poured 
out  on  to  the  surface  of  the  Ijody.  This  occurs  more  often  in  the  groin, 
scrotum,  and  labium  than  in  any  other  part,  and  is  sometimes  the  result 
of  a  wound;  at  other  times  it  proceeds  from  a  varicose  condition  of  the 
vessels,  the  cause  of  which  is  obscure,  but  which  is  often  associated  with 
elephantiasis  of  the  lower  part  of  the  limb.  Dr.  Vandyke  Carter  has 
noticed  that  in  a  case  of  "  chylous  urine  "  a  quantity  of  lymph  was  poured 
out  of  a  minute  opening  in  the  thigh,  and  he  believes  that  in  some  at  least 
of  these  cases  there  is  a  preternatural  communication  between  the  recep- 
taculum  chyli  or  some  of  its  large  branches  and  the  urinary  passages, 
complicated  with  obstruction  of  the  main  lacteals  and  a  varicose  state  of 
the  lower  lymphatics.^ 

Beyond  attention  to  position,  careful  pressure  by  strapping  or  bandages, 
and  avoidance  of  accumulation  in  the  bowels,  I  do  not  see  what  can  be 
done  in  such  cases. 

Inflammation  of  Ahsorhenta  and  Glands. — The  commonest  surgical 
affection  connected  with  the  lymphatic  S3'stem  is  the  inflammation  which 
so  commonly  attends  wounds,  whether  poisoned  or  not,  and  which  affects 
either  the  absorbent  vessels  themselves  (inflamed  absorbents — angeioleu- 
citis )  or  the  glands  (inflamed  glands — adenitis)  or  both. 

Inflammation  of  the  absorbents  is  usually  excited  by  a  wound,  but  it 
occurs  also,  as  has  been  mentioned  in  the  section  on  Erysipelas,  p.  68,  as 
an  idiopathic  affection  premonitory  of  that  disease,  or  one  of  its  earliest 
symptoms.  If  severe,  the  disease  commences  with  considerable  fever  and 
rigors  ;  soon  red  lines  are  seen  running  up  the  course  of  the  lyiyphatics, 
and  terminating  at  the  nearest  gland.  This  is  often  accompanied  by 
sharp  pain,  and  always  by  great  tenderness.  The  redness  and  tenderness 
are  easily  distinguished  from  those  which  are  found  in  phlebitis,  inas- 
much as  the  lines,  tiiough  much  thicker  than  the  absorbent  vessels,  are 
far  less  extensive  than  would  be  caused  by  inflammation  of  the  cellular 
tissue  around  the  veins,  and  the  red  streaks  run  in  tlie  course  of  the  ab- 
sorbents, not  in  that  of  the  veins.  The  redness  in  all  cases  ceases  at  the 
igland  or  glands  to  which  the  absorbents  run  ;  and  those  glands  are  tender, 
red,  and  hot,  and  they  are  very  liable  to  suppuration,  which  involves 
mainl}'  the  cellular  tissue  around  the  gland,  and  which  on  its  subsidence 
does  not  seem  to  leave  the  gland  permanently  impaired  in  function, 
though,  no  doubt,  suppuration  takes  place  in  the  tissue  of  the  gland  as 
well  as  in  that  wliich  surrounds  it.  In  rare  cases  there  are  abscesses  in 
the  course  of  the  lynipliatic  before  it  reaches  the  gland. 

Inflammation  of  a  gland,  however  (adenitis),  occurs  constantly  without 

1  See  Harley,  Mcd.-Chir.  Trans.,  vol.  xlvii,  p.  55  et  seq. 

2  Med. -Chip.  Trans.,  vol.  xlv. 


AFFECTIONS    OF    GLANDS    IN    VARIOUS    DISEASES.       567 

aii}^  previous  inflammation  of  the  lymphatics  which  supply  it,  as  we  see 
every  day  in  the  cervical  glands,  in  the  bubo  of  gonorrhoea  and  syphilis, 
and  in  a  thousand  other  cases. 

This  inflammation,  or  bubo,  seems  in  all  cases  conservative — the  prod- 
ucts of  inflammation  are  resolved  in  the  gland,  and  instead  of  passing 
into  the  mass  of  the  blood  to  excite  fermentation  and  septiciiemia,  they 
are  expended  in  the  production  of  an  abscess  which,  in  all  ordinary  cases, 
is  a  mere  local  trouble.  There  are,  of  course,  exceptions  to  this,  and  they 
have  been  already  alluded  to  in  the  chapter  on  Poisoned  Wounds  (p.  94), 
but  it  remains  true  that  inflammation  of  the  absorbent  glands  is  a  safe- 
guard against  the  passage  of  poisonous  material  into  the  blood,  and 
one  which,  considering  the  constant  occurrence  of  the  danger,  is  very 
efficient. 

The  treatment  of  inflamed  absorbents  is  generally  very  simple.  If  the 
inflammation  is  of  moderate  severity,  the  application  of  nitrate  of  silver 
in  a  strong  solution  (gr.  x-xv  to  tlie  ounce)  or  pencilling  them  lightly 
with  a  stick  of  caustic,  after  wetting  the  skin,  seems  useful.  I  have  seen 
much  benefit  from  the  application  of  mercurial  ointment  over  the  inflamed 
vessels,  but  it  is  very  apt  to  salivate;  and  after  all  the  inflammation  of 
the  vessels  themselves  almost  always  subsides  spontaneously.  The  use 
of  warm  opiate  lotions  is  generally  grateful.  The  bowels  should  be  freely 
purged  ;  and  the  general  treatment  should  be  the  same  as  for  erysipelas, 
to  which  this  disease  bears  such  a  close  relationship. 

Inflammation  of  the  absorbent  glands  requires  the  same  general  treat- 
ment. Locally,  warm  poultices  are  the  best  application.  It  is  an  error,  I 
think,  to  believe  that  poultices  promote  suppuration ;  on  the  contrary, 
they  seem  to  prevent  it,  when  it  is  preventable,  though  when  it  has  com- 
menced they  soften  and  relax  the  tissues,  and  facilitate  its  progress 
towards  the  skin.  As  soon  as  matter  is  detected  it  should  be  freely 
opened. 

If  the  inflammation  remains  long  in  a  chronic  state  nothing  is  so  useful 
as  a  blister.  In  some  cases  it  causes  the  recession  of  the  inflammation 
and  subsidence  of  the  glandular  enlargement ;  more  commonly  it  brings 
the  abscess  to  a  head. 

Affections  of  Glands  in  Various  Diseases. — The  glands  sympathize,  or 
more  properly  speaking  are  involved,  in  a  great  number  of  diflTerent  kinds 
of  inflammatory  and  constitutional  diseases — in  struma,  syphilis,  and 
cancer  especially.  In  all  these  diseases  the  affection  of  the  glands  is,  as 
a  general  rule,  secondary  to  a  similar  affection  in  the  soft  parts  from 
which  they  are  supplied,  but  in  struma  the  glands  are  ver^^  often  affected 
with  little  evidence  of  any  such  primary  disease,  and  in  constitutional 
sjqjhilis  they  are  often  enlarged  without  any  aflTection  of  the  parts  from 
which  they  are  supplied.  Still  it  is  prudent  in  all  cases  of  strumous  or 
syphilitic  enlargement  of  glands  to  examine  narrowly  all  the  parts  from 
which  they  derive  their  absorbents,  for  assuredly  the  glandular  affection 
will  be  most  easily  treated  by  the  cure  of  that  on  which  it  depends. 

Strumous  glands  are  most  common  in  the  neck,  and  often  constitute  a 
disease  by  themselves.  It  is  understood  that  the  absence  of  eruptions  of 
the  scalp,  caries  of  the  teeth,  etc.,  has  been  ascertained,  and  that  the  sur- 
geon has  satisfied  himself  that  the  glandular  disease  is  the  specific  object 
of  treatment.  In  this,  as  in  all  other  strumous  diseases,  the  surgical 
treatment  should  not  be  too  active.  If  the  glands  be  merely  in  the  ordi- 
nary condition  of  chronic  enlargement  the  only  local  application  they 
will  require  will  be  slight  counter-irritation  with  iodine,  or  light  touches 


568  DISEASES    OF    ABSORBENTS. 

of  the  actual  cautery,  or  flying  blisters.  In  this  condition  they  are  ilsually 
the  seats  either  of  definite  tubercular  deposits  or  of  low  inflammation.  In 
the  former  case  abscess  is  very  probable,  though  it  is,  of  course,  possible 
that  the  tubercle  may  calcify  or  become  indolent.  In  the  other  case  the 
gland  may  return  entirel}^  to  the  health}'  condition.  The  remedies  pre- 
scribed for  scrofula  (page  380)  must,  of  course,  be  eraplo^^ed,  and  when 
suppuration  is  plainly  perceived  a  small  incision  should  be  made,  or  exit 
given  to  it  b}'  a  seton  of  a  single  thread,  which  often  affords  a  vent  for 
the  pus,  with  but  little  resulting  deformity.  If  the  abscess  is  left  to  find 
its  own  wa}'  out  it  often  leaves  several  depressed  cicatrices,  or,  worse 
still,  a  heaped-up  strumous  scar  (page  419). 

The  treatment  of  syphilitic  glands  resolves  itself  into  that  of  the  con- 
stitutional affection  on  which  it  depends.  Cancerous  glands  usually  ad- 
mit of  no  treatment,  unless  the  surgeon  thinks  fit  to  regard  them  as  part 
of  the  primary  tumor  and  extirpate  them  along  with  it. 

It  is,  however,  hardly  ever  desirable  to  operate  on  enlarged  glands, 
otherwise  than  as  a  part  of  an  operation  for  cancer.  I  have  seen  stru- 
mous glands  extirpated,  and  have  myself  performed  such  operations ; 
but  though  I  have  obtained  occasional  good  results,  it  has  been  at  the 
expense  of  difficulty  and  danger  far  out  of  proportion  to  the  advantage, 
and  I  would  strongly  dissuade  the  attempt,  unless  in  very  exceptional 
circumstances. 

Lymphadenoma. — Finally,  we  must  speak  of  a  peculiar  hypertrophic 
disease  of  the  lymphatic  glands,  first  distinctly-  described  by  Dr.  Hodgkin,^ 
and  often  called  after  his  name  "  Hodgkin's  disease,"  but  now  more  com- 
monly spoken  of  as  "  Lymphadenoma,"  "  Lympho-sarcoma,"  or  "  Lym- 
phoma." The  enlargement  affects  usually  the  cervical  glands,  sometimes 
those  of  the  axilla  also,  sometimes  the  glands  in  man}'  parts  of  the  bod}'. 
The  blood-glands  are  also  often  affected,  particularly  the  spleen  and  th}'- 
roid,  and  there  maybe  thus  combined  with  the  glandular  disease  the  con- 
dition known  as  "  leucocythsemia,"  in  which  the  elaboration  of  the  blood 
is  imperfect,  so  that  the  white  cells  are  disproportionately  numerous.- 
Finally,  the  same  disease  affects  the  lymphatic  channels  in  many  parts  of 
the  body,  forming  tumors  in  the  lungs,  liver,  and  other  organs,  which  are 
believed  to  depend  on  deposit  of  adenoid  tissue  in  the  cellular  membrane 
enveloping  the  lymphatic  vessels.  This  deposit  consists  of  cells  exactly 
resembling  those  of  the  lymph,  arranged  more  or  less  concentrically  in 
a  transparent  stroma,  and  often  grouped  around  a  bloodvessel,  the  whole 
presenting  a  great  resemblance  to  the  glands  in  the  condition  described 
b}'  br.  Sanderson  as  "fibroid  induration,"  the  result  of  chronic  inflam- 
mation.'' 

Lymphadenoma  is  nearly  allied  to  phthisis,  being  appai'ently  a  similar 
deposit  in  lymphatic  tissue  to  that  which  in  phthisis  surrounds  the  ulti- 
mate bloodvessels.  It  proves  fatal  in  various  ways,  by  the  local  eflfects 
of  its  deposits  in  the  viscera,  by  its  effect  on  the  blood,  by  general  ex 
haustion,  and  sometimes  by  a  peculiar  fever. 

Treatment  is,  however,  successful  in  many  of  the   milder  cases.     It 

'  Med.-Chir.  Trans.,  vol.  xvii. 

2  There  are  many  cases,  however,  in  whicli  no  .such  condition  of  the  blood  exists. 

•'•  The  whole  ."subject  of  lymphiidenorna  has  recently  been  summarized  in  an  excel- 
lent paper  by  Drs.  Murchison  and  Sanderson,  in  Path.  Trans.,  vol.  xxi,  p.  372,  where 
the  reader  will  find  a  complete  account  of  the  literature  of  the  subject,  as  well  as  mi- 
cro.«copical  and  otlier  anatomical  details. 


HARELIP. 


569 


consists  in  attention  to  the  genei'al  health,  sea-air,  and  tlie  local  and 
general  administration  of  iodine.  Surgical  operations  should  never  be 
thought  of. 


CHAPTER    XXX. 

SURGICAL  DISEASES  OF  THE  HEAD  AND  FACE. 
CONGENITAL  MALFORMATIONS. 


Fig.  253. 


Diagram  of  the  common  single  harelip. — 
Holmes's  Surg.  Dis.  of  Childhood. 


Harelip  is  one  of  the  commonest  of  all  the  congenital  deformities.  It 
is  named  from  the  general  resemblance  which  no  doubt  it  bears  to  the 
cleft  lip  of  the  hare ;  though,  as  Sir  W.  Fergusson  remarks,  the  resem- 
blance fails  in  this  important  particular, 
that  the  cleft  in  the  hare's  lip  is  in  the 
middle  line,  which  it  hardly  ever  is  in  the 
malformation.^  It  is  often  hereditary,  and 
in  children  who  suffer  from  it,  or  in  mem- 
bers of  the  same  family,  other  deformities 
are  often  found.  (See  a  remarkable  in- 
stance ill  Cooper  Forster's  Surgical  Dis- 
eases of  Children.,  p.  30.)  Harelip  may 
be  divided  into  simple,  double,  and  com- 
plicated. 

In  simple  harelip  there  is  a  cleft  through 
the  upper  lip,^  on  one  side  of  the  middle 
line,  but  no  other  deformity.  The  cleft, 
for  some  unknown  reason,  is  usually  on  the  left  side,  and  it  generally 
extends  from  the  nostril  to  the  free  edge  of  the  lip.  The  nostril  also  is 
expanded  on  the  affected  side.  These  features  are  shown  in  the  ap- 
pended diagram,  which  shows  also  what  is  very  common  in  harelip,  viz., 
that  the  vertical  extent  of  one  side  of  the  cleft  is  less  than  that  of  the 
other. 

In  some  cases  this  inequality  is  still  more  marked  ;  and  in  others,  again, 
the  two  halves  of  the  lip  lie  on  different  levels  (Figs.  254,  25.5). 

The  cure  of  the  simplest  cases  of  this  deformit}'  is  very  easy.  Noth- 
ing is  required  except  to  pare  off  an  amount  of  tissue  from  either  side 
of  the  cleft  sufficient  to  refresh  the  whole  thickness  of  the  lip  on  both 
sides,  and  then  to  bring  the  two  sides  together  with  the  harelip  suture. 
Before  paring  the  edges  it  is  well  to  turn  out  the  two  parts  of  the  lip,  and 

1  In  one  instance  of  extensive  deformity  figured  by  Mr.  Pollock  (Syst.  of  Surg., 
vol.  iv,  p.  419,  2d  ed.)  the  cleft  was  in  the  middle  line,  and  Rokitansky  refers  to 
another  case  ;  but  both  these  were  instances  of  complete  cleft  of  the  palate,  and  the 
incisive  bone  was  absent.  I  have,  however,  heard  of  a  case  in  which  simple  harelip 
was  median. 

^  As  surgical  curiosities  clefts  of  the  lower  lip  or  clefts  of  the  cheek  have  been  re- 
corded.— See  Holmes's  Surgical  Diseases  of  Childhood,  2d  ed.,  p.  127. 


570 


CONGENITAL     MALFORMATIONS. 


divide  any  adhesion  to  the  jaw  which  might  possibly  displace  either  half. 
A  few  points  in  this  little  operation  call  for  more  detailed  notice.  1.  As 
to  the  age  at  which  to  operate.  In  simple  cases  there  is  no  reason  at  all 
wh^'  the  operation  should  not  be  done  at  the  earliest  stage  at  which  the 
infant  is  seen.  It  has  even  been  done  on  the  first  day  of  life  ;  but  this 
is  hardly  desirable;  and  as  there  is  no  hurry  (for  the  defect  occasions  no 
impediment  to  suckling),  it  is,  on  the  whole,  better  to  wait  till  the  child 
is  two  or  three  months  old,  and  is  seen  to  be  healthy  and  vigorous. 


Fig.  254. 


Fig.  255. 


Fig.  254. — A  drawing  from  life  of  a  harelip  with  unequal  sides. — Holmes's  Surg.  Dis.  of  Childhood. 
Fig.  255. — Harelip  showing  the  two  parts  on  different  levels  as  well  as  unequal. — Holmes's  Surg.  Dis. 
of  Childhood. 


Weakly  infants  should  not  be  operated  on,  as  a  general  rule.  2.  As  to 
administering  chloroform  or  ether.  This  seems  to  me  unnecessary,  since 
the  operation  is  so  soon  over;  but  there  is  no  objection  to  it  if  the  sur- 
geon or  the  parents  prefer  it.  .3.  As  to  the  attitude  in  which  the  child 
is  to  be  placed.  I  prefer  the  sitting  posture,  in  the  arms  of  a  steady 
nurse  or  other  assistant.  If  the  recumbent  position  be  adopted  (which 
some  surgeons  prefer)  the  surgeon  sitting  and  holding  the  child's  head 
between  his  knees,  it  is  often  necessary  to  suspend  the  operation  in  order 
to  disembarrass  the  infant  of  blood  which  has  passed  into  the  mouth  ;  and 
thus  the  oi)eration  is  protracted  and  more  blood  is  lost.  And  the  passage 
of  blood  down  the  throat  is  even  more  to  be  apprehended  when  the  opera- 
tion is  performed  under  anaesthesia,  and  constitutes,  to  my  mind,  an  ob- 
jection to  the  use  of  annesthetics.  4.  As  to  the  stoppage  of  bleeding. 
Very  little  blood  will  be  lost  if  a  handy  assistant  compresses  the  two 
sides  of  the  lip  l)etween  his  finger  and  thuml).  The  flaps  must  be  re- 
leased just  when  the  needles  are  passed,  if  needles  be  used  ;  but  the 
amount  of  blood  thus  lost  is  very  trifling.  A  pair  of  double  forceps  has 
been  introduced  by  Mr.  T.Smith  for  holding  both  sides  of  the  lip  with  a  sort 
of  clamp,  and  this  may  be  useful  in  the  absence  of  a  trained  assistant; 
but  as  a  general  rule,  it  is  superfluous.  5.  As  to  the  instruments.  I 
mucli  prefer  the  knife  ;  some  surgeons,  I  believe,  still  use  scissors,  which 
arc  inferior,  inasmuch  as  they  only  allow  of  a  single  straight  incision, 
whilst,  as  I  shall  pres(uitly  show,  it  is  often  necessary  to  modify  the  direc- 
tion of  the  incision  in  various  ways.  fi.  As  to  the  suture.  "  The  hare- 
lip suture"  will  be  found  figured  in  the  chapter  on  Minor  Surgery,  and 


HARELIP.  571 

it  is  a  veiy  efficient  and  secure  method  of  holding  the  parts  together  till 
union  is  complete.  But  it  has  the  drawback  that  the  needles  may  make 
a  small  scar  at  each  of  their  points  of  puncture.  This  usually  depends 
on  their  having  been  kept  in  too  long.  If  withdrawn,  as  the^'  should  be, 
in  forty-eight  hours,  they  usuall}^  leave  no  mark,  and  it  seems  useless  to 
keep  them  in  longer  than  this,  since  they  are  more  likely  to  do  harm  by 
setting  up  suppuration  than  good  by  keeping  the  parts  in  apposition. 
However,  if  the  lip  is  small,  there  is  no  real  need  for  the  needles.  The 
interrupted  or  continuous  suture  answers  perfectly,  and  is  best  made  of 
silver  wire.  Some  surgeons  prefer  to  clamp  the  wire  with  shot,  or  with 
a  button  of  some  kind.^  But  whatever  be  the  material  or  form  of  the 
suture,  it  is  essential  that  it  should  bring  the  whole  of  the  lip  in  apposi- 
tion, i.  ('.,  that  the  suture  should  be  placed  close  upon  the  mucous  mem- 
brane, and  that  for  two  reasons.  First,  that  as  the  coronary  arteries  lie 
between  the  muscles  and  mucous  membrane  a  too  superficial  suture  might 
leave  them  uncommanded,  and  they  would  bleed  into  the  mouth;  and, 
secondly,  that  if  the  whole  lip  were  not  brought  together  the  resulting 
cicatrix  might  be  too  weak  to  bear  the  traction  of  the  muscles  and  might 
give  way.  Generally  a  fine  suture  at  the  edge  of  the  lip  is  necessary  in 
order  to  maintain  the  perfect  evenness  of  the  red  line  there. 

The  child  should  be  put  to  the  breast  as  soon  as  the  operation  is  over, 
and  very  soon  forgets  it. 

After  two  days  the  whole  of  the  suture  should  be  well  oiled  and  with- 
drawn, the  two  parts  of  the  lip  being  held  firmly  together  with  the  fingers, 
while  two  or  three  long  straps  of  plaster  are  applied,  taking  hold  of  the 
cheeks  by  means  of  broad  ends,  while  their  narrower  central  parts  cover 
the  wound. 

In  cases  where  the  inequality  between  the  two  parts  is  great  this  simple 
operation  will  not  give  a  satisfactory  result.  It  is  then  better  to  leave 
tlie  flap  on  the  narrower  side  attached  by  its  base,  and  to  slope  off  the 
incision  on  the  broader  side,  as  shown  in  the  annexed  figure.     The  flap 

Fig.  256. 


Operation  for  harelip  witli  unequal  sides,  by  leaving  one  of  the  pared  edges  (that  on  the  left  side) 
attached,  and  implanting  it  into  the  opposite  flap,  the  edge  of  which  has  been  sloped  to  receive  it. 
— Holmes's  Surg.  Dis.  of  Childhood. 

left  attached  on  the  narrower  side  is  implanted  into  the  broader  flap,  and 
fills  up  the  gap  which  would  otherwise  be  left.  Of  course,  if  the  pendu- 
lous flap  seems  too  large  for  the  gap,  it  may  be  trimmed  away  as  much  as 
necessary.  In  other  cases,  where  both  sides  of  the  cleft  are  much  inferior 
in  depth  to  the  rest  of  the  lip,  both  flaps  or  portions  of  them  may  be  left 

1  An  ingenious  clamp  was  lately  introduced  by  my  colleague  Mr.  Pollock  under 
the  name  of  the  "  gun-nipple  button." 


572 


CONGENITAL    MALFORMATIONS. 


attached  at  their  lower  part,  turned  down,  and  sewn  together,  so  as  to 
form  a  prominent  tubercle.  This  tubercle,  though  it  ma}^  appear  redun- 
dant at  first,  will  gradually  become  modelled  down. 

Incom])Ie(e  Cleft. — Closely'  allied  to  this  operation  (which  bears  the 
name  of  Nelaton)  is  a  proceeding  introduced  by  M.  Cl^mot  for  the  cure 
of  cases  of  incomplete  harelip,  i.  e.,  clefts  which  do  not  extend  into  the 
nostril.  It  consists  in  making  an  incision  like  a  V  reversed  around  the 
cleft,  leaving  both  flaps  attached  at  their  base,  and  .drawing  them  down, 

Fig.  257. 


Fig.  258. 


Diagram  of  Cleinot's  operation  for  incomplete  harelip,  a  shows  the  furrow  which  unites  the  two 
halves  of  the  lip  ;  b  the  incision  on  one  side,  which  runs  down  towards  but  not  to  the  red  edge  of  the  lip. 
The  second  figure  shows  these  tlaps  drawn  down  and  the  suture  which  unites  this  wound,  which  is  now 
of  a  diamond  shape. — Holmes's  Surg.  Dis.  of  Childhood. 

so  as  to  form  a  diamond-shaped  wound,  which  is  then  sewn  together,  and 
thus  a  considerable  protuberance  is  substituted  for  the  cleft. 

Double  Harelip. — Uncomplicated  double  harelip  is  not  a  very  much 
more  serious  malformation  than  single  harelip ;  at  least,  it  is  almost  as 

easy  to  cure  by  operation,  though  the  deformity 
left  will  probably  be  greater.  In  this  form  of 
malformation  there  is  a  median  tubercle, 
bounded  on  either  side  by  clefts,  of  which 
very  commonly  one  reaches  into  the  nostril, 
while  the  other  does  not,  or  both  may  be  com- 
plete. The  nose  is  depressed  and  the  nostrils 
widened.  The  incisive  bone,  which  corresponds 
to  the  median  tuliercle,  carries  generally  four 
teeth,  but  their  number  varies.  In  uncompli- 
cated harelip  there  is  no  actual  fissure  in  the 
bou}^  palate,  nor  any  malposition  of  the  os  in- 
cisivum,  though  some  trace  of  a  cleft  on  one  or 
both  sides  is  not  infrequently  noticed  on  close 
examination. 

The  operation  for  uncomplicated  double 
harelip  consists  in  paring  both  sides  of  the 
median  tubercle  by  two  incisions  meeting  in  a 
point  below,  so  as  to  leave  in  the  centre  a  trian- 
gular piece,  with  its  base  ui)wards.  Tlie  edges  of  the  two  lateral  portions 
of  the  111)  are  then  pared,  and  these  i)ieces  attaclied  above  to  the  central 
piece,  and  below  this  (for  the  central  piece  is  always  narrower  than  the 
i(!st  of  tlie  lip)  to  each  other.  As  there  is  often,  if  not  always,  considera- 
ble, traction  on  this  lower  part,  and  a  gap  or  fissure  generally  exists  after 
tliis  simple  oj)eration,  it  is  often  advisable  to  leave  part  or  the  wliole  of 
tlies*'  lateral  flaps  attached  and  to  implant  them  into  each  other,  to  fill 
up  the  gap. 


Diagram  of  double  harelip.— 
Holmes's  Surg.  Dis.  of  Childhood 


HARELIP. 


573 


Complicated  Harelip. — Harelip,  either  single  or  double,  may  be  com- 
plicated with  fissure  of  the  palate,  and  when  this  is  the  case  in  double 
harelip  the  incisive  bone  often  projects  considerably,  and  appears  to  hang 
on  to  the  end  of  the  nose  (Fig.  200).  In  such  cases,  or  in  single  harelip 
when  the  two  portions  of  the  jaw  are  on  a  diflTerent  level  (Fig.  255),  the 
gap  may  be  very  wide,  and  there  will  be  much  difficulty  in  filling  it  up. 
Hence  the  importance  of  not  removing  any  of  the  alread}^  existing  tissue 
if  it  can  jjossibly  be  saved  and  made  available  for  that  purpose.  It  would 
be  out  of  place  here  to  describe  all  the  ingenious  operations  which  have 
been  invented  for  the  cure  of  complicated  harelip.  I  will  limit  myself  to 
two  or  three  of  the  more  useful.  In  cases  with  very  extensive  cleft,  or 
with  a  projection  of  one  portion  of  the  jaw,  the  "  operation  of  Giraldes  "^ 


Fig.  259. 


Fig.  260. 


'      ../ 


Fig.  259. — Front  view  of  double  harelip  with  projection  of  intermaxillary  bone. 
Fig.  260. — Side  view  of  the  same  case. — Holmes's  Surg.  Dis.  of  Childhood. 

will  be  found  useful.     Flaps  are  cut  on  either  side,  and  are  left  attached 
on  one  (the  right  in  the  diagram)  by  the  lower,  on  the  other  (the  left  in 

Fig.  261. 


Operation  of  Giraldes  for  harelip. — ^Holmes's  Surg.  Dis.  of  Childhood, 

the  diagram)  by  the  upper  end,  the  incisions  being  carried  round  the  nose 
as  far  as  may  be  deemed  necessary.  The  flap,  attached  by  its  lower  end, 
is  then  turned  downwards,  so  that  its  red  edge  forms  the  border  of  the 


Le9ons  cliniques  sur  les  Mai.  Chir.  des  Enfants,  1868,  pp.  155-6. 


574 


CONGENITAL    MALFORMATIONS. 


lip,  ^Yhile  the  other  is  drawn  upwards,  towards  the  nostril,  and  they  are 
thus  dovetailed  together  with  interrupted  sutures.  If  the  surgeon  thinks 
it  safer  he  can  support  his  sutures  for  a  day  or  two  by  a  harelip  pin  in  the 
centre. 

When  the  median  tubercle  projects  (Fig.  260)  it  is  often  removed  with 
the  cutting  pliers  before  the  operation,  the  skin  covering  it  being  saved, 
either  to  fit  into  the  gap  or  to  sew  on  to  the  central  incision  and  help  to 
form  the  columella;  and  if  the  projection  be  very  great  and  the  portion 
of  bone  much  isolated  it  may  be  well  to  follow  this  course.  But  if  the 
incisive  bone  can  be  preserved  it  will  be  found  useful  in  preventing  the 
extremely  disagreeable  under-hung  appearance  which  its  removal  gives 
to  the  profile.'  There  are  several  ways  of  dealing  with  this  projection. 
The  easiest  but  also  the  rudest  and  least  secure  method  is  to  break  it 
from  the  vomer  and  press  it  back  into  the  cleft  between  the  two  halves 
of  the  upper  jaw.  A  better  plan  is  either  to  make  an  incision,  with  a 
strong  pair  of  scissors,  through  the  septum,  or,  as  recommended  by 
Blandin,  to  cut  out  a  triangular  piece  from  the  septum.  This  allows  tlie 
surgeon  to  press  back  the  intermaxillary  portion  between  the  two  max- 
illae. Bruns  recommends  that  the  two  parts  of  the  septum  nasi  be  drawn 
together  with  sutures;  but  this  recommendation  is  by  no  means  easy  to 
carr}^  out  in  practice,  and  Langenbeck  fixes  tiie  intermaxillary  portion 
by  sutures  to  the  maxillte.  It  is  very  true  that  the  intermaxillary  por- 
tion, thus  replaced,  often  remains  more  or  less  loose,  and  it  is  also  true 
that  the  teeth  which  it  contains  are  often  misplaced,  but  they  can  be 
drawn,  and  the  incisive  bone  will  form  a  useful  support  for  a  tooth-plate 
when  the  median  tubercle  has  been  thus  depressed.  The  case  is  then  to 
be  dealt  with  as  anj'  other  complicated  case  of  harelip,  and  in  doing  so 
the  surgeon  must  always  remember  the  great  benefit  which  may  be 
obtained  in  relieving  tension  and  favoring  the  adaptation  of  the  flaps  by 
carr^'ing  incisions  round  the  nostrils.'^ 

In  these  operations  for  wide  cleft  the  use  of  Hainsby's  truss  to  sup- 
port and  i)ress  together  the  flaps  is  very  advisable,  as  it  prevents  drag- 
ging on  the  sutures  without  opposing  any  impediment  to  suckling. 

Tlie  operation  for  harelip,  if  practiced  with  moderate  dexterity,  and  on 

healthy  children,  almost  always  suc- 
ceeds in  simple  cases,  and  usually 
even  in  those  which  are  more  com- 
plicated. It  is  not,  however,  devoid 
of  danger,  either  from  the  exhaustion 
of  hemorrhage,  or  from  diphtheritic 
or  other  unhealtliy  inflammation  of 
the  wound.  Failure  of  primary  union 
sometimes  occurs,  and  in  such  cases 
it  may  be  advisable,  when  the  granu- 
lations from  the  two  cut  surfaces  look 
quite  healthy,  to  bring  them  together 
again  with  sutures  or  strapping,  and 
so  attempt  a  cure  by  ''secondary  ad- 
hesion "  (see  page  44). 


Fig.  262. 


Hainsby's  tru.ss. 


(The  head  in  the  diagram  U 
too  large.) 


Fissured  palate  is  a  malformation 
which  often  exists  along  with  harelip, 
but  also  very  often  without  it.    When 


'  See  two  Fig.s.,  Nos.  21  imd  25,  in  my  book  on  Surgical  Diseases  of  Childhood. 
*  See  S^dillot,  Contributions  i  la  Chirurgio,  vol.  ii,  p.  G2'2. 


FISSURED    PALATE. 


575 


the  fissure  is  confined  to  the  soft  palate,  or  extends  only  through  a  part 
of  the  bony  palate,  there  will  be  no  deformity  of  the  lip,  whilst  if  harelip 
is  complicated  with  fissure  of  the  hard  palate  the  cleft  generally  extends 
through  the  whole  mouth,  from  the  red  edge  of  the  lip  in  front  to  the 
uvula  behind. 

Three  grades  of  this  deformity  may  be  described  :  (1)  Simple  fissure 
of  the  soft  palate  ;  (2)  fissure  of  the  soft  and  part  of  the  hard  palate  ; 
(3)  complete  cleft. 

The  simple  fissure  of  the  soft  palate  is  an  affection  which  is  now 
treated  with  almost  uniform  success.  The  operation  which  was  intro- 
duced into  general  practice  by  Roux,  and  was  perfected  by  Sir  W. 
Fergusson,  was  applied  exclusively  to  adults,  or  at  least  to  persons  above 
the  age  of  puberty,  who  could  endure  the  pain  of  the  operation,  and 
assist  the  surgeon  during  its  performance.  Since  that  time,  Mr.  T. 
Smith,  by  the  invention  of  the  gag  which  bears  his  name,  and  the  use  of 
anaesthetics,  has  rendered  it  possible  to  operate  in  early  infancy,  before 
the  child  has  acquired  that  vicious  habit  of  defective  articulation  which 
is  so  difficult  afterwards  to  unlearn.'  The  only  infirmit}'  of  any  conse- 
quence which  is  connected  with  the  minor  grades  of  the  malformation  is 
the  defect  of  articulation.  Children  easily  acquire  the  power  of  degluti- 
tion, though  perhaps  at  first  some  of  the  fluid  will  run  out  at  the  nose; 
and  patients  with  fissured  palates  are  usually  as   healthy  and  well-nour- 


Smith'a  gag  for  staphyloraphy. 


ished  as  any  others.  But  the  defect  in  speaking  is  a  most  serious  im- 
pediment to  the  education  and  comfort  of  a  }'Oung  person,  and  it  is  of 
great  importance  to  remedy  it  as  early  as  possible.     Cases  have  been 

*  Other  operators  had  made  use  of  chloroform,  and  had  obtained  some  success, 
about  the  same  time  as  Mr.  Smith's  earliest  operations  (see  note  on  page  118  of 
the  second  edition  of  my  woriv  on  the  Surgical  Treatment  of  Children's  Diseases)  ; 
but  the  merit  of  introducing  the  operation  in  infancy  into  general  use  certainly 
belongs  to  him.     Mr.  Smith's  paper  will  be  found  in  Med.-Chir.  Trans.,  vol.  li. 


576 


CONGENITAL    MALFORMATIONS. 


Fig.  264. 


operated  on  y,\{]i  success  at  the  very  earliest  periods  of  life;  but  there  is 
some  little  risk  in  so  doing  from  the  bleeding,  and  there  is  much  greater 
probabilit}-  of  failure  from  non-union  of  the  wound,  in  consequence  of 
some  of  the  numerous  disturbances  of  health  to  which  young  infants  are 
liable,  so  that  the  age  of  three  or  four  is  generally  selected.  The  olyect 
of  the  operation  is  first  to  pare  the  edges  of  the  cleft,  then  to  pass  sutures 
through  the  flaps,  to  bring  the  edges  together  in  their  whole  extent,  and 
to  divide  the  muscles  sufficiently  to  obviate  any  traction  on  the  sutures, 
which  are  finally  to  be  tied.  The  patient  being  fully  aniesthetized,  the 
gag,  shown  in  Fig.  263,  is  to  be  introduced  closed  and  dilated  to  its  full 
extent,  it  having,  of  course,  been  carefully  fitted  to  the  mouth  on  a 
previous  day.  Then  the  edge  of  one  of  the  halves  of  the  palate  is  to  be 
seized  with  a  long  pair  of  clawed  forceps,  and  the  whole  edge  (including 
the  part  which  has  been  grasped  by  the  forceps)  rapidly  removed,  and 
the  same  on  the  other  side.  If  the  surgeon  be  completely  ambidexterous 
this  is  perhaps  most  rapidly  done  by  changing  the  knife  into  the  left 
hand,  but  most  operators  find  it  more  convenient  to  cross  the  hands. 
Then  tlie  sutures  are  passed  rapidly  through  each  flap,  each  suture  being 
passed  double ;  but  the  upper  ones  may  be  guided  through  both  at  once, 
while  the  lower  suture  in  the  uvula  on  each  side  is  left  double,  in  order 
that  the  surgeon  may  put  the  palate  on  the  stretch  by  drawing  on  that 

suture  while  he  divides  the  muscles. 
The  usual  way  of  passing  the  sutures 
is  to  draw  that  on  one  side  out  of  the 
mouth  double — i.  e.,  in  a  long  loop — 
and  having  drawn  the  opposite  suture 
out  single,  to  pass  its  nearer  end  into 
the  loop  of  the  first,  and  then  draw 
the  looped  suture  completely  out  of 
the  mouth.  As  it  comes  through  it 
carries  the  single  one  with  it,  which 
then  lies  completely  across  the  cleft 
(Fig.  264).  The  two  ends  should  then 
be  lightly  tied  together,  so  that  there 
may  be  no  risk  of  the  suture  being 
jerked  out  by  any  accident.  All  this 
having  been  completed,  the  surgeon 
proceeds    to   divide    the    muscles   by 

Method  of  passing  and  tying  the  sutures  in  passing    a    fine     knife    (that     USCd     for 
fissumj  palate    6  shows  the  single  suture  passed  ■        ^^         |  ^^JH  answer  perfectly) 

through  tlie  left  half  of  the  palate,  the  double  i  °,      .1  1    ,  1  ■       ^^       A 

suture  through  the  right,  and  the  end  of  the  through     the     palate    ClOSe    UlSUle    tlie 

single  suture  passed  into  the  loop  of  the  double   hamular  proccss,  and  drawing  its  edge 
one,  which  is  drawn  out  of  the  mouth  for  that   ^^  far  aloug  the  upper  surfacc  of  the 

purpose,    a  shows  the  loop  drawn  back  again,  „  ,^  **,  , 

carrying  the  single  thread  with  it,  which  now   soft    palate  as   may   be    ucccssary  to 
lies  across  the  cleft,   c  shows  the  running  knot  paralyze  the  actiou  of  the  levator  palati 

made  by  casting  a  knot  on  one  string  and  pas.s-  (Fio".  2(1.5).  A  very  slight  acquaint- 
ingjhe  other  end  through  it  before  it  is  tight-  ^^^^^  ^^.j^j^  ^.j^^  auatomy  of  the  Soft  pal- 
ate will  suffice  to  prove  the  correctness 
of  the  opinion  expressed  first  by  Sir  W.  Fergusson,  that  the  division  of 
this  muscle  is  the  most  effectual  and  necessary  method  of  obviating  any 
traction  on  the  edges  of  the  wound  after  staphylorapliy.  This  muscle 
may  be  divided,  without  fail,  by  the  method  recommended  by  Sir  W. 
Fergusson,  viz.,  to  take  a  rectangular  knife,  which  is  to  be  introduced 
behind  tlie  flap,  and  with  whicii  an  incision  is  to  be  made  perpendicular 
to  the  centre  of  a  line  joining  the  iiamular  process  with  the  PJustachian 


STAPHYLORAPHY. 


577 


tube,'  and  prolonging  the  incision  downwards  till  it  reaches  the  pterygoid 
process.  Anyone  who  will  practice  this  incision  on  the  dead  snbject  will 
see  that  it  infallibly  accomplishes  its  object,  and  Sir  William  attribntes 
to  it  the  additional  advantage  that  the  swelling  wiiich  follows  it  draws 
the  flap  downwards  and  keeps  it  steady.  Bnt  it  is  somewhat  ditlicult  to 
execute  on  the  living  subject,  and  is  apt  to  be  followed  by  a  good  deal  of 
bleeding.  Besides,  what  makes  Mr.  Pollock's  i)lan  so  much  more  con- 
venient is  that  it  can  be  put  ofl'  till  all  other  stejjs  of  the  operation  have 
been  completed.  If  the  operator  chooses  the  sutures  can  even  ))e  tied 
before  the  incisions  are  made,  and  this  is  no  small  convenience  in  an 
operation  under  anctsthesia.    What  makes  these  operations  often  so  trou- 


Dlssection  of  the  muscles  of  the  soft  palate,  showing  the  levator  palatl  on  the  right  side,  with 
the  knife  (a)  entered  close  to  the  hamular  process  (which  is  exposed  on  the  other  side  by  the  re- 
moval of  the  levator  palati).  It  will  be  seen  that  by  applying  the  edge  of  tlie  knife  to  the  posterior 
or  upper  surface  of  the  palate-flap  almost  the  whole  of  the  muscle  may  be  divided.  The  palato- 
pharyngeus,  or  posterior  pillar  of  the  fauces,  is  also  shown  on  this  side.  The  muscle  can  be  easily 
cut  across  with  a  pair  of  scissors,  if  necessary. 

blesome  and  so  exhausting  to  the  patient  is  the  necessity  for  sponging 
away  the  blood,  and  for  allowing  the  patient  to  vomit  out  all  blood  and 
bloody  fluid  which  he  may  have  swallowed.  The  touch  of  the  sponge 
causes  more  effusion  of  fluid;  the  vomiting  fills  the  mouth  with  fluid, 
which  has  to  be  sponged  awa^',  by  which  time  the  patient  has  probably 

1  The  hamuhir  process  is  always  plainly  to  be  felt  in  the  mouth  just  behind  the 
last  molar  tooth.  In  fissured  palate  the  opening  of  the  Eustachian  tube  will  be 
seen  through  the  cleft. 

87 


578  CONGENITAL    MALFORMATIONS. 

half  recovered  his  senses.  Then  the  gag  has  to  be  withdrawn  and  the 
whole  hnsiness  recommenced.  If,  on  the  other  hand,  the  patient  is 
brought  compl  'tely  under  the  anajsthetic  at  first,  a  handy  operator  can 
often  [)are  the  edges  witii  no  great  loss  of  blood,  pass  the  sutures  and  tie 
them  before  consciousness  has  in  any  degree  returned,  and  with  little  or 
no  need  of  sponging.  Then  a  slight  extra  dose  may  be  given,  and  the 
incisions  completed.  Mr.  Pollock's  incision  may,  in  dexterous  hands, 
comi)letel3'  sever  the  levator,  though  it  appears  to  me  less  certain  to  do 
this  than  Sir  W.  Fergusson's,  but  this  is  really  of  little  moment.  The 
knife  can  be  used  till  the  flaps  are  perfectly  flaccid,  and  no  traction 
exists  on  the  sutures  to  an}'  extent  that  can  interfere  with  union,  and 
this  is  all  that  is  wanted  in  practice.  It  seems  to  me  hardly  ever  neces- 
sary to  divide  any  other  muscle,  but  if  the  surgeon  thinks  proper  the 
posterior  pillar  of  the  fauces  can  be  cut  through  to  any  depth  which 
seems  requisite. 

The  sutures. for  the  soft  palate  sliould  always  be  soft.  Some  surgeons 
prefer  liorsehair  sutures,  which  have  the  recommendation  of  not  requir- 
ing removal  for  a  very  long  time,  since  they  produce  very  little  irrita- 
tion ;  but  they  have  the  disadvantage  of  being  somewhat  brittle  (though 
less  so  if  well  soaked)  and  difficult  to  tie.  Silk  sutures  answer  very  well, 
and  can  be  left  in  position  for  five  or  six  days,  b}^  which  time  union  is 
always  quite  firm,  uidess  any  irritation  is  going  on,  and  if  it  is  the  reten- 
tion of  tlie  sutures  will  be  of  little  use. 

After  the  operation  the  patient  should  be  well  fed  on  fluid  or  soft  semi- 
solid food,  with  wine.  It  used  to  be  thought  necessary  to  prevent  him 
from  speaking  for  some  da3^s,  but  this  is  impossible  with  children,  and 
indeed  seems  unessential. 

When  the  fissure  extends  only  a  little  way  through  the  hard  palate  it 
may  be  treated  like  one  of  the  soft  palate  only.  If  a  small  i)erforation 
is  left  it  will  probably  fill  up  spontaneously  or  can  be  filled  up  afterwards. 
But  if  the  wliole  or  the  greater  part  of  the  hard  palate  is  cleft,  the  mucous 
membrane  and  periosteum  must  he  dissected  away  from  the  bene,  and 
the  muco-periosteal  flaps  thus  made  brought  down  and  united  in  the 
middle  line.  In  doing  this  an  incision  is  first  made  along  the  line  of 
junction  of  the  nose  and  mouth,  and  another  parallel  to  it  near  the  alve- 
olar process,  and  the  soft  parts  raised  from  the  bone  with  rectangular 
raspatories.  Langenl)eck  lias  laid  much  stress  on  the  advantages  of  de- 
nuding the  bones  of  periosteum  in  this  operation,  and  is  often  spoken  of 
as  having  introduced  a  new  method  of  operating;  but  it  appears  certain 
to  me  that  his  operation  differs  in  no  material  particular  from  that  which 
Mr.  Avery  and  Mr.  Pollock  practiced  long  ago,  though  he  may  have  more 
distinctly  laid  stress  on  the  fact  that  the  periosteum  is  (to  some  degree 
at  any  rate)  contained  in  the  flap.  I  say  ''to  some  degree,"  for  the  bone 
is  too  irregular  on  its  surface  to  i)ermit  of  the  periosteum  being  removed 
entire.  Mr.  Pollock'  lias  shown  tiiat  the  prospect  of  success  in  complete 
cleft  of  the  palate  is  in  one  respect  better  than  in  [)artial  cleft,  since  in 
complete  clefts  tiie  edges  of  tlie  fissure  are  nearly  vertical,  while  in  par- 
tial cleft  they  are  more  nearly  iiorizontal.  The  consequence  is  that  when 
the  flaps  are  pared  off  the  former  they  meet  in  the  middle  line  without 
any  tension,  while  in  the  latter  the}'  are  hardly  long  enough  to  fill  the 

gap- 
It  seems  good  policy,  if  there  is  not  too  much  bleeding,  to  unite  the 
whole  cleft  at  once,  as  the  complete  liberation  of  the  whole  of  the  soft 


System  of  Surgery,  2(1  cd.,  vol.  iv,  p.  433. 


MENINGOCELE.  579 

parts  allows  the  flaps  to  come  together  without  an}''  tension,  and  the 
lateral  incisions  will  possibly  render  any  division  of  the  muscles  super- 
fluous.    Many  surgeons  prefer  silver  sutures  for  the  hard  palate. 

Wlien  harelip  is  also  present  it  is  well  to  unite  the  iiarelip  in  early  in- 
fancy, and  this  will  press  the  halves  together  and  limit  the  extent  of  the 
cleft ;  but  it  is  better  to  defer  the  more  serious  operation  till  four  or  five 
years  of  age. 

Sir  W.  Fergusson  has  lately  introduced  a  modification  of  the  operation 
of  staphyloraphy,  by  osteoplasty.  Instead  of  paring  the  membrane  off 
the  bone  he  divides  the  latter  with  bone  scissors  in  the  line  of  the  inci- 
sion made  near  the  alveolar  process  (for  which  purpose  a  hole  is  first 
made  through  it  with  a  sharp  chisel),  and  then  displaces  the  whole  moiety 
of  the  cleft  (bone  and  all)  to  meet  its  fellow  of  the  opposite  side,  which 
is  similarly  treated.  The  edges  are  then  pared  and  the  flaps  sevvn  to- 
gether witli  stout  sutures. 

Meningocele  and  Encephalocele. — The  other  malformations  which  oc- 
cur about  the  head  and  face  are  too  rare  and  too  little  amenable  to  treat- 
ment to  render  it  worth  while  to  discuss  them  here;  but  I  must  refer 
shortly  to  meningocele  and  encephalocele,  on  account  of  the  interesting 
questions  of  diagnosis  to  which  they  give  rise.  They  are  congenital 
affections,  having  the  same  relation  to  the  cranium  and  brain  which  spina 
bifida  has  to  the  spinal  column  and  cord  ;  that  is  to  say,  the  ossification 
of  the  bony  case  being  incomplete,  the  effusion  of  fluid — the  result  of 
some  ill-understood  action  during  foetal  life — forces  either  the  membranes 
or  the  nervous  substance  itself  through  the  unossified  pavt.^  In  the  spinal 
column  the  nerve-centre  is  rarely  affected.  In  the  brain  it  is  so  compara- 
tively often.  The  fluid  collects  in  the  ventricular  cavity,  and  some  part 
of  the  brain  is  forced  out  of  the  hole  in  the  skull.  This  is  an  encephalo- 
cele. When  the  effusion  is  wholly  outside  the  brain,  so  that  the  pro- 
trusion is  formed  only  by  a  bag  of  the  membranes,  the  tumor  is  called  a 
meningocele.  These  protrusions  are  most  common  at  the  proral  part  of 
the  occi[)ital  bone,  which  in  early  foetal  life  is  usually  composed  of  four 
distinct  centres  of  ossification  ;'^  and  it  is  between  these  centres — i.  c,  just 
behind  the  foramen  magnum — that  the  protrusion  occurs.  Another 
favorite  situation  is  at  the  junction  of  the  frontal  and  nasal  bones,  but 
any  part  of  the  cranium  may  be  the  seat  of  the  protrusion,  even  the  base 
of  the  skull,  and  here  the  effusion  is  probably  in  the  third  ventricle. 

The  fluid  of  a  meningocele  is  sometimes  completely  free  in  a  cyst 
formed  by  the  dura  mater  and  its  arachnoid  covering,  exactly  as  in  a 
common  hydrocele.  Such  tumors  may  be  completel}^  transparent,  and 
hang  over  the  nape  of  the  neck  from  a  pedicle  which  reaches  up  to  the 
occiput.  But  at  other  times  the  fluid  is  contained  in  a  multilocular  tissue, 
much  resembling  an  enormous  over-development  of  the  pia  mater,^  or 
possibly  formed  by  protrusions  from  the  falces  of  the  dura  mater.  Very 
often  along  with  the  water}^  fluid  a  small  portion  of  the  surface  of  the 
brain  projects  just  i)eyond  the  hole  in  the  skull,  forming  what  is  called  a 

1  Such  at  loast  is  the  common  opinion,  though  Mr.  Hewett  has  given  strong  ren- 
sons  fur  doubting  it  If  the  hole  in  the  skull  be  not  the  result  of  arrested  develop- 
ment, it  must  be  attributed  to  pressure  by  the  dropsical  brain  ;  but  then  it  is  difficult 
to  see  wliy  it  aflects  one  situation  rather  than  another.  Now,  the  protrusion  is  as 
common  in  the  occipital  region  as  in  all  the  other  situations  put  together.  See  Pres- 
cott  Hewett,  in  St.  George's  Hosp.  Keports,  vol.  vi. 

*  See  Gray's  Anatomy,  7th  ed.,  p.  23,  lootnote. 

3  See  Holmes,  On  a  case  of  Meningocele,  in  St.  George's  Hosp.  Keports,  vol.  i,  p.  40. 


580  TUMORS    OF    THE    CRANIUM. 

hydrenceplialocele.  Pure  encephaloceles— ?.  e.,  protrusions  consisting  of 
the  brain-substance  lying  immediately  beneath  the  hernial  sac — are  rare. 
The_y  are  of  small  size,  and  very  often  produce  no  symptoms  and  display 
little  tendency  to  increase  (llewett,  op.  cit..,  p.  133). 

Little  or  nothing  can  be  done  for  such  tumors.  Their  removal,  even 
when  they  consist  obviously  of  nothing  but  water,  is  too  dangerous  to  be 
justirial)le.  Pressure  after  evacuation  of  part  of  the  fluid  may  be  tried, 
and  in  some  cases  seems  to  have  done  good.  Iodine  injection  has  been 
used  (by  m^'self  and  others),  but  no  success  can  be  claimed.  The  chief 
importance  of  the  subject,  indeed,  is  to  know  the  diagnosis  of  such  a 
tumor,  in  order  to  avoid  an}'  surgical  interference.  Such  tumors  have 
been  mistaken  for  nsevus  (degenerated  or  otherwise),  and  for  sebaceous 
and  other  tumors,  and  many  fatal  operations  have  thus  been  occasioned; 
while  in  other  cases  the  patient  has  been  lucky  enough  to  escape  with 
life,  even  after  the  removal  of  a  portion  of  the  brain. ^ 

The  two  great  points  in  the  diagnosis  of  these  tumors  of  the  brain  are 
the  history — showing  that  the  growth  is  congenital — and  the  situation  in 
which  it  forms.  But  as  n^vus  is  always  congenital,  and  sebaceous  tumors 
also  sometimes,  it  is  necessary  to  study  very  carefully  the  effects  of  pres- 
sure on  the  tumor,  and  to  examine  the  lump  most  minutely,  in  order  to 
ascertain  the  presence  or  absence  of  a  hole  in  the  skull.  In  a  congenital 
tumor  believed  to  be  a  degenerated  nsevus,  or  other  growth  unconnected 
with  the  brain,  no  operation  should  be  ventured  upon  until  the  surgeon  is 
completely  satisfied  that  the  lump  is  in  no  degree  reducible,  that  pressure 
on  it  produces  no  head  symptoms,  and  that  its  base  is  free  from  the  bones 
of  the  skull. 

TUMORS   OF   THE   CRANIUM. 

Tumors  sometimes  arise  in  after-life  which  perforate  the  cranium  and 
lie  in  direct  communication  with  the  membranes  of  the  brain,  as  in  the  re- 
markable instance  figured  on  p.  581.  These  cases  were  first  introduced  to 
the  notice  of  surgeons  in  Louis's  celebrated  memoir  on  Fungous  Tumors 
of  (he  Dura  Mater ^^  where,  however,  it  is  clear  that  several  diff'erent  forms 
of  tumor  are  confounded  together.  Some  of  the  swellings  there  described 
were  ver}'  likely  (like  Mr.  Caesar  Hawkins's  case)  fibrous  or  fibroid  tumors 
springing  from  the  cranium  and  growing  outwards  and  inwards.  Such 
tumors  are  distinguished  b^'^  their  slow  growth,  the  imperfect  pulsation 
they  receive  from  the  subjacent  brain,  and  the  cerebral  symptoms  which 
they  occasion,  and  which  vary  with  the  state  of  congestion  of  the  tumor. 
Others  are  malignant.  These  also  probably  originate  in  the  bone,  but 
they  grow  much  more  rapidlj',  pulsate  much  more  violently  (and  very 
probably,  in  consequence  of  tlie  presence  of  large  cells  in  their  substance, 
as  other  pulsatile  cancers  in  bone  do),  and  destroy  life  rapidly.  I  liave 
seen  a  tumor  of  this  sort  mistaken  for  aneurism  by  anastomosis,  from 
whicti,  however,  the  symptoms  of  pressure  on  the  brain  should  have  dis- 
tinguislied  it.  Then  there  are  swellings  caused  by  a  hernia  of  the  brain 
in  consequence  of  disease  in  the  bones  of  the  skull,  as  in  the  case  related 
by  Mr.  Ctcsar  Hawkins,  op.  cit.^  p.  351  ;  and  several  of  Louis's  cases  seem 
to  have  been  of  this  nature.     Whether  tumors  occur  which  can  in  strict- 

'  Sco  Mr.  Hcwett's  account  of  an  operation  by  Mr.  Tatum,  op.  cit.,  p.  144. 
2  In  tho  Memoirs  of  the  Academy  of  Surgery,  trans,  for  the  Sydenham  Society  by 
Drewry  Otliey. 


DISEASES     OF    THE    LIPS. 


581 


ness  be  called  "of  the  dura  mater" — i.e.,  new  growths  springing  from 
that  membrane  itself — seems  doubtful.  The  cases  altogether  are  very 
rare,  but  are  important  in  respect  of  diagnosis. 


Fig.  266. 


A.  Internal  view.  b.  External  view. 

"Fibrous  tumor  of  the  dura  mater,"  taken  from  a  patient  who  was  under  Mr.  Csesar  Hawkins's  care 
in  St.  George's  Hospital,  at  intervals,  during  a  great  number  of  years,  and  who  died  from  an  accidental 
attack  of  pneumonia,  about  sixteen  years  after  he  had  first  noticed  the  tumor.  The  latter  had  been 
stationary  for  many  years  before  death.  Its  pressure  on  the  brain  caused  slight  epileptic  fits  and  much 
loss  of  memory  and  mental  power,  but  did  not  affect  the  general  health.  Pulsation  existed  in  one  or 
two  of  the  softer  parts  of  the  tumor  (communicated  probably  from  the  brain),  and  pressure  there  made 
him  feel  faint  and  oppressed.  On  post-mortem  examination  the  tumor  was  found  covered  by  the  thick.- 
ened  pericranium,  as  shown  at  b.  It  perforated  the  skull  and  also  the  dura  mater,  so  that  it  rested  on 
the  surface  of  the  brain.  It  consisted  of  a  mixture  of  fibrous  tissue  with  delicate  bony  spiculse,  covered 
in  almost  the  whole  of  its  extent  by  a  thin  layer  of  bone.  The  soft  part  of  the  tumor  was  composed 
entirely  of  a  mass  of  spindle-shaped  fibres.  The  brain,  though  considerably  compressed  by  the  tumor, 
was  not  otherwise  affected. — St.  George's  Hospital  Museum,  Ser.  xvii,  No.  39.  Mr.  Coesar  Hawkins's 
Contributions  to  Pathology  and  Surgery,  vol.  i,  p.  356. 


DISEASES    OF   THE    LIPS    AND    MOUTH. 

Herjies  on  the  lip  is  one  of  the  most  familiar  of  all  affections.  It  is 
generally  held  to  indicate  some  slight  disorder  of  digestion,  but  occurs 
really  in  conditions  of  perfect  health.  If  it  requires  any  treatment  at  all, 
slight  purgation,  the  regulation  of  the  diet,  and  mild  mercurial  ointments 
are  the  appropriate  measures.  A  very  favorite  ointment  is  gr.  x-xv  of 
the  gray  oxide  of  mercuiy  to  the  ounce  of  lard. 

Fissures  on  the  lips  are  closely  allied  to  herpes,  and  are  sometimes  so 


582  DISEASES    OF    THE    LIPS. 

persistent  and  so  painful  as  almost  to  recall  the  fissures  which  occur  near 
the  anus.  But  the}'  rarel_y  if  ever  require  incision.  The  constitutional 
conditions  on  which  the}-  depend  must  be  ascertained,  for  it  seems  certain 
that  they  are  often  a  symptom  of  congenital  syphilis,  and  at  other  times 
ai-e  dependent  on  strumous  disease.  The  local  application  which  is  most 
beneficial  is  the  nitrate  of  silver  in  stick,  with  some  mild  meixurial  oint- 
ment. 

"  Strumous  Lip.'- — The  upper  lip  is  frequently,  and  the  lower  lip  less 
often,  the  seat  of  a  general  enlargement,  due  to  struma,  without  any 
si)ecial  deposit  being  perceptible.  This  affection  is  commonest  in  young 
women,  and  it  requires  no  local  treatment,  as  it  will  subside  under  the 
general  treatment  indicated  for  the  constitutional  disease ;  but  I  mention 
it  here,  as  it  excites  the  patient's  alarm,  and  is  to  be  diagnosed  from 
tumor.  The  diagnosis  is  obvious,  if  the  surgeon  is  acquainted  with  the 
aflection. 

Nsemis. — The  lips  are  ver}'  commonly  the  seat  of  naevus,  which  in  ordi- 
nary cases  is  only  of  the  cutaneous  or  capillar}^  variety,  and  then  requires 
only  the  ordinary'  treatment,  in  fact,  is  often  stationary,  and  requires  no 
treatment  at  all.  But  in  other  cases  the  graver  affection  called  aneurism 
by  anastomosis  occurs  (more  commonly,  I  believe,  on  the  upper  lip)  as 
figured  on  page  359.  The  treatment  of  this  disease  is  often  very  embar- 
rassing. When  it  is  small  the  best  plan  is  to  cut  it  out  and  bring  the 
halves  of  the  lips  together,  just  as  for  any  other  tumor.  But  when  verj'^ 
large  it  cannot  be  thus  dealt  with,  and  then  the  red-hot  wire,  introduced 
and  made  to  cut  through  the  mass — as  by  the  galvanic  cautery — is  the 
best  method  of  treatment ;  or  the  coronary  arteries  may  be  tied  by 
turning  the  lip  out,  and  the  diseased  tissue  consolidated  by  the  action  of 
setons. 

Cancer  is  almost  uniformly  developed  in  the  lower  lip,  though  to  this 
rule  there  are  rare  exceptions.^  It  is  almost  always  of  the  epithelial  va- 
riety, and  often  seems  to  be  excited  by  the  irritation  of  smoking  a  clay- 
pipe.  It  is  frequently  complicated  with  enlargement  of  the  submaxillary 
glands,  and  is  often  the  seat  of  considerable  pain.  It  slowly  spreads  to 
the  tissues  of  the  mouth  ;  but  it  proves  fatal  usually  by  the  secondary 
growth  in  the  neck,  and  not  by  any  symptoms  caused  by  the  primary 
cancer.  Its  removal  is  urgently  indicated,  and  the  operation  should  be 
performed  if  possible  before  the  glands  are  affected.  If  that  affection, 
however,  be  only  slight  and  recent,  possibly  the  enlargement  may  sub- 
side after  the  removal  of  the  original  tumor;  at  any  rate,  the  surgeon  is 
bound  to  give  his  patient  the  chance.  Thediairnosis  is  not  usually  diffi- 
cult. The  warty  surface,  the  surroundingdeposit  of  hard  substance,  and 
the  persistent  nature  of  the  disease  sufficiently  distinguish  it  from  all 
other  affections,  except  perhaps  chancre.  Chancres  on  the  lip  are  not  at 
all  uncommon,  and,  I  believe,  are  often  incurred  innocently  from  acci- 
dental inoculation  of  a  crack  on  the  lip.  In  tiiis  case  tlie  patient  can  give 
no  histor}'  of  the  origin  of  the  sore,  and  wlien  the  disease  arises  from 
lascivious  conduct  he  will  give  none,  so  that  there  is  usually  no  assigned 
cause  to  assist  in  the  diagnosis.  But  the  surface  of  chancre  is  less  warty 
and  irregular  than  that  of  a  cancer;  the  hardness,  if  there  is  any  (and 
not  unfrequently  there  is  little  enough),  is  uniform,  and  extends  a  very 
little  distance  beyond  the  sore,  and  the  bubo  is  earlier  in  its  appearance 
than  the  malignant  deposit  in  the  submaxillary  glands  is.     Secondary 

'  Mr.  Vennin£<  and  I  related  each  a  case  of  cancer  of  the  upper  lip  in  the  St. 

George's  IIo«j)itul  Kcports,  vol.  vi. 


RANULA.  583 

symptoms  will  generally  appear  in  six  weeks  or  two  months  and  settle 
the  qnestion,  or  the  administration  of  mercnry  will  sj*eedily  cure  the  sore. 

In  removing  a  cancer  of  tiie  lip.  if  the  disease  spreads  any  distance  fiom 
the  edge,  it  is  best  to  make  a  V-shapcd  incision,  running  entirely  through 
healthy  parts,  and  sew  the  two  llai)s  of  tlie  lip  together  with  tlie  harelip 
suture.  An  assistant  stands  behind  the  patient's  head  and  holds  the  two 
sides  of  the  lip  firmly,  so  as  to  prevent  bleeding  from  the  coronary  ar- 
teries. A  small  stitch  may  be  put  in  at  the  red  edge  of  the  lip  to  obviate 
any  break  in  its  line.  When,  as  sometimes  happens,  the  disease  appears 
in  the  form  of  a  deposit  diffused  along  the  border  of  the  lip,  but  not 
spreading  far  into  its  substance,  it  is  better  to  shave  it  off  with  a  pair  of 
curved  scissors  and  approximate  the  skin  and  mucous  membrane  with  a 
few  points  of  suture. 

If  a  very  large  part  of  the  li[)  requires  removal  the  cheeks  must  be 
liberated  by  curved  incisions  running  round  the  ahe  of  the  nose,  when  the 
flaps  can  be  brought  together,  but,  of  course,  with  a  good  deal  of  tension 
and  a  most  unpleasant  •'  underhung  "  look. 

Other  tumors,  cystic  and  solid,  ai"e  found  in  the  substance  of  the  lip, 
but  there  are  no  peculiarities  here  due  to  the  seat  of  the  tumor. 

Ranula  is  a  cyst,  very  analogous  to  a  ganglion,  found  in  the  floor  of  the 
mouth  and  raising  up  the  tongue.  It  is  of  a  flattened  form,  something 
like  the  body  of  a  frog,  and  is  generally  confined  to  the  mouth.  Some- 
times it  grows  to  a  large  size,  and  presents  also  under  the  jaw,  forming 
a  large  swelling,  which  fluctuates  from  the  neck  to  the  interior  of  the 
mouth. 

Ranulfe  are  formed  sometimes  by  the  obstruction  of  one  of  the  large 
salivary  ducts,  as  by  a  salivary  calculus,  at  other  times,  as  it  seems,  by 
the  expansion  of  one  of  the  processes  of  a  salivary  gland,  and  probably  at 
others  by  the  independent  formation  of  a  C3st  in  the  cellular  tissue.  The 
fluid  contained  in  the  cyst  bears  tiie  strongest  resemblance  to  that  of  a 
ganglion — i.  e.,  it  is  a  clear,  yellowish,  ghitinous  fluid,  something  like 
isinglass. 

The  tumor  is  troublesome  from  the  interference  it  causes  with  the  mo- 
tions of  the  tongue  and  jaws. 

It  can  in  most  cases  be  cured  by  simply  making  a  free  incision  into  it 
in  the  mouth,  pressing  all  the  fluid  out,  and  taking  care  to  keep  the  wound 
open  by  passing  a  director  along  it  dailj'  till  the  cavity  has  quite  filled 
up.  But  it  has  often  seemed  to  me  better  to  take  a  piece  of  the  mucous 
membrane  out,  by  pinching  up  the  wall  of  the  c\'st  with  a  pair  of  clawed 
forceps  and  snipping  out  a  piece  with  the  scissors  large  enough  to  allow 
the  end  of  the  finger  to  be  passed  in.  When  this  is  done  the  cavit}^  can 
hardly  close  till  it  is  filled  up.  But  the  disease  is  sometimes  obstinate, 
and  then  either  a  seton  must  be  passed  through  it  or,  after  free  incision, 
the  cavity  must  be  cleaned  out  and  the  lining  membrane  pencilled  with 
nitrate  of  silver,  or,  if  that  is  not  strong  enough,  with  nitric  acid. 

Those  which  project  into  the  neck  must  be  opened  by  a  free  incision  in 
the  middle  line  below  the  hyoid  bone,  which  must  be  kept  open  till  the 
cavity  is  obliterated. 

Salivary  calculi  are  chiefly  seen  in  connection  with  ranula.  They  are 
small  calcareous  masses  sticking  out  of  and  obstructing  the  orifice  of  one 
of  the  larger  ducts — usually  Wharton's.  They  require  onl^'  a  slight  in- 
cision for  their  discharge. 

Acute  Tonsillitis. — The  tonsils  are  subject  to  acute  inflammation  and 


584  DISEASES    OF    THE    MOUTH. 

abscess  from  various  causes,  as  in  scarlatina,  in  phagedena  after  syphil- 
itic sore  throat,  in  dissecting  wounds,  and  "  hospital  "  sore  throat.  But 
the  disease  especially  denominated  acute  tonsillitis,  or  quinsy — Cynanche 
tonsillaris — is  an  ati'ection  allied  to  common  cold,  usually  attacking  pei*- 
sons  who  are  out  of  health,  and  somewhat  predisposed  to  sore  throat.  It 
often  commences  with  rigors,  stitfness,  and  pain  at  the  back  of  the  throat, 
and  especial  pain  in  swallowing.  The  whole  of  the  back  of  the  throat  is 
red  and  swollen,  and  one  side  of  the  soft  palate  and  the  correspond.ing 
tonsil  is  especially  svvoUen  and  red  ;  the  tongue  is  much  loaded  with  a 
creamy  fur,  the  saliva  may  run  copiously  out  of  the  mouth,  and  in  severe 
cases  there  is  so  much  difficulty  of  breathing  that  the  patient  thinks  him- 
self in  danger  of  sutfocation.  Gradually  the  parts  around  the  tonsil 
soften,  the  color  of  the  matter  becomes  perceptible  through  the  red  mem- 
brane, and  an  abscess  form*  in  the  substance  of  the  tonsil  or  in  the  cellu- 
lar tissue  around.  This  having  burst  or  being  opened,  the  symptoms 
rapidly  subside.  It  is  rare  for  both  tonsils  to  be  affected  at  the  same 
time,  though  not  uncommon  for  one  to  be  attacked  after  the  inflammation 
in  the  other  has  subsided. 

The  treatment  required  is  almost  always  somewhat  stimulating,  for  the 
patient  has  generally  been  out  of  health  and  the  pulse  is  low.  Steaming 
the  throat  sometimes  gives  a  good  deal  of  relief ;  and  a  mustard  emetic  at 
the  commencement  of  the  attack  is  often  very  beneficial.  Gargling  is  very 
painful,  and  does  little  good.  If  any  local  application  is  advisable  min- 
eral acids  and  hone}'  applied  with  a  brush  seem  best.  When  the  patient 
suffers  grievousl}'  from  the  swelling  yet  no  pus  can  be  perceived,  it  is 
justifiable  to  make  incisions  or  scarifications  into  the  inflamed  tissues,  in 
order,  if  possible,  to  relieve  the  swelling  and  hasten  the  approach  of  pus 
to  the  surface;  but  care  must  be  taken  not  to  direct  the  point  of  the 
knife  outwards,  especially  if  the  incisions  are  made  at  all  deeply.  If  a 
knife  is  used  its  blade  should  be  wrapped  in  lint  to  within  an  inch  of  the 
point,  the  patient's  mouth  should  be  widely  opened  in  a  good  liglit,  and 
the  handle  of  the  knife  being  directed  outwards  as  it  is  entered  into  the 
tonsil  or  the  parts  near  it,  its  point  will  incline  towards  the  middje  line. 
In  this  position,  even  if  the  patient  should  start,  the  large  vessels  around 
the  tonsil  can  hardl}'  be  injured.' 

Sometimes,  after  the  opening  of  an  abscess  in  the  tonsil,  the  opening 
becomes  phagedenic,  or  other  acute  forms  of  sore  throat  supervene,  but 
this  is  very  rare. 

Putrid  or  sloughing  sore  throat,  and  diphtheritic  affections  are  happily 
now  rarely  met  with,  except  in  epidemics,  when  they  come  more  under  the 
notice  of  the  physician.     1  would  refer  the  reader  to  works  on  medicine. 

Chronic  enlargement  of  the  tonsils  is  an  extremely  common  affection, 
generally  due  to  constant  irritation  from  cold  and  neglect  in  children  of 
strumous  constitutions,  but  occurring  also  in  those  who  are  well  cared 
for,  and  not  rarely  in  young  women  of  weak  health.  As  a  general  rule, 
when   the  aflTection   is  moderate  in  extent  it  is  more  troublesome  than 

'  Sevoro  and  even  fatal  bleeding  has  occurred  from  incisions  into  the  tonsil,  possi- 
bly in  Sf)me  cases  from  tlie  int<>rnal  carotid  itself,  in  otliers  from  the  enlarged  arteries 
of  the  gland  In  such  cases  it  has  .sometimes  been  thought  necessary  to  tie  the  com- 
mon carotid  lint  usually  the  bleeding  may  bi;  stopped  by  firmly  pressing  a  com- 
press of  lint  steeped  in  the  jierchlrjride  of  iron  on  tiie  bleeding  spot  for  some  time.  If 
the  ])atient  is  too  nervous  or  distressed  to  tolerate  this  without  auiesthesia,  ether  or 
chloroform  may  be  administered  ;  and  then  the  mouth  being  held  open  with  a  gag 
in  ft  good  light,  the  bleeding  spot  will  be  well  under  command. 


RELAXED    UVULA.  585 

daiio-erons.  But  tlie  enlarsfed  tonsils  are  liable  to  constant  attacks  of 
sore  throat  and  ulceration ;  the.y  spoil  the  Aoice ;  sometimes  they  (or 
rather  the  inflamed  and  thickened  condition  of  the  mucous  meml)rane 
around  them)  impede  the  hearing;  they  prevent  sleep  except  with  the 
mouth  open  ;  and  when  extremely  large  in  early  life  they  may  so  obstruct 
the  respiration  as  to  produce  a  partial  vacuum  within  the  chest,  and  thus 
the  pressure  on  the  soft  parietcs  of  the  thorax  may  much  alter  the  shape 
of  the  chest. 

Slighter  cases  may  be  left  with  confidence  to  constitutional  treatment;  as 
the  health  improves  the  enlargement  will  subside.  But  when  the  swell- 
ing is  great  the  removal  of  the  projecting  part  of  the  tonsil  is  urgently 
indicated,  and  affords  the  patient  instant  relief  at  the  expense  of  only 
momentary  inconvenience.  When  the  enlarged  tonsil  projects  fairly 
from  this  surface  this  little  operation  is  most  quickly  performed  with  the 
French  (or  Charriere's)  guillotine.  This  instrument  terminates  behind 
in  a  ring,  into  which  the  surgeon's  thumb  is  inserted  ;  at  either  side  is 
another  ring  for  his  fore  and  middle  fingers.  The  instrument  consists  of 
three  parts, — a  base,  or  lowest  stem,  which  ends  in  front  in  a  ring,  which 
is  to  be  slipped  over  the  tonsil;  above  this  and  travelling  in  it  in  a  groove 
is  another  stem  which  ends  in  a  ring,  and  the  edge  of  this  ring  is  sharp, 
so  that  as  it  is  pushed  forward  it  cuts  ofif  the  part  of  the  tonsil  over  which 
the  instrument  has  been  slipped  ;  and  above  this  again,  also  travelling  in 
a  groove  on  the  base  of  the  instrument,  is  a  stalk,  ending  in  the  thumb- 
ring  behind  and  in  a  double  hook  in  front,  and  so  jointed  on  to  the  base 
that  as  it  is  pushed  forwards  it  rises  away  from  the  stem.  In  using  this 
guillotine  the  surgeon  sees  first  that  it  travels  freely  ;  then  he  draws  all 
its  parts  well  home,  passes  it  into  the  mouth,  where  it  serves  as  a  spatula, 
gets  the  ring  fairly  round  the  tonsil,  then  by  pushing  his  thumb  forwards 
digs  the  double  hook  into  the  tonsil,  and  as  he  pushes  his  thumb  on  as 
far  as  it  will  go  the  double  hook  rising  away  from  the  stem  draws  the 
tonsil  still  further  into  the  grasp  of  the  ring,  and  the  knife-blade  shaves 
it  off.     The  whole  affair  is  momentary,  and  the  pain  very  slight. 

But  when  the  tonsil  is  flatter  and  more  irregular  in  shape  it  is  better  to 
seize  it  with  a  vulsellum,  and  cut  it  off  with  a  curved  blunt-pointed  bistoury', 
its  blade  guarded  with  lint  to  within  half  an  inch  of  its  end,  directed  from 
above,  upwards  and  inwards. 

Children,  and  other  nervous  persons,  who  cannot  be  persuaded  to  open 
the  mouth,  may  be  narcotized,  the  mouth  being  kept  open  by  Smith's  gag 
(page  575). 

There  is  not  much  bleeding  after  the  removal  of  the  tonsil,  unless  the 
surgeon  has  been  more  anxious  to  remove  the  whole  mass  than  is  at  all 
necessary.  All  that  is  really  required  is  to  cut  the  surface  off  freely.  The 
swelling  is  produced  by  obstruction  of  the  orifices  of  the  gland-ducts,  lead- 
ing to  a  retention  of  epithelial  secretion  within  them,  which  dilates  the 
follicles  and  gives  rise  to  inflammatory  exudation  into  the  cellular  tissue. 
When  the  follicles  have  been  freely  cut  across  all  this  will  subside. 

Relaxed  Uvula. — Relaxation  of  the  uvula  is  an  affection  very  trifling 
in  itself,  but  it  produces  distressing  symptoms,  such  as  constant  cough 
and  frequent  vomiting,  which  when  the  cause  is  overlooked  often  causes 
needless  alarm  for  the  patient.  In  many  cases  the  relaxation  is  habitual, 
recurring  on  au}^  trifling  cold  or  disturbance  of  health.  Painting  with  an 
astringent  lotion  (as  glycerate  of  tannin  or  nitrate  of  silver),  with  purges 
and  tonics,  is  sufficient  in  such  cases.  When  the  elongation  is  consider- 
able and  inveterate,  the  uvula  should  be  taken  hold  of  with  clawed  for- 
ceps and  snipped  oflf. 


586  DISEASES    OF    THE    MOUTH. 

"  Alveolar  ah^ce!<!<  may  be  defined,"  says  Mr.  Salter,  "  as  a  suppuration 
around  the  fang  or  fangs  of  a  tooth,  usually  carious,  accompanied  by  ab- 
sorption and  expansion  of  the  bony  walls  of  the  alveolus  or  alveoli,  and 
the  enlargement  of  the  little  pus-sac,  the  matter  gradually  finding  its  way 
to  the  surface  either  along  a  canal  l)y  the  side  of  the  fang  of  the  tooth, 
opening  at  the  edge  of  the  gum,  or  through  the  gum  itself  at  a  point  cor- 
responding to  the  root  or  roots  of  the  tooth  implicated.  When,  however, 
the  fangs  are  unusually  long,  or  the  reflection  of  the  mucous  meml)rane  from 
the  gum  to  the  cheek  or  lip  is  very  superficial,  this  same  discharge  may 
burrow  still  more  outwardly  and  find  its  exit  upon  the  surface  of  the  face." 
Mr.  Salter,  however,  points  out  that  the  extension  of  an  alveolar  abscess 
to  the  external  integument  is  limited  in  the  upper  jaw  to  those  which  are 
connected  with  the  back  teeth.  Where  the  central  teeth  give  rise  to  ab- 
scess which  extends  to  a  distance  it  burrows  along  the  hard  palate,  and 
the  lateral  incisor  is  the  usual  source  of  this  suppuration.  In  the  milk- 
teeth  it  is  rare  for  alveolar  abscess  to  extend  to  a  distance. 

The  common  alveolar  abscess,  or  gumboil,  which  points  above  the  gum, 
either  on  its  outer  or  inner  side,  is  easily  recognized  and  generally  easily 
treated.  If  the  tooth  is  so  far  diseased  as  to  render  its  removal  desirable 
this  is,  of  course,  a  radical  cure.  If  the  irritation  is  connected  with 
stopping,  the  stopping  should  be  removed ;  and  if  tlie  tooth  is  to  be  pre- 
served, free  leeching  of  the  gum  and  fomentation,  vvith  purgatives,  will 
sometimes  avert  suppuration ;  but  when  matter  has  formed  it  should  be 
early  evacuated. 

The  difficult  cases  are  those  in  which  matter,  having  its  origin  in  caries 
and  suppuration  around  a  tooth-fang,  burrows  to  a  considerable  distance 
and  appears  as  a  sinus,  usually  with  a  protruding  granulation,  at  a  distant 
part  of  the  face  or  under  the  chin.  Such  cases  are  constantly  mistaken 
for  cases  of  disease  of  the  jawbone,  though  an  attentive  examination  will 
show  that  there  is  no  exposed  surface  in  the  jaw,  and  that  there  is  a  cari- 
ous tooth  surrounded  by  thickened  and  inflamed  tissues.  Such  cases  are 
aptly  compared  b}'  Mr.  Salter  to  cases  of  necrosis,  the  diseased  tooth 
being,  in  fact,  a  sequestrum  ;  and  their  treatment  must  be  precisely  the 
same,  viz.,  the  removal  of  the  tooth,  in  doing  which  great  care  must  be 
taken  to  see  that  it  comes  away  entire,  or  if  not  that  every  fragment  is 
afterwards  removed. 

NecTosis  attacks  the  jaws  from  various  causes.  In  strumous  disease, 
along  with  the  caries  of  the  teeth,  to  which  such  patients  are  so  liable, 
portions  of  the  jaw  not  unfrequently  perish,  and  becoming  exposed  in  the 
mouth,  give  rise  to  a  fetid  discharge  which  poisons  the  breath,  and  in 
some  cases  is  a  source  of  real  danger,  from  the  cachexia  which  it  induces. 
Necrosis,  especially  of  the  lower  jaw,  often  follows  fracture.  But  there 
is  nothing  peculiar  in  the  pathology  or  treatment  of  such  cases,  except 
that  the  surgeon  will  be  more  anxious  than  in  other  regions  of  the  body 
to  extract  the  sequestrum  early,  in  order  to  free  the  patient  from  the 
putrid  odor  which  it  causes. 

Phosphorus  Necrosis. — There  is,  however,  a  peculiar  form  of  disease 
which  affects  the  jaws,  caused  b}'  the  local  action  of  the  poison  of  phos- 
phorus in  persons  who  are  exposed  to  the  fumes  of  that  mineral  in  lucifer 
match  manufactories.  It  has  been  abundantly  proved  that  the  disease  is 
only  generated  in  tiiose  who  have  carious  teeth,  and  tiiat  it  is  caused  by 
the  acid  fumes  of  the  phosphorus  (/.  e.^  either  phospiiorus  or  phosphoric 
acid)  dissolved  in  tlie  saliva,  and  so  applied  directly  to  the  exposed 
alveolar  process.     The  disease,  tlierefore,  might  be  prevented  by  seeing 


TOOTH    TUMORS.  587 

that  all  the  work-people  had  healthy  teetli,  and  by  the  use  of  a  mask  in 
which  the  acid  fumes  would  be  stopped  by  passing  the  air  through  a 
sponge  or  some  fabric  saturated  with  a  solution  of  one  of  the  fixed  alka- 
lies or  their  carbonates.  But  the  use  of  tlie  amorphous  phosphorus,  which 
does  not  give  off  any  such  deleterious  fumes,  and  which  is  now  largely 
used  to  form  the  coating  of  the  box  on  which  the  match  ignites,  has 
tended  more  than  any  such  precautions  to  diminish  the  prevalence  of  the 
disease,  which  is  accordingly  now  much  more  rare  than  it  vvas  some  years 
since.  The  same  consideration  renders  it  inexpedient  to  devote  much 
space  to  this  subject.^  The  advent  of  the  disease  is  marked  by  much 
suffering,  and  occasionally  by  considerable  bronchial  irritation  produced 
by  the  fumes.  The  diseased  periosteum  swells  up,  and  an  enormous  mass 
of  spongy  bqne  surrounds  the  sequestrum,  especially  in  the  lower  jaw. 
The  dead  bone  often  takes  long  to  separate,  even  after  the  teeth  have 
come  away,  and  when  it  is  removed  an  enormous  mass  of  bone  is  left  to 
replace  it.  In  some  cases  this  new  bone  remains,  and  performs  all  the 
functions  of  its  normal  predecessor.  Even  when  the  whole  lower  jaw  and 
both  condyles  have  come  away,  the  reproduced  l)one  has  been  both  useful 
and  movable,  being  doubtless  attached  by  ligament  to  the  skull.  In 
other  cases  the  reproduced  jaw,  though  exuberant  at  first,  has  withered 
away  and  left  only  a  thin  scarlike  band,  so  that  the  patient  has  been 
permanently  deformed. 

The  main  indications  of  treatment  are,  first,  to  place  the  patient  in  a 
pure  atmosphere  and  support  the  strength  ;  next,  during  the  process  of 
separation  to  hasten  it  as  far  as  may  be  and  liberate  tension  by  as  free 
incisions  through  the  thickened  periosteum  as  may  seem  prudent;  then 
to  remove  the  sequestrum  at  the  earliest  possible  moment ;  and,  finally, 
as  Mr.  Salter  suggests,  to  adapt  teeth  to  the  reproduced  bone,  and 
endeavor  by  providing  it  with  a  function  to  avert  the  consecutive  atrophy 
to  which  it  is  sometimes  exposed. 

JExanthemo,tous  Jaw  Necrosis. — Mr.  Salter  also  likens  to  this  phosphorus 
disease  the  necrosis  of  the  alveolar  process  which  sometimes  occurs  after 
scarlet  fever  and  other  exanthemata,  and  which  he  believes  to  be  pro- 
duced, as  tliat  is,  b}^  the  application  of  tlie  morbid  poison  to  the  jaw  ex- 
posed by  the  presence  of  carious  teeth.  The  gums,  he  believes,  are 
affected  in  these  cases  in  the  same  wa}"  as  the  skin  is  by  the  fever  poison; 
and  thus,  if  the  bone  is  exposed  by  caries  of  the  teeth,  the  periosteum 
may  become  implicated.  The  question  is  one  of  much  pathological  in- 
terest, but  its  surgical  bearings  are  the  same  as  those  of  any  other  form 
of  necrosis. 

Tooth  tumors^  or  "odontomes,"  are  divided  by  Mr.  Salter  into  (1) 
enamel  nodules,  or  submerged  cusps  on  tooth-fangs,  which  form  small 
pearly  tumors  consisting  of  a  thick  tubercle  of  enamel,  covered  b}' 
enamel  pulp.  These  are  of  no  surgical  importance,  and  occasion  no 
symptoms.  (2)  Exostoses,  or  over-development  of  the  crusta  petrosa, 
wliich  sometimes  attains  a  size  that  requires  removal;  and  this  affection 
may  attack  one  tooth  after  another,  according  to  Mr.  Salter,  causing  pain 
which  will  persist  till  all  the  teeth  in  one  or  both  jaws  have  been  extracted. 
{\S)  Hypertrophy,  or  dilatation  of  the  fangs,  which  differ  only  physiologi- 
cally from  exostoses.     The  symptoms  they  cause  are  the  same,  and  they 

'  I  would  refer  the  reader  to  Dr.  Bristowe's  report,  On  the  Manufactories  in  which 
Phosphorus  is  Produced  or  Employed  ;  Fifth  Report  of  Med.  Off.  of  Privy  Council, 
1863,  and  to  Mr.  Salter's  article  in  the  4th  vol.  of  the  Syst   of  Surgery,  2d  ed. 


588  TUMORS    OF    THE    JAWS. 

equally  demand  extraction.  (4)  Dentine  excrescences  growing  from  the 
dentine  into  the  pulp-cavity,  and  i)roducing  constant  and  sevei'e  neuralgia, 
which  requires  the  extraction  of  the  teeth.  The  disease  cannot  be  rec- 
ognized till  after  removal.  (5)  Warty  teeth,  the  "  dentinal  odontomes  " 
of  Broca,  in  which  one  or  more  teeth  are  affected  by  a  large  lobed  warty 
tumor  growing  from  some  part  of  the  tootli  either  into  the  mouth  or  into 
the  substance  of  the  jawbone,  and  composed  of  a  confused  mass  of  bony 
structure  and  dental  tissues.  The  chief  importance  of  aknowledge  of  these 
tumors  is  to  avoid  the  removal  of  the  bone  in  these  cases,  as  the  simple 
extraction  of  the  tooth  along  with  the  tumor  will  be  sufficient;  but  if  the 
growth  has  been  allowed  to  attain  extraordinary  size  the  diagnosis  may 
be  ditllcult. 

Finall}',  it  will  suffice  just  to  mention  the  polypous  tumors  which  grow 
from  the  tooth-pulp,  either  in  caries  or  after  the  fracture  of  a  healthy 
tooth.  The  chief  surgical  importance  of  the  latter  subject  is  that  such 
fracture  of  a  tooth  is  common  in  fractured  jaw,  and  that  the  growth  of 
this  pol^'pous  tumor  from  the  pulp,  which  is  acutely  sensitive,  may  prove 
a  most  troublesome  complication  unless  it  is  detected  and  the  tooth  re- 
moved. 

TUMORS   OF   THE   JAWS. 

Tumors  of  the  jaws  are  best  described  as  cystic  and  solid,  innocent 
and  malignant. 

Cyds. — The  true  cystic  tumors  in  the  bone  are  more  common  in  the 
lower  than  the  upper  jaw,  and  these  are  often,  if  not  alwa3^s,  the  conse- 
quence of  irritation  around  the  sac  of  a  tooth  which  has  been  misplaced 
or  ill-developed.  In  many  cases  the  connection  is  rendered  obvious  by 
the  fact  that  the  wall  of  the  tumor  contains  one  or  more  teeth  more  or 
less  imperfect  and  more  or  less  misplaced  ;  but  in  other  cases  the  connec- 
tion between  the  cyst  and  the  teeth  can  only  be  a  matter  of  inference. 
Small  cysts  are  also  found  in  connection  with  the  fangs  of  perfect  teeth.^ 
In  other  cases  multilocular  cj^sts  have  been  found,  i.e.^  tumors  in  which 
the  main  cavity  has  been  divided  by  septa  into  two  or  more  secondary 
spaces,  and  others  which  would  be  more  correctly  described  as  a  con- 
geries of  small  independent  cysts.  Finally,  there  are  cases  of  cystic  sar- 
coma or  carcinoma,  i.e.,  cases  in  which  a  large  cyst  is  formed  in  the  sub- 
stance of  a  tumor  which  is  itself  more  or  less  malignant. 

Cysts  of  (he  Antrum. — The  subject  of  cysts  of  the  antrum  and  dilata- 
tion of  that  cavity  is  so  closely  connected  with  that  of  cj^stic  tumors  of 
the  jaw,  tliat  although  such  cases  hardly  come  logicall_v  under  the  desig- 
nation of  tumors  of  the  jaw — and  some,  in  fact,  are  hardly  to  be  styled 
tumors  at  all — I  must  treat  of  them  in  this  place. 

Most  of  these  cases  of  dilatation  of  the  antrum  appear  to  be  due  to 
the  development  of  cysts  in  the  substance  of  the  lining  membrane,  as  was 
long  ago  pointed  out  by  Mr.  W.  Adams  and  M.  Giraldes,^  tiie  cyst  being 
formed  by  the  dilatation  of  one  of  the  crypts  of  the  mucous  membrane. 
In  some  cases  such  cysts  are  very  numerous,  and  then  do  not  generally 
increase  much,  but  in  others  they  are  single,  and  their  constant  increase 
may  lead  to  tlie  suspicion  of  a  tumor  of  the  jaw,  and  oven  ( in  one  lamenta- 
ble case  referred  to  by  Mr.  Heath)  has  occasioned  the  total  removal  of 
the  jaw.     Usualh',  however,  the}^  are  easily  distinguishable  from  cancer 

'  See  Heath,  On  Disoasos  and  Injuries  of  the  Jaws,  2d  od.,  p.  IGO. 
2  Heath,  op.  cit.,  p.  150. 


CYSTIC    TUMORS.  589 

or  any  other  solid  tumor,  and  they  are  spoken  of  as  drops}'  of  the  antrum, 
and  used  to  be  regarded,  before  the  publication  of  Mr.  Adams's  and  M. 
Giraldes's  researches,  as  uniformly  due  to  inflammatory  distension  of  tlie 
entire  cavity,  sometimes  followed  by  suppuration  or  abscess  of  the  an- 
trum. And  it  seems  certain  that  such  general  irritation  followed  by  ab- 
scess does  exist  in  some  cases,  being  in  all  probability  caused  by  morbid 
action  around  the  fangs  of  the  bicuspid,  canine,  or  first  molar  tooth, 
whicli  are  in  close  proximity  to  the  lining  of  the  antrum.^  The  symptoms, 
then,  of  a  large  C3'st  developed  in  tlie  antrum  are  identical  with  those  of 
dropsy  of  the  antrum,  that  is  to  say,  general  distension  of  the  upper  jaw 
below  the  orbit,  with  some  aching  pain,  and  a  sensation  of  yielding  or 
perhaps  positive  crackling  on  pressure  above  the  alveoli ;  sometimes  also 
purulent  or  other  fluid  exudes  into  the  mouth  on  pressure,  and  in  cases 
of  abscess  the  distinctive  symptoms  of  suppuration  may  have  been  noted. ^ 

The  treatment  of  cysts  and  of  distensions  of  the  antrum  is  at  first  the 
same,  namely,  to  make  a  dependent  opening,  by  drawing  one  or  more 
teeth  if  they  are  carious  or  loose  ;  or,  if  the  teetii  are  sound,  but  the  bone 
much  thinned  above  the  alveoli,  to  make  a  tolerabl}^  free  incision  through 
the  wall  of  the  antrum  in  that  position,  and  then  to  keep  the  cavity 
syringed  out  with  some  disinfectant,  of  which  perhaps  Condy's  fluid 
diluted  is  the  best.  Simple  drops}'  and  abscess  will  yield  to  this  treat- 
ment; but  if  the  enlargement  is  due  to  a  cyst  it  ma}'  be  necessary  to  en- 
large the  opening  sufficiently  to  scrape  out  all  the  tissue  connected  with 
the  cyst  or  cysts.  The  total  removal  of  the  upper  jaw  can  never  be 
required. 

Gydic  Tumors. — The  other  cysts  in  the  lower  or  upper  jaw  require 
free  incision,  the  removal  of  any  misplaced  teeth  which  may  be  found  in 
their  interior,  and  the  approximation  of  their  walls  by  well-adapted  pres- 
sure of  pad  and  bandage.  The  opening  into  the  tumor  must  always  be 
kept  perfectly  free,  and  stimulating  injections  are  thought  sometimes  to 
hasten  the  closure  of  the  cyst.  Removal  of  the  jaw  has  been  practiced 
in  these  cases,'^  and  it  might  perhaps  become  necessary  if  the  simpler 
operation  failed  to  give  effectual  relief;  but  it  is  generally  unjustifiable. 
A  sufficiently  free  opening  can  almost  always  be  obtained  in  these  cases 
from  tiie  interior  of  the  mouth. 

I  ought  to  add  that  care  must  be  exercised  in  the  case  of  any  supposed 
solid  tumor  of  the  jaw,  which  is  at  all  elastic,  to  make  sure  that  it  is  not 
of  the  cystic  variety,  for  many  cases  are  on  record  in  which,  after  extir- 
pation of  the  jaw,  tlie  surgeon  has  been  shocked  to  find  that  he  was  deal- 
ing with  a  simple  cyst  with  somewhat  thick  walls,  and  therefore  that  the 
patient  could  have  been  cured  without  any  mutilation.  The  condition  of 
the  teetli  also  should  be  carefully  studied.  And  finally,  the  opposite 
mistake  should  be  avoided  of  taking  for  a  simple  cyst  that  which  is  only 
a  cystic  formation  in  a  solid  tumor.  The  majority  of  such  cyst-bearing 
tumors  will  be  malignant  clinically,  though  perhaps  anatomically  to  be 
reckoned  among  the  sarcomata. 

The  solid  tumors  of  the  jaws  may  be  divided  into  the  innocent  and  the 
malignant. 

1  On  the  Anatomy  of  the  Antrum,  see  Salter,  in  Syst.  of  Surg.,  2d  ed.,  vol.  iv, 
p.  356. 

2  In  very  rare  cases  (three  are  referred  to  by  Mr.  Salter,  op.  cit ,  p.  538)  abscess 
of  the  antrum  has  caused  amaurosis,  the  sight  returning  on  the  relief  of  the  abscess. 

3  As  in  a  celebrated  case  operated  on  by  Sir  B.  Brodie,  and  figured  in  Syst.  of  Surg., 
vol.  iv,  p.  459. 


590  TUMORS    OF    THE    JAWS. 

The  innocent  tumors  will  be  subdivided  into  fibrous  or  fibroid,  carti- 
laginous and  osseous. 

Epulis. — The  most  familiar  of  the  fibroid  growths  are  called  epulis, 
from  their  position  just  above  the  gums.  These  are  either  purely  fibrous 
or  fibro-cellular  or,  as  is  frequently  the  case,  mixed  with  myeloid  ele- 
ments. The  first  class  are  unquestionably  innocent;  the  two  latter,  like 
the  other  sarcomata,  are  of  a  more  suspicious  character — i.  e.,  they  may 
recur  locally — but  they  are  hardlj'  of  a  truly  malignant  or  cancerous  na- 
ture. To  this  rule  I  have,  however,  seen  two  exceptions  in  which  epithe- 
lioma occurred  in  the  situation  of  an  epulis.  Epulis  has  its  root  just 
above  the  teeth,  and  frequently  from  the  lining  membrane  of  one  of  the 
alveoli ;  at  other  times  it  makes  its  appearance  at  some  distance  from  the 
alveolus,  usuall)'  on  the  exterior,  in  rarer  eases  in  the  cavity  of  the  mouth; 
but  in  these  cases  also  Mr.  Salter'  suspects  that  the  tumor  is  connected 
primarih'  with  the  periodontal  membrane  ;  and  even  in  cases  where  an 
epulis  forms  on  a  jaw  apparently  edentulous  it  will  be  found,  according 
to  Mr.  Salter,  that  some  fangs  of  teeth  have  been  left  behind.  Epulis  is 
more  common  in  the  upper  than  in  the  lower  jaw,  the  proportion  being 
fixed  by  the  same  author  at  about  two  to  one. 

The  treatment  of  epulis  consists  in  its  removal,  along  with  the  tissue 
from  which  it  springs,  i.  e.,  the  periodontal  membrane,  or  the  lining  of  the 
alveoli.  Yery  often  the  growth  of  the  epulis  has  completely  displaced  the 
teeth,  and  in  such  cases  all  that  will  be  necessary  is  to  cut  the  tumor  freel}^ 
away  from  its  base,  and  rasp  the  latter  away  from  the  subjacent  bone  with 
a  strong  knife.  This  will  cut  away  all  the  alveolar  tissue,  and  the  peri- 
odontal membrane,  if  anj'  is  left,  will  atrophy,  and  so  the  whole  tissue  from 
which  the  tumor  springs  vvill  ultimately  have  been  removed,  and  then  no 
recurrence  need  be  feared.  If  the  teeth  have  been  left  at  the  first  opera- 
tion and  recurrence  takes  place,  which  is  tolerably  often  the  case,  the 
surgeon  must  be  careful  to  remove  them  at  the  second,  and  then  the  cure 
will  probably  prove  permanent.  But  in  inveterate  cases,  after  the  removal 
of  the  teeth,  it  is  necessary  to  clip  away  the  bone  to  some  extent  with 
curved  cutting  forceps,  so  as  to  make  sure  of  having  removed  tlie  whole 
of  the  alveolar  portion  of  the  jaw  ;  and  if  any  doubt  exists  on  this  point, 
or  if  suspicious-looking  granulations  sprout  from  the  wound,  some  strong 
caustic  (of  which  the  pure  nitric  acid  is  the  best)  must  be  unsparingly 
employed.  Under  such  treatment  a  definite  cure  may  be  confidently 
promised. 

Fibrous  Tumor  of  Body  of  Bone. — Fibrous  and  cartilaginous  or  fibro- 
cartilaginous tumors  also  spring  from  the  body  of  the  bone  unconnected 
with  the  teeth.  The  antrum  is  the  favorite  seat  of  the  purely  fibrous 
tumors,  and  here  tiiey  often  extend  widely  in  all  directions.  But  it  must 
be  recollected  that  in  many  of  these  cases,  as  in  Mr.  Hewett's  case  ^ 
(quoted  by  Mr.  Pollock,  Hyst.  of  Surg.,  vol.  iv,  p  463),  the  growtii  which 
has  been  taken  for  a  tumor  of  the  antrum  really  springs  from  the  base  of 
the  skull,  a  point  which  will  be  hereafter  again  alluded  to.  Fibrous  tu- 
mors are  also  found  springing  from  tiu;  interior  of  the  skull  and  expand- 
ing the  bone  around  tlieni.  In  one  curious  case,  referred  to  b}'  Mr.  Pol- 
lock, in  the  Museum  of  St.  George's  Hospital,  there  is  a  nucleus  of  bone 
in  the  centre  of  the  tumor;  and  in  another,  which  Mr.  Heath  describes,  in 
the  College  of  Surgeons'  Museum,  tlie  tumor  is  calcifying  like  a  uterine 
fibroid. 

The  diaauosis  of  these  fibrous  tumors  from  others  which  are  of  a  softer 


1  Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p.  339.     ^  Mod.-Chir.  Trans.,  vol.  xx.xiv,  p.  43. 


ENCHONDROMA.  591 

consistence  and  of  a  more  malignant  character  rests  on  their  slow  growth, 
their  regular  rounded  outline,  especially  in  the  lower  jaw,'  and  their  firm, 
uniform  consistence.  They  may  bleed  to  a  certain  extent^  from  the  con- 
stant irritation  to  which  the}'  are  subject. 

When  a  truly  fibrous  tumor  is  entirely  removed  along  with  all  the  bone 
from  which  it  springs,  it  will  not  recur.  The  numerous  instances  on  record 
of  recurrence  after  operations  of  this  nature  have  depended,  no  doubt  on 
the  fact  that  the  tumor  was  not  purel}'^  fibrous,  but  sarcomatous  in  part, 
or  in  some  other  cases  on  imperfect  removal.  In  operating  on  a  fibrous 
tumor,  therefore,  it  is  desirable  to  cut  wide  of  the  tumor,  and  whenever 
it  is  possible  to  remove  the  whole  of  that  part  of  the  bone  from  which  the 
tumor  springs. 

Enchondroma. — Cartilaginous  tumors  are  rare,  but  they  sometimes 
attain  an  immense  size.  Mr.  O'Shaughnessy  removed  a  fibrous  enchon- 
droma from  the  upper  jaw  which  was  nearly  as  large  as  the  patient's  head, 
and  overlapped  the  lower  jaw,  which  was  contained  in  a  groove  on  the 
lower  surface  of  the  tumor.  (Heath,  p.  243.)  In  the  Museum  of  St. 
George's  Hospital  is  an  enormous  mass  of  enchondroma  (Ser.  xvii.  No. 
6fi),'^  which  implicates  the  upper  jaw,  but  is  chiefly  connected  with  the 
base  of  the  skull.  A  few  other  cases  of  a  similar  nature  are  recorded,  and 
one  was  operated  on  by  Mr.  Morgan,  of  Guj^'s  Hospital,  with  some  suc- 
cess. Mr.  Moore,  however,  in  an  attempt  to  remove  such  a  growth  found 
the  disease  to  be  myxomatous,  and  the  patient  died  on  the  table. 

Exoftiosi^  of  the  jaws  is  often  of  the  ivor}-  variety,  as  in  the  cases  figured 
on  pp.  449-50 — the  former  from  the  lower,  the  latter  from  the  upper  jaw. 
For  the  main  considerations  relative  to  their  treatment  I  would  refer  the 
reader  to  that  place. 

Malignant  Tumoi^s. — The  malignant  forms  of  solid  tumor  in  tlie  jaws 
are  sarcomata  and  carcinomata;  the  former  are  often  mixed  with  cysts, 
the  solid  matter  being  usually  of  the  round-  or  spindle-celled  variety,  some- 
times mj'xomatous.  Myeloid  tumors  are  more  common  in  tlie  form  of 
epulis  than  as  diseases  of  the  body  of  the  bone,  and  are  usually  innocent, 
though  to  both  rules  there  are  many  exceptions.  Cancerous  tumors  are 
usually,  if  not  always,  of  the  medullary  variety. 

These  forms  of  tumor  of  course  demand  complete  and  free  removal,  if 
seen  early  enough;  but  the  prognosis  is  highly  unfavorable.  In  all  cases 
that  I  have  had  the  opportunity'  of  watching  recurrence  has  taken  place 
very  earl}'. 

It  appears  probable,  from  cases  recorded  by  Mr.  WagstafFe  and  Mr. 
Heath,*  that  in  some  of  these  cases  of  cystic  sarcoma  the  disease  "com- 
mences in  the  mucous  or  submucous  glands  of  the  gum  and  cheek,  and 
only  subseciuently  invades  the  jaw."  Mr.  Heath  refers  to  a  case  under 
Mr.  Skye's  care  in  which  the  outer  wall  of  both  the  upper  and  lower  jaws 
was  involved.  The  disease  was  freely  cut  away,  and  the  patient  made  a 
good  recovery. 

Tumorn  of  the  Antrum. — Any  of  these  forms  of  tumor  may  originate 
in  the  antrum  of  Highmore.  Some  tumors  of  the  antrum  are  purely 
fibrous,  otliers,  no  doubt,  glandular,  or  adenomatous — i.  e.,  morbid  imita- 
tions of  the  glandular  tissue  of  the  mucous  membrane  lining  the  antrum. 

1  The  fibrous  tumors  of  the  antrum  consist  of  a  sjreat  number  of  large  lobes  which 
pass  into  all  the  spaces  communicating  with  that  cavity. 

2  Pollock,  op.  cit.,  p.  465. 

3  See  also  Path.  Trans.,  vol   x,  for  a  description  of  this  case,  with  a  drawing. 
■•  Wagstaft'e,  Path.  Trans  ,  vol.  xxii ;  Heath,  op.  cit.,  p.  303. 


592  TUMORS    OF    THE    JAWS. 

I  have  already  referred  to  the  existence  of  exostosis  in  the  antrum,  and 
the  occurrence  of  malignant  tumor  is  unluckily  only  too  common. 

The  diagnostic  sign  of  a  tumor  having  its  origin  in  tlie  antrum  is  that 
it  exjiands  tlie  walls  of  that  cavit3'  in  various  directions,  so  as  to  invade 
several  of  the  spaces  with  wliich  the  antrum  is  in  relation.  It  presses 
laterally  into  the  nostril,  downwards  into  the  mouth,  upwards  into  the 
orbit,  backwards  into  the  pharynx  or  pterygomaxillary  fossa,  and  out- 
wards into  the  zygomatic  and  temporal  fossae,  and  very  commonljan  man}'^ 
or  all  these  directions  at  once.  A  tumor,  however,  growing  from  the  base 
of  the  skull  may  so  envelop  the  upper  jaw  as  to  grow  in  several  of  these 
directions,  as  exemplified  by  Mr.  Hewett's  case  above  mentioned,  so  that 
the  diagnosis  should  not  be  arrived  at  without  careful  examination. 

The  origin  of  a  tumor  from  the  antrum  is  a  matter  of  importance,  be- 
cause then  the  surgeon  may  be  confident  of  removing  the  whole  of  its 
attachment.  The  complete  excision  of  the  upper  jaw  removes  every  part 
of  the  antrum,  and  is  therefore  much  more  satisfactory  than  operations 
on  tumors  of  the  base  of  the  skull  can  ever  be. 

Operations  on  the  Jaws. — The  upper  jaw  may  be  removed  either  par- 
tially or  entirely.  In  the  partial  removal  the  orbital  plate  is  left  behind, 
while  in  the  other  operation  not  only  the  entire  maxilla,  but,  if  it  is 
wished,  the  malar  bone  also,  may  be  excised.  The  plan  formerly  in  use 
was  to  make  two  incisions,  one  somewhat  vertical  from  the  inner  angle  of 
the  orbit,  coasting  round  the  nose  and  dividing  the  lip  in  the  middle  line  to 
its  free  edge  ;  the  other  sloping  down  from  the  malar  prominence  (or  if 
the  whole  malar  bone  also  is  to  be  removed,  from  the  zygoma)  to  the 
outer  angle  of  the  mouth.  But  these  extensive  incisions  are  rarely  neces- 
sar}-.  A  single  cut  running  under  the  lower  border  of  the  orbit,  and 
embracing  more  or  less  of  the  extent  of  that  cavity  as  may  be  thought 
necessary,  and  extending  from  thence  along  the  outer  side  of  the  nose 
through  the  lower  lip,  enables  the  operator  to  turn  back  as  large  a  flap 
of  the  cheek  as  is  ordinarily  necessary ;  one  or  two  of  the  front  teeth 
should  be  drawn  at  the  commencement  of  the  operation.  If  the  facial  or 
any  large  arterj-  has  been  divided  it  is  to  be  tied.  Then  the  two  upper  jaw- 
bone's are  separated  from  each  other  b}-  a  cut  with  the  saw  or  bone  nip- 
pers, the  ascending  process  of  the  superior  maxillary  bone  is  cut  across, 
and  the  malar  divided  from  the  superior  maxillary  by  notching  it  with 
the  saw  and  then  completing  the  division  with  the  forceps.  Now,  on 
twisting  the  bone  with  the  lion  forceps  it  will  become  loose,  and  is  to  be 
severed  from  the  soft  palate  and  its  remaining  attachments  with  the  knife. 
In  doing  this  the  internal  maxillary  artery  is  sometimes  divided,  but  as 
there  is  now  a  large  and  free  opening  there  will  be  no  difficulty  in  secur- 
ing it.  The  large  gap  is  to  be  filled  with  a  piece  of  dry  lint,  and  the  soft 
parts  united  with  numerous  sutures  and  a  harelip  pin  or  two.  Recovery 
is  generally  rapid.  A  large  gap  will  be  left  in  the  mouth,  which  must  be 
filled  up  with  an  obturator. 

Partial  lienwval  of  Upper  Jatv. — If  only  the  bod}-  of  the  bone  is  to  be 
removed,  the  orbital  plate  being  left,  after  severing  the  ascending  pro- 
cess of  the  superior  maxillary  bone,  the  cut  is  to  be  extended  outwards, 
with  a  keyhole  saw  or  cutting  forceps,  beneath  tlie  orbit,  until  the  whole 
of  the  wall  of  the  antrum  has  been  separated  from  its  roof,  and  then  the 
loosened  bone  is  to  be  twisted  out  witli  the  lion  forceps.  This  operation 
is  used  chiefly  to  obtain  access  to  the  base  of  the  skull  in  the  case  of 
fibrous  nasopharyngeal  polypus.  The  end  is  attained  with  less  deformity 
than  if  the  entire  bone  be  removed. 

Finally,  Langenbeck  has  devised  an  operation  in  these  cases  which  he 


CLOSURE    OF    THE    JAWS.  593 

denominates  "the  osteoplastic  resection  of  the  upper  jaw."  Instead  of 
reraovino;  the  soft  parts  from  the  jaw  "  the  requisite  incisions  are  made 
down  to  the  bone  at  once,  the  bone  is  sawn  through  in  the  same  incisions, 
and  the  portion  thus  forcibly  detaclied  turned  inwards,  without  otherwise 
dividing  it  from  its  connection  with  the  nasal  and  frontal  bone.  The 
tumor  is  then  removed  from  behind  the  bone,  and  the  latter  replaced  in 
its  original  position.  No  incision  is  made  at  the  place  where  this  bend- 
ing or  fracture  must  necessarily  occur." — Pollock. 

I  must  refer  the  reader  to  the  original  {Deutsche  Klmik,  1859  and  1861) 
for  details  as  to  this  plan  of  treatment.  It  has  not  commended  itself  to 
surgeons  in  this  countr}',  nor  do  I  believe  that  it  is  now  in  much  use 
anywhere. 

Removal  of  Loioer  Jaw. — Operations  on  the  lower  jaw  may  be  con- 
ducted entirely  inside  the  mouth,  if  only  a  portion  of  its  thickness  is  to 
be  removed  ;  but  wiien  any  part  of  the  whole  depth  of  the  bone  is  to  be 
taken  away  an  external  incision  will  be  required. 

The  whole  of  one  side  of  the  lower  jaw  may  be  removed  by  making  an 
incision  through  the  middle  line  of  the  lower  lip  and  along  the  lower  bor- 
der of  the  jaw  to  the  situation  of  the  articulation,  denuding  the  anterior 
surface  of  the  bone  and  tying  the  arteries,  sawing  through  the  bone  in  the 
middle  line,  cutting  the  muscles  and  mucous  membrane  away  from  its 
inner  surface,  then  seizing  the  bone  with  the  lion  forceps  and  twisting 
it  out,  so  as  to  dislocate  it  from  the  skull,  any  remains  of  the  ligaments 
being  touched  with  the  knife,  which  is  kept  very  close  to  the  bone  in  order 
to  avoid  the  external  carotid  arter3^  In  this,  as  in  all  other  extensive  op- 
erations on  the  lovver  jaw,  the  tongue  should  be  commanded  by  a  stout 
ligature  passed  through  it  before  the  operation  is  begun,  otherwise  the 
patient  may  be  in  danger  of  suffocation  from  its  falling  back  over  the 
entrance  to  the  larynx.  If  it  is  necessary  to  remove  the  whole  jaw,  the 
same  operation  may  be  repeated  on  both  sides,  or  the  incision  through 
the  middle  line  of  the  lip  may  be  dispensed  with,  the  whole  of  the  lower 
lip  and  lower  part  of  the  face  being  turned  off  the  bone  by  a  free  incision 
from  one  side  to  the  other,  after  which  the  bone  is  divided  in  the  centre 
and  its  two  halves  dissected  out  as  before. 

Closure  of  the  Jaios. — Finally,  I  must  say  a  few  words  about  that  very 
troublesome  affection  which  consists  in  permanent  closure  of  the  jaws. 
In  rarer  cases  this  is  caused  by  anchylosis  of  the  temporamaxillary  joint, 
but  more  commonly  by  the  destruction  of  the  mucous  lining  of  the  mouth 
by  sloughing  from  cancrum  oris  or  mercurial  poisoning,  by  phagedenic, 
or  by  lupoid  ulceration,  and  the  sui)stitution  for  it  of  a  cicatricial  tissue, 
which  will  go  on  for  years  contracting  more  and  more  tightly,  and  in 
which  bone  is  sometimes  developed.  In  the  slighter  cases  of  this  cica- 
tricial contraction,  as  in  other  cicatrices,  it  may  be  possible  to  stretch 
the  cicatrix  and  keep  it  stretched  by  mechanical  means,  just  as  is  done 
in  contractions  of  burns.  But  when  the  contraction  is  formidable  1  have 
never  seen  this  plan  successful.  Two  operations  have  been  proposed  for 
the  partial  relief  of  the  painful  consequences  of  this  infirmity,  by  estab- 
lishing a  false  joint  in  the  lower  jaw.  One  (Rizzoli's)  consists  in  dividing 
the  jaw  from  within  the  mouth  with  a  fine  saw,  and  preventing  the  union 
of  its  segments  either  by  constant  motion  or  by  inserting  a  piece  of 
gutta-percha  between  them.  This,  however,  is  now  rarely  practiced,  being 
apparently  less  eflficient  than  Esmarch's  plan  of  dividing  the  jaw  by  an 
external  incision  in  front  of  the  cicatrized  part  and  taking  a  wedge- 
shaped  piece  out  of  it.  This  operation,  if  practiced  fairly  in  front  of  the 
cicatrix,  is  said  by  Mr.  Heath  to  yield  good  and  permanent  results.     Or 

38 


594  DISEASES    OF    THE    NOSE. 

attempts  maybe  made  to  divide  the  tissues  between  the  bones  and  screw 
the  bones  apart  by  instruments  applied  between  silver  shields  moulded 
to  the  upper  and  lower  jaw. 

In  contraction  from  anch^dosis  the  ramus  of  the  jaw  should  be  divided 
with  a  line  saw  as  near  the  joint  as  is  found  practicable,  and  a  small  piece 
removed.     This  can  be  eftected  without  external  incisions. 

I  must  refer  the  reader  to  Mr.  Heath's  work  for  a  full  description  and 
discussion  of  these  rare  and  somewhat  unsatisfactory  cases. 

DISEASES    OF   THE    NOSE. 

The  diseases  of  the  nose  are  divided  naturally  into  those  of  the  exter- 
nal parts, — the  skin  and  cellular  tissue ;  and  those  of  the  interior, — the 
bones,  cartilages,  and  mucous  membrane. 

External  Parts. — The  commonest  affection  of  the  external  parts  of  the 
nose  is  that  to  which  the  name  of  Acne  rosacea  is  generally  applied, 
though  the  name  may  not  be  an  exactl}'  appropriate  one,  acne  being  con- 
sidered to  be  in  all  cases  an  affection  of  the  sebaceous  follicles  ;  while  in 
acne  rosacea,  though  the  sebaceous  follicles  may  in  many  cases  be  affect- 
ed, in  others  they  certainly  are  not.  The  disease  in  its  simple  form  con- 
sists in  an  injection  of  the  capillaries  of  the  skin,  which  produces  a  red, 
shiny,  greasy  appearance,  in  some  cases  limited  to  the  tip,  at  others  ex- 
tending over  the  whole  of  the  organ.  The  sebaceous  follicles  may  be  also 
affected,  and  in  those  cases  the  skin  is  marbled  and  irregularly  knobbed. 
The  simple  form  of  acne  is  more  common  in  women  than  in  men,  and 
is  generally  developed  about  the  cessation  of  the  menstruation,  with 
which  function  it  seems  to  have  some  unexplained  connection.  In  the 
male  sex  it  may  be  referred  to  disorders  of  digestion,  exposure  to  the 
weather,  or  other  sources  of  ill-health,  but  seems  to  have  no  necessary 
connection  with  intemperance.  The  "  acne  hypertrophica,"  "  spirit-drink- 
er's nose,"  vulgarl}'  "  grog-blossoms,"  is  a  severer  form  of  the  same  com- 
plaint, due  to  the  abuse  of  wine  or  alcohol,  in  which  the  sebaceous  glands 
are  always  much  affected,  and  which  is  followed  by  enormous  hypertro- 
phy, producing  the  pendulous  masses  called  lipoma,  which  are  so  familiar 
in  old  topers. 

In  all  cases  of  acne  the  first  care  of  the  surgeon  is  to  ascertain  if  possible 
whether  any  inordinate  indulgence  in  the  pleasures  of  the  table  has  given 
rise  to  the  disease,  or  whether  it  is  connected  with  any  obstruction  to  the 
menstrual  discharge,  and  to  counteract  such  deleterious  agencies  by 
gradual  and  judicious  treatment.  Local  applications  are  numerous,  and 
are  chiefly  of  the  stimulating  kind.  Hot  bathing  of  the  part,  followed  by 
the  application  of  a  lotion  of  the  perchloride  of  mercury,  one  or  two  grains 
to  the  ounce,  is  said  by  Mr.  Durham  to  be  efficacious  in  the  milder  cases. 
Soaps  of  carbolic  acid  or  some  salt  of  sulphur,  or  i)astes  of  these  substances 
laid  on  the  parts  overnight  and  washed  off  in  the  morning,  or  ointment  of 
iodide  of  suli)hur,  may  be  tried  in  more  advanced  cases.  In  obstinate 
cases  Hebra  recommends  longitudinal  incisions  to  be  made  through  the 
hypertroi)hied  parts,  and  after  the  bleeding  has  somewhat  ceased  to  brush 
the  surface  of  the  incisions  over  with  Liq.  Hyd.  Perchloridi.  But  when 
the  pendulous  masses  called  lipomata'  are  developed  nothing  short  of 
their  extirpation  will  do  any  good,  and  the  operation  is  often  quite  suc- 
cessful, though  in  })atients  of  this  kind  erysipelas  and  other  complica- 
tions are  of  course  to  be  apprehended.     The  best  plan  is  to  make  a  free 

'  The  name  is  so  far  inappropriate  that  the  tumors  are  not  fatty,  but  consist  of 
hyportrophied  skin  and  sebaceous  follicles  with  connective  tissue. 


AFFECTIONS    OF    THE    INTERIOR.  595 

median  incision,  and  others  at  the  sides,  turning  flaps  down  sufficient  to 
cover  the  framework  of  tlie  nose  witliout  any  tension,  i-emove  the  inter- 
vening mass,  and  unite  the  flaps.  Care  must  be  tal<en  not  to  open  the 
interior  of  the  nose  by  cutting  through  the  cartilages,  so  that  tlie  left 
forefinger  must  be  kept  in  tlie  nose. 

The  nose  is  peculiarly  subject  to  the  forms  of  ulceration  spoken  of  at 
p.  415  as  lupous  and  rodent  ulcers,  but  1  need  add  nothing  here  to  what 
is  said  there  and  in  the  chapter  on  Diseases  of  the  Skin  on  that  subject. 
Epithelioma  also  is  not  uncominon  at  the  angle  of  the  nose,  and  should 
be  early  and  freely  removed  with  the  knife,  caustic  being  applied  to  the 
section  if  any  tissue  in  it  looks  suspicious. 

Malformation. — Congenital  absence  of  the  nose  has  been  recorded,  and 
it  has  even  been  said  that  plastic  operations  have  been  performed  for  its 
cure ;  but  I  confess  that  I  do  not  understand  how  any  surgical  operation 
could  restore  anything  like  the  natural  api)earance  in  such  cases. ^  But 
in  cases  (which  are  also  very  rare)  of  congenital  occlusion  of  one  or  both 
nostrils,  or  of  adhesion  between  the  nostril  and  septum,  an  operation 
ma}^  be  of  the  greatest  service,  and  should  be  at  once  undertaken,  since 
the  obstruction  much  interferes  with  sucking.  The  obstruction  is  some- 
times merely  membranous,  while  at  other  times  a  considerable  depth  of 
tissue  has  to  be  penetrated.  A  free  opening  into  the  nasal  cavity  should 
be  secured  and  kept  permanently  dilated  by  means  of  a  metal  or  gum 
catheter  retained  for  many  weeks,  and  the  case  should  be  watched  to 
prevent  recontraction.  Similar  in  principle  should  be  the  treatment  of 
occlusion  or  narrowing,  the  result  of  cicatrization,  the  usual  cause  for 
which  is  lupus ;  but  here  the  prospects  of  cure  are  far  less  encouraging, 
since  the  tissue  of  the  cicatrix  tends  to  recontract.  The  constant  ex- 
pansion of  tents  of  laminaria  may,  however,  ultimately  overcome  this 
tendency  if  the  patient  will  persevere. 

Deviations  of  the  nose  are  very  common  to  a  slight  and  hardly  percep- 
tible extent.  But  sometimes,  whether  as  the  result  of  injury  or  as  a  con- 
genital formation,  the  septum  inclines  so  much  to  one  side  as  almost  to 
close  one  nostril,  while  the  turbinated  bone  on  the  opposite  side  projects 
so  much  into  the  other  as  to  be  mistaken  for  a  tumor.  A  little  attention 
will  enable  the  surgeon  to  avoid  this  error  and  explain  the  nature  of  the 
case ;  but  no  treatment  has  as  yet,  I  believe,  proved  successful,  though 
removal  by  the  knife  of  a  portion  of  the  cartilaginous  septum  is  recom- 
mended by  Professor  Gross. 

Affections  of  the  Interior. — The  examination  of  the  nasal  cavity  may 
be  made  from  the  nostril,  for  which  purpose  special  instruments  are  con- 
trived ;  but  the  spoon  end  of  a  director,  or  a  couple  of  directors  intro- 
duced on  opposite  sides,  will  serve  well  enough  ;  or  by  means  of  careful 
probing — very  necessary  in  the  search  for  foreign  bodies  ;  or  by  reflected 
light  from  the  mouth,  by  which  the  posterior  nares  may  be  illuminated, 
as  will  be  explained  in  speaking  of  Laryngoscopy,  of  which  this  exam- 
ination, "Rhinoscopy,"  is  a  variety.  It  is  a  very  difficult  method  of 
examination,  but  has  afforded  useful  results  in  cases  of  foreign  bodies 
impacted  in  the  respiratory  pharj'nx,  and  in  tumors  situated  near  the 
posterior  nares. 

Rhinolithes. — I  have  already' spoken  of  foreign  bodies  in  the  nostril  (p. 
196)  and  of  the  importance  of  detecting  and  extracting  them  at  the 
earliest  possible  moment.     Such  bodies  sometimes  attract  inspissated 

1  See  Holmes's  Surg.  Dis.  of  Childhood,  2d  ed.,  p.  128. 


596  DISEASES    OF    THE    NOSE. 

mucons  and  purulent  secretions,  and  thus  form  the  nuclei  of  rhinolithes, 
or  nose-stones,  which  are  found,  though  rarely,  in  the  inferior  meatus, 
while  at  other  times,  as  it  seems,  such  concretions  form  without  any 
foreign  nucleus;  and  in  anj'^  case  of  constant  discharge  and  inflammation, 
for  which  no  cause  is  obvious,  it  is  important  to  examine  the  meatus 
thoroughly  for  one  of  these  concretions.  When  detected  it  must  be  re- 
moved entire  if  possible,  otherwise  it  can  probably  be  crashed  with  a  toler- 
ably stout  pair  of  forceps  and  the  fragments  extracted  or  sj'ringed  out. 

Epistaxis,  or  bleeding  from  the  nose,  is  a  very  common  affection,  both 
in  youth  and  old  age.  It  occurs  in  consequence  of  injuries,  though  I'arely 
to  any  great  extent.  In  fractures  of  the  base  of  the  skull,  as  pointed  out 
above  (p.  174),  it  is  sometimes  copious  and  persistent.  But  the  epistaxis 
which  is  usually  the  subject  of  treatment  is  spontaneous.  In  _youth  this 
is  rarelv  of  much  consequence,  except  in  persons  the  subjects  of  the 
hiemorrhagic  diathesis.  Any  slight  congestion  will  induce  epistaxis  in 
some  children,  but  it  will  almost  always  subside.  There  are  many  ways 
of  treating  it  in  popular  use,  and  their  success  is  generally  to  be  ex- 
plained b}'  the  spontaneous  cessation  of  the  discharge.  Cold  to  the 
spine,  as  by  dashing  cold  water  in  the  nape,  or  "the  nursery  remedy  of 
slipping  a  cold  key  down  the  back,"  or  raising  the  arms  vertically  above 
the  head,  certainly  seem  to  stop  the  bleeding.  But  the  direct  applica- 
tion of  cold,  as  by  washing  out  the  nose  with  ice-cold  water  or  passing 
pieces  of  ice  into  the  nostril  and  applying  ice-cold  lotion  to  the  forehead, 
is  still  more  efficient. 

In  young  women  epistaxis  is  sometimes  vicarious  when  the  menstrual 
discharge  is  suppressed,  and  then  requires  no  treatment  except  that  which 
is  directed  to  the  re-establishment  of  the  natural  function. 

In  fevers  and  scurvy  epistaxis  is  liable  to  occur,  and  sometimes  can 
only  be  suppressed  by  plugging  the  nose. 

In  advanced  life  epistaxis  is  often  indicative  of  cerebral  congestion, 
and  in  such  cases  must  be  regarded  with  anxiety,  though  in  itself  and 
for  the  time,  if  not  excessive,  it  will  probably  avert  graver  mischief. 

Olniously,  then,  the  treatment  will  depend  on  a  knowledge  of  the 
cause,  and  as  a  general  rule  there  is  little  occasion  for  any  violent  attempt 
at  suppressing  the  haemorrhage.  It  usuall}^  subsides  of  itself,  having  done 
only  good.  If  it  seems  necessary  to  suppress  it  by  surgical  means,  a  free 
washing  out  of  the  nose  by  the  method  to  be  presently  described,  as  Dr. 
Thudiclium's,  with  ice-cold  water,  or  with  some  astringent  solution,  hardly 
ever  fails  to  stop  it,  except  in  the  case  of  the  depravation  of  the  blood  by 
the  haemorrhagic  diathesis,  or  by  fever  or  scurvy,  in  which  cases  and  in 
some  of  the  more  violent  haemorrhages  of  later  life  it  may  be  necessary 
to  plug  the  nares. 

Phigr/ing  the  Nares. — Plugging  the  posterior  nares  is  most  easily  ef- 
fected by  means  of  Bellocq's  sound,  here  figured.     The  sound  is  hollow, 

and  carries  a  stilet  of  whalebone  on 
a  handle.  The  stilet  has  a  large  63^6 
at  its  end.  It  is  introduced  along 
the  floor  of  the  nostril  into  the 
pharynx,  and  then  by  pressure  on 
the  handle  the  whalebone  stilet  is 
made  to  protrude,  and  curves  round 
the  soft  palate  into  the  mouth.  The 
Bellocq's  sound.  eye  is  drawn  out  as  far  as  it  will 

come  (Fig.  208),  and  the  string  on 
which  the  plug  is  fastened  is  then  passed  into  the  eye,  and  by  withdraw- 


CHRONIC   CORYZA. 


597 


ing  the  instrument  the  string  is  brought  out  of  the  nose.  There  is  then 
nothing  to  do  but  to  draw  the  plug  up  to  tlie  posterior  nares.  The  plug 
should  be  fastened  in  the  middle  of  a  long  piece  of  string.  It  should  be 
made  of  lint  or  sponge,  and  its  size  should  be  that  of  the  first  joint  of  the 
surgeon's  thumb,  which  is  a  little  more  than  the  size  of  the  posterior 
nares  ;  so  that  the  plug  cannot  be  drawn  into  the  nose.  When  lodged 
in  the  posterior  nares  there  are  two  ends,  one  projecting  from  the  nose, 
the  otlier  from  the  mouth.  On  the  one  which  projects  from  the  nose  a 
plug  should  be  strung,  which  fills  the  anterior  nares,  and  on  this  the 
thread  siiould  be  firmly  tied,  so  that  both  plugs  are  kept  securely  in  posi- 
tion. This  is  best  done  by  sewing  the  string  into  the  substance  of  the 
plug  and  making  all  fast  with  a 

secure  knot.     If  both  nares  are  Fig.  268. 

plugged  the  strings  sliould  then 
be  tied  together.  The  other  string 
which  emerges  from  the  mouth  is 
to  be  left  loosely  tied  to  the  an- 
terior string,  or  secured  on  the 
cheek  with  a  piece  of  strapping, 
so  as  not  to  irritate  the  soft  pal- 
ate. It  is  very  useful  in  with- 
drawing the  plug.  If  Bellocq's 
sound  is  not  at  liand  a  soft  gum 
catheter  is  to  be  taken  and  per- 
forated  opposite  its  eye,  so  as  to 
make  it  into  a  gigantic  needle. 
This  is  passed  through  the  nose 
into  the  pharj'nx,  and  its  end  is 
caught  there,  brought  out  of  the 
mouth,  and  threaded.  The  plugs 
are  very  inconvenient  to  the  pa- 
tient, especially  when,  as  is  usu- 
allj'  the  case,  both  nostrils  require 
plugging,  since  he  can  only  sleep  with  the  mouth  open,  and  the  strings 
are  very  much  in  his  way.  They  may  be  removed  in  about  two  days.  The 
anterior  plug  being  removed,  an  interval  of  an  hour  or  two  may  be  given 
to  see  whether  any  bleeding  persists.  If  not,  by  cutting  the  anterior 
string  and  drawing  on  the  posterior,  the  plug  is  at  once  removed  from 
the  posterior  nares. 

Chronic  coryza  is  a  troublesome  complaint,  which  sometimes  lasts  for 
years  or  for  life,  producing  no  ozsena  or  other  unpleasant  symptoms  be- 
yond catarrhal  discharge  and  loss  of  the  sense  of  smell.  In  other  cases, 
and  especially  in  strumous  cliildren,  the  mucous  membrane  becomes 
chronically  thickened,  especially  over  the  end  of  the  inferior  turbinated 
bone,  giving  at  first  sight  the  impression  of  a  polypus,  and  being  very 
often  mistaken  for  one,  though  most  easily  distinguished  from  it,  b}'  the 
absence  of  any  stalk,  by  the  immobility  of  the  thickened  membrane,  and 
by  its  red,  opaque  tint. 

The  treatment  of  these  chronic  aflfections  of  the  pituitary  membrane  is 
difficult.  When  the  chronic  thickeningis  obviously  connected  with  struma, 
the  constitutional  cachexia  must  be  treated  more  than  the  local  disease, 
though  the  persevering  application  of  astringents  and  stimulants,  either 
in  powder,  lotion,  or  pulverized,  and  injected  into  the  nostril,  seems  often 
to  do  o;ood.     I  have  seen  cases  where  it  has  seemed  to  me  that  the  mis- 


Plugging  the  jiares. 


598  DISEASES    OF    THE    NOSE. 

take  of  taking  the  thickened  membi-aiie  for  a  polypus  and  tearing  part  of 
it  olf  has  done  good  instead  of  harm,  thongh  I  should  not  venture  to 
recommend  the  practice. 

Ozfcna. — One  of  tlie  most  terrible,  as  it  is  also  one  of  tlie  commonest, 
of  the  maladies  which  affect  the  nose  is  ozsena,  or  fetid  discharge  from  the 
nostrils.  This  occurs  from  man}'  causes,  of  which  syphilis  and  struma 
are  the  chief,  but  frequentl}^  also  from  no  definite  exciting  cause,  as  far 
as  our  investigation  enables  us  to  determine.  The  mucous  membrane 
becomes  inflamed,  possibly  more  or  less  ulcerated,  and  covered  with  crusts 
of  inspissated  discharge.  There  is  also  a  horrible  odor  not  easy  to  de- 
scribe, though  when  once  experienced  impossible  to  forget ;  the  discharge 
seems  to  disappear  down  the  pharynx  ;  at  least  none  is  perceptible  ex- 
ternally in  most  cases.  True  oza^na  often  lasts  for  years  without  any 
further  changes,  but  the  syphilitic  variety  will  spread  to  the  bones  and 
cartilages,  external  openings  will  form,  and  the  nose  will  be  destroyed. 

Thevictims  of  oztBna  are  usually  young  children,  and  their  infirmity 
secludes  them  from  the  society  of  their  playmates  and  interferes  with 
their  education,  as  well  as  rendering  them  miserable  by  the  persistent 
odor. 

The  first  thing  in  the  management  of  this  disgusting  complaint  is  to 
ascertain  its  cause.  I  have  already  dwelt  on  the  importance  of  making 
sure  of  the  absence  of  foreign  substances  or  nasal  concretions.  I  have 
brought  many  a  case  of  so-called  ozsena  to  an  end  by  removing  a  foreign 
body.  The  cure  of  the  syphilitic  ozjiena  must  be  undertaken  by  anti- 
sypiiilitic  measures,  and  b}'  the  application  of  mercurial  vapors  and 
lotions.  It  is  a  phenomenon  generally  of  a  late  stage  of  syphilis  or  of 
the  congenital  disease.  When  it  has  spread  to  the  bones  abscesses  must 
be  opened  and  the  general  health  attended  to  ;  but  the  shape  of  the 
features  will  hardly  be  preserved. 

TJivdichum^s  Naml  Douche. — In  strumous  oztena  the  use  of  cod-liver 
oil  with  arsenic  or  of  iodide  of  iron  is  generally  indicated,  and  in  this 
and  the  idiopathic  form  the  use  of  the  nasal  douche,  as  explained  by  Dr. 
Thudichum,^  is  of  the  greatest  importance.  This  method  of  applying 
solutions  to  the  nose  rests  on  a  fact  first  noticed  by  E.  II.  Weber  of 
Leipzig,  that  when  the  patient  inspires  deeply,  and  only  through  the 
mouth,  the  soft  palate  is  so  drawn  against  the  posterior  wall  of  the 
pharynx  that  the  nose  and  respiratory  pharynx  may  be  filled  with  fluid 
which  will  run  from  the  nostril  into  which  it  is  injected  over  the  pharynx 
and  out  of  the  other  nostril  without  running  down  into  the  mouth  or 
oesophagus.  The  apparatus  necessary  is  a  receiver  for  the  fluid,  which 
must  be  raised  over  the  patient's  head  to  a  sufficient  height  to  insure 
the  requisite  force  of  stream,  so  as  to  loosen  the  crusts  from  the  mem- 
brane, an  india-rubber  tul)e  proceeding  out  of  the  receptacle,  and  a  nozzle 
which  will  fill  the  nostril  completely,  so  as  to  prevent  any  reflux.  The 
patient  is  then  to  sit  witii  his  mouth  open,  breathing  exclusively  through 
the  mouth,  and  abstaining  from  any  movement  of  deglutition."'  A  little 
practice  soon  enables  him  to  jxass  the  fluid  through  the  nose  without 
letting  any  run  into  his  mouth,  and  till  he  has  acquired  the  knack  it  is 
well  only  to  use  lukewarm  salt  and  water.    The  constant  stream  detaches 

>  Lancet,  Nov,  26,  Dec.  3,  1804. 

2  Special  apparatus  are  i^old  lor  the  purpo.'^c,  l)ut  wlicn  these  are  not  at  hand  a  per- 
fectly .serviceable  one  can  be  extemjK)rizc(l  witli  a  common  ewer  and  a  siphon  pro- 
vided with  a  tube.  The  addition  ot'  a  stopcock  near  the  nozzle  is  convenient ;  but 
if  there  is  none  the  patient  can  easily  stop  the  stream  when  necessary  by  pressure  with 
his  thumb  and  finger. 


POLYPUS.  599 

the  crusts,  and  it  can  easily  be  increased  or  diminished  in  force  by  raising 
or  lowering  the  receptacle,  or  by  suddenly  stopping  and  opening  the  tube. 
The  detachment  of  the  crusts  is  also  much  hicilitated  by  reversing  the 
stream,  the  nozzle  being  changed  from  one  nostril  to  the  other.  The 
lotions  recommended  liy  Dr.  Thudichum  are — for  mere  ablution  warm 
salt  and  water,  which  iritates  the  nose  less  than  plain  water ;  for  deodor- 
izing purposes  Condy's  solution  diluted  or  carbolic  acid  lotion,  1  to  40; 
solutions  of  the  alkaline  phosphates  (phosphate  of  soda,  or  phosphate  of 
ammonia  and  soda)  for  dissolving  the  crusts  and  promoting  their  removal ; 
as  astringents,  alum,  sulphate  of  copper  or  of  zinc;  and  as  alteratives 
and  specifics  nitrate  of  silver,  bichloride  of  mercury,  or  a  solution  of 
chloride  of  calcium,  with  suboxide  or  oxide  of  mercury  suspended  in  it, 
made  by  mixing  the  ordinary  black  or  yellow  wash  with  common  salt. 
In  obstinate  cases  these  applications  must  be  often  varied. 

Blood  Tumors. — Deviations  of  the  septum  have  been  spoken  of  above. 
The  septum  is  also  liable  to  the  formation  of  blood  tumors  from  injury, 
which  affect  both  sides  of  the  septum,  and  sometimes  proceed  to  such  an 
extent  as  to  obstruct  respiration  and  render  an  incision  necessary.  But 
this  is  rare.  The  affection  is,  it  seems,  usually  accompanied  by  fracture 
of  the  septum.  In  most  cases  it  will  subside  under  the  local  application 
of  cold. 

Abticess  of  the  septum  is  sometimes  the  result  of  injury,  but  it  occurs 
also  spontaneously,  and  sometimes  in  a  chronic  form,  going  on  to  per- 
foration, which  may  produce  a  disagreeable  whistling  in  speaking  or  deep 
breathing.  The  diagnosis  of  the  complaint  is  sometimes  a  little  ditHcult 
at  first,  the  swelling  being  confounded  either  with  polypus  or  chronic 
thickening  of  the  Schneiderian  membrane;  but  an  attentive  examination 
will  show  the  difference  in  the  seat  of  the  swelling,  and  an  exploratory 
puncture  will  clear  up  the  case.  Free  and  early  incision  is  always  desira- 
ble, and  Mr.  Durham  sa^s  that  benefit  may  be  derived  by  injection  of  a 
weak  solution  of  nitrate  of  silver  or  of  some  detergent  lotion  into  the 
nostril.  If  the  septum  is  perforated  by  a  small  opening  and  the  unpleas- 
ant whistling  sound  distresses  the  patient  his  conditiom  may  sometimes 
be  relieved  by  making  the  opening  larger. 

Enchoiidroma. — The  septum  is  not  unfrequently  the  seat  of  cartilag- 
inous tumors,  which  sometimes  also  spread  to  the  other  cartilages. 
Those  I  have  seen  have  been  of  small  size,  and  have  grown  into  both 
nostrils,  and  it  has  been  sufficient  to  remove  such  portions  as  could  be 
got  at  from  the  nostril  without  any  external  incision.  But  larger  tumors 
might  require  the  free  division  of  the  nostril  in  order  to  allow  of  their 
complete  extirpation. 

Nasal  polypus  is  a  very  frequent,  and  in  some  of  its  forms  (though 
these  are  fortunately  the  less  common  ones)  a  very  formidable  disease. 
The  division  generally  made  of  nasal  polypi,  and  that  which  best  corre- 
sponds to  what  is  seen  in  practice,  is  into  three  chief  forms, — gelatinous 
or  mucous,  fibrous,  and  malignant. 

The  first  are  by  far  the  most  common.  They  originate  generally  from 
the  mucous  membrane  which  covers  one  or  other  of  the  turbinated  bones, 
more  commonly,  as  I  believe,  from  the  middle,  though  opinions  differ  as 
to  what  is  commonly  their  precise  attachment;  but  all  authorities  agree 
that  they  rarely  if  ever  spring  from  the  septum  or  from  the  roof  of  the 
nose.  They  are  often  multiple.  Their  structure  consists  of  a  fine  fibrous 
tissue  covered  externally  by  the  mucous  membrane  with  its  ciliated  epi- 
thelium, whilst  at  other  times  adenoid   structure  is  found  in   them  as 


600 


DISEASES    OF    THE    NOSE. 


The  common  polypus  of  the  nose. 
After  Listen. 


tbougli  from  a  hypertrophy  of  the  glands  of  the  part.     The  microscopic 

structure  is  generally  of  the  myxomatous 
character  (see  p.  366).  Other  polypi  ap- 
proach more  to  the  character  of  fibrous  or 
fibro-cellular  tumors,  and  in  some  cysts  are 
found  developed.  They  produce  well-de- 
fined symptoms  by  which  the  nature  of  the 
disease  may  often  be  suspected  before  phys- 
ical examination  converts  the  suspicion  into 
certainty.  These  symptoms  are  a  mixture 
of  catarrh  and  obstruction.  Tlie  patient 
seems  to  be  constantly  catching  cold  and 
sneezing,  but  besides  this  he  notices  that 
his  breathing  is  obstructed,  he  cannot  sleep 
but  with  his  mouth  open,  his  voice  is  aff'ected 
and  acquires  a  nasal  tone,  he  observes  that 
he  cannot  breathe,  or  can  hardl}'  breathe 
thi'ough  the  nostril ;  but  the  nose  is  scarcely 
ever  deformed.  The  obstruction  as  well  as  the  catarrh  are  noticed  to  in- 
crease in  damp  weather,  when  the  tumor  increases  in  bulk. 

The  proper  course  to  pursue  is  to  remove  the  polypus,  but  it  frequently 
presents  again,  either  in  consequence  of  renewed  growth  from  the  base 
or  from  there  having  been  really  several  polypi,  of  which  one  or  more 
have  been  left  behind  unperceived.  The  best  security  against  this  recur- 
rence is  when  the  portion  of  bone  from  the  covering  of  which  the  polypi 
grow  has  been  designedly  or  accidentally  removed  along  with  them. 

Polypi  ma}'  be  removed  either  with  the  snare  or  forceps.  The  snare 
is  a  loop  of  wire,  the  ends  of  which  are  passed  into  the  tube  of  a  double 

canula,  either  before  or 
after  the  loop  has  been 
conveyed  around  the  poly- 
pus and  pushed  up  as  near 
its  base  as  possible.  The 
canula  has  a  handle  at- 
tached to  it,  by  means  of 
which  the  wire  is  drawn 
through  the  base  of  the 
polypus  gradually  or  rap- 
idly, as  the  surgeon  thinks 
best.  Some  operators 
even  use  the  galvanic 
ecraseur  for  this  purpose, 
but,  as  far  as  I  can  see, 
without  any  sufficient 
cause.  The  main  point 
is  to  get  up  to  the  root 
of  the  polypus,  and  I 
confess  that  it  appears  to  rae  that  this  end  is  better  attained  by  means 
of  the  common  force])S.  If  the  nostril  is  wide  the  tumor  may  be  gently 
diawn  down  with  one  pair  of  forceps,  while  another  is  pushed  firmly  up 
to  its  attachment  and  the  mass  twisted  off.  Then,  after  bleeding  has 
somewhat  ceased,  or  next  da}',  the  nostril  is  to  be  carefully  examined  to 
see  wiiether  there  are  any  others.  The  chief  error  made  in  tiie  diagnosis 
of  polypus  is  to  confound  the  chronic  thickening  of  the  mucous  mem- 
brane, which   often   occurs   in   strumous  young  persons,  with   polypus. 


Fig.  270. 


Hilton's  na.sal  polypus  snare,  a,  ring  for  the  surgeon's  thumb ; 
h  h,  movable  crosspiice,  pushed  backwards  and  forwards  by  the 
fore  and  middle  lingers,  .so  as  to  advance  and  retire  tlie  loop  ff, 
wliieli  in  practice  is  far  larger  than  is  here  shown.  The  stem  c 
is  hollow  for  the  ends  of  the  wire  to  run  in.  They  are  wound 
round  the  crosspiece.  e  is  a  hinge-joint,  by  means  of  which  the 
stalk  (I  which  is  in  the  nose  can  be  placed  at  the  requisite  angle 
■with  the  stem  c.  Its  bulbous  end,/,  is  perforated  by  two  holes 
to  convey  the  wire.  The  end  of  tlie  wire  is  pushed  round  the 
polypus  either  with  the  fingers  or  a  kind  of  fork. 


FIBROUS    POLYPI.  601 

When  the  end  of  the  inferior  turbinated  bone  is  covered  with  this  thick 
pulp.y  mass  it  looks  at  first  sight  exactly  like  a  polypus ;  but  careful  ex- 
amination can  hardly  fail  to  detect  the  nature  of  the  case,  if  the  surgeon 
is  alive  to  the  possibility  of  the  error,  since  there  is  in  this  case  no  stalked 
pendulous  soft  tumor,  as  in  the  other,  and  the  neighboring  mucous  mem- 
brane will  be  found  similarly',  though  perlmps  less  distinctly,  affected. 
The  success  of  astringents  as  applied  for  the  cure  of  so-called  polypus 
is,  I  suspect,  more  real  in  cases  of  this  sort  than  in  true  polypoid  growths. 
At  the  same  time  Mr.  Bryant  has  spoken  highly^  of  the  success  some- 
times obtained  by  the  insufflation  of  the  powder  of  tannin  (about  ten 
grains  blown  into  the  nose  with  a  tube)  in  some  cases  even  of  large 
polypi,  though  he  owns  that  it  is  a  very  uncertain  remedy. 

Cases  have  been  known  in  which  the  deviation  of  the  septum  has  been 
mistaken  for  polypus,  but  this  is  mere  carelessness.  Tumors  of  the  sep- 
tum are  distinguished  from  ordinary  polypus  by  their  position. 

Fibrous  polypi  are  far  more  formidable  tumors  than  the  gelatinous. 
They  spring  generally  from  the  roof  of  the  nasal  fossfe  or  from  the  base 
of  the  skull  behind  the  posterior  nares,-'  and  they  grow  into  the  nasal 
cavity,  displacing  the  bones  of  the  nose  (causing  the  peculiar  appearance 
called  "  frog's  face  ")  or  into  the  nose  and  pharynx  at  the  same  time 
(naso-pharyngeal  polypus).  These  polypi  are  usually  accompanied  by 
considerable  bleeding,  and  I  have  known  this  bleeding  allowed  to  go  on 
so  long  (in  consequence  of  its  cause  having  been  overlooked)  that  it 
threatened  at  last  to  prove  fatal.  Yet  the  tumors  are  not  themselves  so 
vascular  as  to  occasion  any  formidable  luvmorrhage  on  removal,  though 
they  get  congested  and  their  depending  surface  bleeds  freely  on  being- 
touched.  Their  continued  growth  causes  various  symi)toms  due  to  pres- 
sure on  the  neighboring  organs  (deafness,  epiphora,  etc.),  and  they  may 
even  absorb  the  base  of  the  skull  and  cause  pressure  on  the  brain.  The 
extirpation,  therefore,  of  the  tumor  is  urgently  indicated,  and  there  are 
many  ways  in  which  this  may  be  done.  In  some  cases  it  may  be  possible 
to  reach  the  base  of  the  tumor  either  from  the  nostril  (if  this  is  much 
dilated)  or  under  chloroform  from  the  pharynx,  the  mouth  being  kept 
wide  open  by  means  of  Smith's  gag,  and  thus  a  wire  can  be  convej^ed 
round  the  base  of  the  tumor,  which  can  be  connected  either  with  the  gal- 
vanic or  common  ecraseur,  or  with  the  ordinary  snare,  and  then  the  mass 
may  be  removed.  In  some  cases  it  is  perfectly  easy  to  twist  ofl'  the  tumor 
from  the  mouth  with  a  pair  of  curved  forceps.  But  such  cases  are  the 
minority'.  In  most  instances  of  fibrous  polypus  a  way  must  be  made  by 
surgical  operation  through  the  tissues  of  the  face  to  the  base  of  the  tumor, 
and  this  by  one  of  three  operations:  (1),  from  below,  through  the  hard 
and  soil  palate  ;  (2),  from  above,  through  the  nose  ;  (3),  from  the  front, 
through  the  upper  jaw.  The  first  method  is  known  as  Nelaton's.  It  is 
little  practiced  in  this  country  and  seems  much  inferior  to  the  third  in 
cases  where  the  nostrils  are  not  much  dilated,  and  to  the  second  in  those 
where  they  are.  The  soft  and  hard  palates  having  been  divided  with  the 
knife,  and  as  much  of  the  palate  processes  of  bone  as  may  be  necessary 
having  been  removed  with  the  bone  forceps,  the  tumor  is  to  be  exposed 
and  removed,  and  the  palate  then  sewn  up. 

1  Lancet,  Feb.  1867. 

2  1  ought  to  mention  that  these  tumors,  besides  their  primary  attachment,  are  some- 
times implanted,  as  it  were,  into  other  parts  of  the  nasal  mucous  membrane,  where 
probably  ulceration  has  occurred  both  on  the  surface  of  the  polypus  and  of  the  Schnei- 
derian  membrane,  and  the  ulcerated  surfaces  have  coalesced. 


602 


DISEASES    OP    THE    NOSE. 


2.  When  the  nose  is  much  dilated  ample  room  may  be  obtained  l\y  an 
incision  on  one  side  of  the  middle  line  from  the  roof  of  the  nose  to  the 
nostril.  The  nasal  bone  is  to  be  divided  in  the  course  of  the  incision, 
the  soft  parts  turned  aside,  and  the  tumor  exposed.  Then  the  wonnd  is 
accnratoly  adjusted  by  sutures,  and  unless  any  accidental  complication 
interferes  with  union  only  a  trifling  mark  will  be  left. 

3.  An  incision  is  to  be  made  along  the  lower  margin  of  the  orbit  along 
the  side  of  the  nose,  curving  round  the  nostril  to  the  middle  line  of  the 
lip.  and  so  to  its  free  edge,  and  the  cheek  turned  outwards.  Then  the 
hard  i)alate  is  to  l)e  sawn  through,  and  next  the  zygoma,  and  then  the 
saw  or  bone  nippers  must  be  carried  through  the  nasal  process  below  the 
orbit,  and  in  this  way  the  whole  of  the  alveolar  portion  and  body  of  the 
jaw  are  removed,  when  the  operator  will  have  free  access  to  the  base  of 
the  skull.  After  the  tumor  has  been  taken  awa}'  the  bone  from  which  it 
grows  is  to  be  freel}'  rasped,  and  the  actual  or  potential  cauter}^  applied 
to  the  place  of  implantation. 

Again,  the  whole  upper  jaw  may  be  removed,  or  Langenbeck's  method 
adopted,  by  which  tlie  soft  parts  are  incised  down  to  the  bone  externally 
and  internally,  as  in  the  old  method  of  removing  the  jaw  ;  then  the 
attachments  of  the  bone  are  sawn  through  in  the  same  lines,  the  palatal 

Fig.  271. 


A  fibrous  nasn-pharyngeal  polypus,  whicli  had  long  caused  epistaxis,  so  that  the  patient  .was  ex- 
hausted by  daily  loss  of  blood.  It  was  removed  from  the  base  of  the  skull  by  partial  resection  of 
the  upper  jaw.  The  portion  of  lione  removed  is  figured  with  the  tumor,  and  is  seen  to  comprise 
the  whole  of  the  u])per  jaw,  with  the  exception  of  its  orbital  jjortion.  The  tumor  consists  of  two 
parts— rt,  that  which  projoelcd  into  the  nostril,  and,  c,  that  which  hung  down  into  the  pharynx. 
Between  these  is  a  constricted  pari,  6,  where  the  mass  was  implanted  into  the  base  of  the  skull 
just  behind  the  posterior  nares.  On  microscopical  examination  it  consisted  almost  entirely  of  fibrous 
tissue  with  some  cellular  elements.  The  patient  remained  well  for  some  years,  but  gradually  the 
bleeding  recurred,  and  tlie  tumor  was  found  to  be  growing  again.  It  was  again  removed  eight  years 
after  the  original  operation,  and  was  found  to  have  the  same  structure.  The  patient  again  rapidly 
recovered  his  health. — See  Clin.  Soc.  Trans.,  vol.  vii. 


attachments  divided,  and  tiie  jaw  with  its  coverings  turned  up  over  the 
eye,  and  after  the  removal  of  tiie  tumor  brought  down  again  and  fixed 
in  its  place  by  deep  sutures  ;  the  soft  palate  is  left  undivided. 


DISEASES    OF    THE    TONGUE.  603 

Malignant  Polypus. — Sometimes  cancer  grows  in  the  form  of  a  poly- 
pus from  tlie  mucous  membrane  of  tlie  nose.^  Sucli  tumors  are  usually 
of  very  rapid  growth  ;  tliey  speedily  dilate  the  side  of  the  nose,  and 
cause  much  haemorrhage.  They  rapidly  fuugate  out  of  the  nostril,  and 
are  very  apt  to  infiltrate  the  skin  of  the  face.  The  patient  is  usually 
somewhat  advanced  in  years,  and  the  general  health  is  much  impaired. 
The  diagnosis  is  not  difficult,  from  the  rapid  growtli  of  the  tumor,  the 
change  of  shape  in  the  features,  and  the  great  cachexia  which  is  com- 
monly found. 

The  removal  of  the  tumor  is  urgently  indicated,  for  which  purpose 
any  of  the  plans  previously  proposed  in  the  case  of  naso-pharyngeal 
polypus  may  be  selected,  according  to  the  presumed  attachments  of  the 
tumor,  which,  however,  it  is  by  no  means  easy  to  ascertain.  Careful 
examination  should  be  made  both  anteriorly  and  from  the  posterior 
nares  with  the  finger,  and  if  possible  by  rhinoscopy,  before  such  an  oper- 
ation is  attempted  ;  and  the  surgeon  ought  to  have  the  actual  cautery 
and  all  other  necessary  haemostatics  ready,  in  case  he  finds  the  tumor 
implanted  by  a  broad  base  of  vascular  tissue.  After  all,  a  speedy  recur- 
rence is  to  be  feared. 


CHAPTEE   XXXI. 

SUEGICAL  DI8EASES  OF  THE  DIGESTIVE   TRACT. 

DISEASES  OF   THE  TONGUE. 

Tongue-tie  is  a  tolerably  common  deformity,  which,  in  its  higher  de- 
gree, will  prevent  the  cliild  from  sucking,  and  may  hereafter  interfere  to 
some  extent  with  articulation  ;  though  this  is  more  spoken  of  than  really 
proved.  However,  if  the  deformity  be  at  all  pronounced,  it  is  well  to 
perform  the  little  operation  which  will  release  the  tongue  and  restore  its 
motion.  If  performed  carefully  this  slight  incision  is  free  from  danger 
of  any  kind.  All  that  is  necessary  is  to  avoid  dividing  the  ranine  artery 
as  it  passes  along  the  fri^num  linguae.  The  tongue  is  pushed  up  and  the 
artery  siiielded  from  harm  either  by  the  surgeon's  fingers  or  by  a  slit  in 
the  flat  end  of  the  director,  which  used  always  to  be  made  in  this  shape 
for  the  purpose.  The  incision  or  little  nick  need  only  extend  through 
the  semi-transparent  edge  of  the  constricting  tissue,  and  then  the  tongue 
can  be  forcibly  pressed  upwards  to  the  roof  of  the  mouth,  by  which  ma- 
noeuvre the  rest  of  it  will  be  torn.  I  have  performed  this  little  operation 
a  very  great  number  of  times — chiefly  for  the  satisfaction  of  the  parent  — 

'  I  hMd  lately  under  treatment  a  case  in  which  the  tumor  was  of  the  mehinotic 
variety  (spindlu-celled  sarcoma,  with  black  pigment  in  the  cells).  It  grew  from  the 
outer  side  of  the  nasal  cavity,  and  was  easily  removed  by  laying  open  the  nostril. 
The  patient,  a  man  of  advanced  age,  recovered  from  the  operation,  but  died  from 
some  aftection  of  old  age  not  long  afterwards.  Similar  melanotic  deposits  were 
found  on  the  lining  membrane  of  the  antrum. 


604  DISEASES    OF    THE    TONGUE. 

thoiigb  in  onl}'  a  small  proportion  of  thera  could  I  persuade  myself  that 
it  was  really  indispensable.  I  have,  however,  seen  cases  in  which  the 
child  undoubtedly  could  not  take  the  breast  till  the  tongue  was  released. 

Ulceration. — The  forms  of  ulceration  to  which  the  tongue  is  liable  are 
the  irritable,  the  dyspeptic,  the  syphilitic,  and  the  cancerous.  The  fol- 
lowing are  the  rules  for  their  diagnosis  and  treatment,  abbreviated  from 
one  of  the  excellent  clinical  lectures  of  Mr.  Cresar  Hawkins:'  1.  Irrita- 
ble ulcers  are  excited  by  the  irritation  of  rough  teeth  ;  they  also  affect 
the  lips;  they  are  very  painful,  and  afford  considerable  impediment  to 
eating;  are  apt  to  become  phagedenic,  and  are  accompanied  often  by  a 
gooddeal  of  indigestion.  The  haggard  aspect  of  the  patient  produced  by 
pain  and  loss  of  food  may  cause  them  to  be  mistaken  for  cancer;  but 
they  are  generally  multiple,  while  cancer  is  single,  and  they  lack  any 
evidence  of  solid  deposit  around  the  ulcers. 

The  treatment  consists  in  extracting  or  filing  down  the  offending  teeth, 
correcting  the  state  of  the  digestive  organs  (by  a  mei'curial  pill,  followed 
by  a  brisk  purge,  alkaline  tonics  and  laudanum,  etc.),  and  attending  to 
the  local  condition  of  the  ulcers  by  cleaning  their  surface  with  a  poultice, 
and  when  clean  touching  them  with  nitrate  of  silver,  either  solid  or  in 
solution,  which  often  relieves  the  pain  considerably. 

2.  Closely  allied  to  these,  but  still  more  nearly  resembling  cancer,  is 
the  dyiipeptic  ulcer  of  the  tongue,  which  arises  without  any  local  irrita- 
tion, often  as  the  result  of  psoriasis.  This  ulcer  is  usually  situated  at 
the  middle  of  the  tongue,  which  is  an  unusual  situation  for  cancer ;  it  is 
often  accompanied  by  similar  cracks  and  fissures  in  other  parts,  which 
have  not  gone  so  far  as  to  form  a  definite  ulcer;  there  is  no  hard  deposit 
beneath  the  base  of  the  ulcer,  and  there  are  signs  of  disturbance  of  the 
digestive  organs.  The  diagnosis  from  syphilitic  ulcer  must  be  made 
chiefly  by  the  absence  of  the  history  and  signs  of  syphilis. 

The  treatment  is  very  much  the  same  as  in  the  irritable  form,  and  of 
the  tonics  which  become  necessary  in  the  treatment  after  the  unhealthy 
state  of  the  mucous  membrane  is  corrected  Mr.  Hawkins  especially 
praises  arsenic. 

3.  The  si/jihilitic  ulcer  when  in  its  worst  state  forms  a  large  excavation, 
with  foul  raised  edges  and  sloughy  surface  on  the  back  or  sides  of  the 
tongue,  which  greatly  resembles  cancer.  The  diagnosis,  indeed,  cannot 
in  all  cases  be  confidently  made  without  testing  the  efficacy  of  treatment, 
in  persons  who  have  had  primary  and  secondary  syphilis.  At  the  same 
time  there  is  in  syphilis  an  absence  of  the  characteristic  induration  of  the 
cancerous  ulcer,  and  a  presence  in  most  cases  of  other  syphilitic  symp- 
toms, which  enables  the  surgeon  to  come  to  a  correct  opinion.  The 
glands  may  be  enlarged  in  either,  but  are  more  frequently  so  in  the  can- 
cerous ulcer,  since  the  syphilitic  is  usually  a  tertiary  symptom,  and  in 
S}  philitic  ulcers  if  any  glands  are  enlarged  in  the  neck  they  are  not 
usually  the  sui)maxillar3',  which  are  in  direct  connection  with  the  ulcer, 
but  tlie  posterior  chain  of  cervical  glands  beneath  the  trapezius.  In 
doubtful  cases  the  effect  of  a  mercurial  course  will  in  all  probability  settle 
the  matter.  Mercury,  however,  siiould  not  in  these  late  cases  of  syphilis 
be  given  eitiier  rapidly  or  in  large  (luautities.  The  calomel  fumigation 
is,  I  doubt  not,  by  far  the  best  form,  and  is  very  easily  managed  by 
adapting  a  mouthpiece  to  the  vaporizing  machine  and  inhaling  the  vapor. 
Five  grains  of  calomel  every  night  is  the  quantity  usually  prescribed,  or 

^  Contributions  to  riitli.  aiul  Surg.,  vol.  i,  p.  '214. 


OPERATIONS    ON    THE    TONGUE. 


605 


the  ulcer  may  be  dusted  with  gray  powder  (gr.  v)  daily.  In  some  cases 
sarsaparilla  and  iodide  of  potassium  may  be  given  when  the  surgeon 
dares  not  risk  the  debilitating  effect  of  mercury,  which,  however,  is  very 
trifling  in  the  method  of  fumigation. 

4.  The  cancerous  ulcer  appears  on  the  side  of  the  tongue,  generally  at 
first  as  a  small  common  ulcer,  which  is  attributed  to  the  irritation  of  a 
bad  tooth ;  but  the  removal  of  this  does  not  stop  the  disease  (though  I 
think  there  can  be  no  doubt  that  if  the  irritation  of  a  bad  tooth  had  not 
originated  the  cancer  it  is  at  any  rate  powerful  in  determining  its  out- 
break at  that  precise  spot),  and  soon  a  deposit  of  hard  tissue  is  apparent 
at  the  base  of  the  ulcer,  which  spreads  an  indefinite  distance  into  the  sub- 
stance of  the  tongue,  with  much  pain,  salivation,  difficulty  in  articulation, 
loss  of  appetite  from  the  foulness  of  the  discharge,  and  consequent  ca- 
chexia. The  glands  below  the  jaw  are  apt  to  be  affected  early,  and  the 
sore  will  spread  to  the  floor  of  the  mouth  or  arches  of  the  palate. 

The  diagnosis  will  follow  from  what  has  been  said  above  on  the  other 
forms  of  ulcer.  Though  it  may  be  often  difficult  or  impossible  at  first,  it 
becomes  only  too  easy  as  the  disease  progresses. 

Trfa(me7it.. — In  doubtful  cases  the  treatment  consists  in  removing  all 
irritating  teeth  (which,  indeed,  ought  to  be  done  in  all  ulcerations, 
whether  cancerous  or  not),  and  treating  the  disease  as  either  dyspeptic  or 
s^'philitic,  as  the  case  ma_Y  be.  If  the  cancerous  nature  of  the  affection 
admits  of  no  doubt,  the  only  question  is  whether  a  surgical  operation  is 
to  be  recommended,  and  if  so,  of  what  nature.  If  the  glands  or  the  floor 
of  the  moutli  or  the  palate  be  implicated,  surgical  operations  should  be 
declined.^    But  if  the  whole  disease  can  be  clearly  removed  the  patient  will 

Fig.  272. 


Mr.  Henry  Lee's  clamp.    The  curved  shape  of  the  blades  causes  this  clamp  to  make  uniform  pressure 
on  all  the  tissue  which  it  embraces. 

no  doubt  derive  much  temporary  benefit  from  the  operation,  though  the 
disease  will  in  all  probability  return  in  no  long  time. 

When  on\y  a  small  portion  of  the  tongue  requires  removal  this  is  best 
effected  by  means  of  the  knife  or  scissors.  A  clamp  with  curved  blades 
being  fixed  around  the  part  to  be  removed  so  as  to  control  the  vessels, 

1  Perhaps,  if  the  pain  and  distress  is  great,  and  the  affection  seems  merely  epithe- 
lial, a  surgeon  may  be  justified  in  risking  an  operation,  even  though  there  be  a  small 
hard  gland  under  the  jaw  ;  but  the  general  rule  is  as  above. 


606 


DISEASES    OF    THE    TONGUE. 


tlie  portion  affected  with  cancer  is  to  lie  completely  cut  awa3^  The  blood- 
less condition  of  the  parts  cut  through  enables  the  surgeon  to  judge  much 
more  certainl}'  whether  those  parts  are  healthy  or  not.  When  he  is  satis- 
fied that  all  is  as  it  should  be  the  arteries  are  to  be  tied  and  the  clamp 
cautiously  relaxed.  Some  surgeons  either  instead  of,  or  in  addition  to, 
the  use  of  the  ligature  to  the  large  vessels,  use  the  actual  cautery  to  the 
cut  surface  ;  but  tliis  is  oiijectionable  if  it  can  be  avoided,  on  account  of 
the  sloughing  and  fetor  which  ensues. 

Bemoval  of  Pai't  of  the,  Tongue. — When  larger  portions  of  the  tongue 
are  to  be  removed,  either  the  ordinary  ecraseur  or  the  galvanic  ecraseur^ 

Fig.  273. 


Ecraseur. 

are  preferable,  as  affording  more  security  against  secondary  haemorrhage, 
provided  the  chain  is  drawn  through  the  tissues  very  slowly.  Haemor- 
rhage during  or  after  the  use  of  the  ecraseur  depends  generally  on  hurry 
on  the  surgeon's  part. 

In  all  operations  on  the  tongue  the  surgeon  should  alwa3's  have  a  com- 
mand on  the  part  left  behind  by  means  of  a  stout  ligature  passed  through 
it,  tied  loosely,  and  held  by  an  assistant,  so  that  on  the  occurrence  of 
acute  htemorrhage  the  tongue  can  be  at  once  pulled  out  and  the  bleeding 
part  exposed ;  and  the  mouth  must,  of  course,  be  kept  open  b}^  a  gag,  the 
smaller  and  stronger  the  better.  Hutchinson's  gag,  here  figured,  is  rec- 
ommended by  Mr.  Heath,  and  is  a  very  convenient  one  as  taking  up  no 
room  in  the  mouth. 

Removal  of  the  Whole  Tongue. — When  the  whole  or  the  greater  part 
of  the  tongue  is  to  be  removed  it  becomes  necessary  by  some  preliminary 

operation  to  obtain  access  to  the  root  of  the 
organ,  and  this  is  done  in  one  of  three  ways: 
1.  A  small  incision  may  be  made  close  inside 
the  lower  jaw  from  the  mouth  to  the  skin, 
through  which  the  chain  of  the  Ecraseur  can 
be  passed ;  and  the  tongue  being  then  pulled 
forcibly  out  of  the  mouth,  the  chain  is  passed 
around  the  base  of  the  organ  as  near  the  epi- 
glottis as  practicable,  and  so  the  whole  organ 
is  removed  except  a  stump,  which  is  left  at- 
tached to  the  hyoid  bone.  2.  Sir  J.  Paget 
recommends  that,  in  order  to  render  it  easier 
to  drag  the  tongue  out,  all  the  muscles  which 
Hutchinson's  gag.  pass  from  the  jaw  to  the  hyoid  bone  should  be 


Fig.  274. 


'  Tlio  giilviinic  ecraseur  i.s  a  stout  wire  chain  attacliod  to  the  polos  of  a  galvanic 
hattery.  The  tissues  to  be  removed  are  taken  uji  ))y  means  of  curved  needles;  the 
wire  is  then  conv(!yed  around  th(im  beneath  the  needles,  drawn  tight,  and  connected 
with  the  battery,  when  it  turns  white  hot.  As  it  burns  its  way  into  the  ti.ssues  it  is 
slowly  wound  u[)  h)y  a  contrivance  insid<'  tiie  machine,  and  so  gradually  cuts  its  way 
out.    In  practice  it  is  well  to  have  the  battery  managed  by  an  electrical  mechanician. 


OPERATIONS    ON    THE    TONGUE.  607 

divided  on  botli  sides  as  near  tlie  jaw  as  possible  by  an  incision  inside  tlie 
month.  When  this  has  been  done  tlie  tongue  can  l)e  drawn  almost  entirely 
out  of  the  month  and  removed  either  with  the  knife  or  ecraseur.  3.  But  the 
method  which  oives  the  freest  access  to  the  root  of  the  tongue  is,  doubtless, 
the  division  of  the  symphysis  of  the  lower  jaw.  An  incision  is  made  in 
the  middle  line  through  the  whole  lower  lip  and  drawn  nearly  down  to  the 
hyoid  bone.  Then  the  jaw  is  sawn  through  and  the  lingual  muscles  cut 
away  from  it  close  to  the  bone  on  either  side.  The  halves  of  the  jaw 
being  held  asunder,  the  tongue  is  forcibly  pulled  forward  and  to  one  side 
by  means  of  a  vulsellum,  and  its  attachments  to  the  hyoid  bone  severed 
on  the  opposite  side,  in  doing  which  the  lingual  artery  is  cut  across,  and 
must  be  tied  at  once.  The  same  manoeuvre  is  repeated  on  the  opposite 
side,  in  doing  which  it  is  desirable  to  get  an  assistant  to  hold  the  parts 
around  the  hyoid  bone  with  a  pair  of  strong  claw  forceps,  in  order  to 
prevent  the  tissues  which  contain  the  severed  end  of  the  lingual  artery 
from  retracting  down  the  neck.  Then  the  second  lingual  artery  and  any 
other  bleeding  vessels  having  been  tied,  the  glosso-epiglottic  ligaments 
and  the  remaining  attachments  of  the  tongue  are  to  be  severed,  and  all 
bleeding  vessels  commanded.  Then  the  severed  halves  of  the  jawbone 
must  be  united  by  means  of  a  silver  wire  passed  through  them  with  a 
drill,  the  wound  of  the  lip  accurately  closed  with  the  harelip  suture,  and 
the  patient  kept  under  the  influence  of  morphia  for  some  time,  and  fed 
if  necessary  by  the  rectum.  The  operation  is  a  severe  and  a  very  dan- 
gerous one,  followed  by  great  distress  of  mind  and  body,  and  often  fatal 
by  its  ulterior  consequences,  even  apart  from  its  operative  risks,  which  are 
nevertheless  considerable.  There  can  be  no  doubt,  however,  that  it  has 
often  prolonged  life,  and  rendered  its  remaining  time  more  bearable  to 
the  patient,  and  therefore,  under  appropriate  circnmstances  and  at  the 
request  of  the  patient,  this  chance  of  relief  ought  not  to  be  refused  to 
him.  At  the  same  time  I  think  it  is  one  of  the  most  unpromising  of  all 
the  operations  of  surgery,  and  one  which  no  surgeon  undertakes  without 
repugnance. 

It  is  curious  that  even  after  the  removal  of  the  whole  tongue,  as  close 
as  possible  to  its  root,  the  patient  is  not  quite  deprived  of  the  power  of 
speech,  though  the  voice  is  reduced  to  a  hoarse  whisper. 

In  some  cases,  in  which  the  pain  is  great  or  in  which  the  growth  of  the 
cancer  is  rapid,  or  where  it  bleeds  profusely,  the  gustatory  nerve  has  been 
divided,  to  relieve  the  pain  ;  or  the  lingual  artery  has  been  tied,  to  check 
growth  or  to  stop  hiemorrhage.  The  division  of  the  nerve  i$  a  very  simple 
operation,  which  can  do  no  harm,  and  the  effect  of  which  ought  to  be  tried 
in  any  case  in  which  pain  is  a  prominent  feature,  or  the  patient  suffers 
much  from  profuse  salivation.  "  The  guide  to  the  nerve,"  says  Mr. 
Moore,'  "  is  the  last  molar  tooth.  A  line  drawn  inside  the  mouth  from 
the  crown  of  the  last  molar  tooth  to  the  angle  of  the  jaw  would  cross  it 
at  right  angles  about  half  an  inch  from  the  tooth.  An  incision,  there- 
fore, in  the  direction  of  such  a  line  three-quarters  of  an  inch  in  length, 
and  carried  through  the  mucous  membrane  to  the  inner  surface  of  the 
bone,  must  divide  the  nerve.''  The  nerve,  as  Mr.  Moore  mentions,  is 
shielded  by  the  alveolar  ridge,  so  that  it  is  necessary  to  take  care  that 
all  the  soft  parts  are  absolutely  severed  down  to  the  bone.  The  opera- 
tion can  be  easil^^  and  safely  performed  on  both  sides,  and  may  afford  a 
good  deal  of  relief  for  the  time. 

The  ligature  of  the  lingual  artery  is  a  much  more  difficult  operation, 

1  Mcd.-Chir.  Trans.,  vol.  xlv. 


608  DISEASES    OF    THE    TONGUE. 

and  one  liable  to  be  followed  by  various  grave  consequences.  It  will  be 
found  described  on  page  543.  I  have  only  had  occasion  to  perform  it 
once — the  only  time  I  ever  saw  it  tried — on  a  patient  rapidly  sinking 
under  ha^moi'rhage,  and  then  it  quite  failed  in  checking  the  bleeding. 

Syphilitic  Affections. — Syphilitic  ulceration  has  been  spoken  of  above 
in  connection  with  the  other  forms  of  ulceration  which  are  met  with  in 
the  tongue.  But  there  are  various  other  sj'philitic  affections  of  tliis 
organ. 

Mr.  Fairlie  Clark^  divides  the  syphilitic  affections  of  the  tongue  into 
four  classes.  1.  Mucous  tubercles  or  vegetations.  2.  Superficial  ulcera- 
tion. 3.  Gnmmatous  tumors  and  deep  ulcerations.  4.  Morbid  condi- 
tions of  the  mucous  membrane. 

1.  Mucous  Tubercle. — The  first,  the  raucous  tubercle,  is  an  early 
secondary  symptom  which  affects  both  tlie  papilhie  and  epithelium,  tiie 
tubercles  in  which  the  epithelium  is  chiefly  implicated  being  broad,  flat, 
and  whitisli ;  the  others  small  prominent,  and  florid.  Tliey  have  much 
resemblance  to  the  mucous  tubercles  so  often  seen  on  other  parts,  and 
are  distinguished  from  the  papillary  elevations  of  cancer  by  the  absence 
of  any  hardening  at  the  base. 

2.  Secondary  Ulcers. — The  superficial  ulceration  is  also  usually  a 
secondary  affection.  It  spreads  from  similar  ulcerations  on  the  sides 
of  the  mouth  and  cheeks,  forming  superficial  and  very  painful  fissures, 
which  in  their  healing  leave  milk-white  scars;  and  if  these  are  very 
numerous  and  the  epithelium  gets  overgrown  around  tliem  the  condition 
named  ichthyosis  is  present.  In  other  cases  the  superficial  cracks  spread 
out  in  large  circular  or  oval  sores. 

3.  Gummafa. — The  gummatous  tumors  which  form  in  the  tongue  are 
seen  either  at  the  edge,  or  more  frequently  close  to  the  septum  of  the 
tongue  ;  and  when  they  soften  they  leave  the  deep  tertiar}'  ulcer,  or  some- 
times deep  fissures  which  may  implicate  and  distort  the  whole  organ.  In 
other  cases  they  become  absorbed,  and  then  may  be  followed  by  some 
distortion  of  tlie  organ  from  loss  of  substance. 

4.  Syphilitic  Glossitis. — The  syphilitic  affections  of  the  mucous  mem- 
brane generally  resemble  psoriasis,  consisting  of  a  heaping  up  of  epithelium 
of  a  dead-white  color  over  a  limited  area;  in  other  cases  the  whole  of  the 
dorsum  may  l)e  attacked  witli  superficial  inflammation  (syphilitic  glossitis), 
but  tliis  is  often  the  result,  not  of  syphilis  only,  but  also  partly  of  the  abuse 
of  mercury,  and  according  to  Mr.  Clarke  iodide  of  potassium,  when  it  does 
not  agree  with  the  2)atient,  may  produce  a  similar  affection. 

It  is  rare  for  any  of  these  syphilitic  ulcerations  to  be  accompanied  by 
an}'  glandular  affection,  belonging  as  they  do  to  tiie  later  stages  of 
secondary  or  to  the  tertiary  period.  Cases  of  indurated  chancre  of  the 
tongue  witli  enlarged  glands  are  said  to  be  met  with,  but  I  have  not  seen 
any  such  case. 

The  treatment  of  these  affections  has  been  alread}'  suflficiently  indicated. 

Glossitis. — Acute  inflammatory  swelling  of  the  tongue  (acute  glossitis) 
is  l)y  no  means  a  common  affection.  It  occurs  from  wounds,  from  mer- 
curial or  iodine  poisoning,  and  from  unknown  causes.  Tlie  swelling  is 
sometimes  so  great  as  to  threaten  suflocation  from  backward  pressure  on 
the  larynx,  and  in  such  cases  the  tongue  should  be  freely  and  deeply'' 
scarified,  in  doing  which  it  is  useful  to  remember  Mr.  Holmes  Coote's 

'  DU.  of  llie  Tongue,  ch.  viii. 


DISEASES    OF    THE    PHARYNX.  609 

caution,  viz.,  that  tlie  swelling  is  sometimes  i-eallv  more  in  the  lower  than 
the  upper  portion  of  the  tongue,  and  that  the  lingual  arteries  have  there- 
by been  pushed  up  so  that  they  may  even  appear  on  the  dorsal  surface  of 
the  organ.  A  little  preliminar}^  examination  before  the  incisions  are 
made  will  point  out  where  they  can  be  placed  with  safety.  At  the  same 
time  astringent  gargles  (alum,  tannin,  or  iron)  and  warm  fomentations 
should  be  assiduously  used,  and  the  patient's  strength  supported  as  may 
be  necessary. 

Most  cases,  however,  which  we  see  are  not  so  severe  as  this,  and 
require  no  incisions.  In  other  respects  the)^  are  to  be  treated  in  the 
same  way. 

Abscess. — Inflammation  of  the  tongue  may  end  in  deepseated  abscess, 
an  affection  which  has  before  now  been  mistaken  for  cancer  and  the 
tongue  removed.  Abscess  forms  a  deepseated,  round,  elastic  tumor, 
situated  in  the  thickness  of  the  tongue.  The  shape  a-nd  feeling  of  the 
tumor,  the  history  of  the  case,  and  the  resemblance  to  those  chronic  ab- 
scesses with  which  the  surgeon  is  familiar  in  the  female  breast,  ought  at 
any  rate  to  awaken  suspicion,  when  an  exploratory  puncture  will  clear  up 
the  diagnosis,  and  a  small  incision  will  form  all  the  treatment  required. 

Macroglossia. — A  few  other  and  much  rarer  diseases  of  the  tongue  re- 
quire little  beyond  mention.  There  are:  1.  The  congenital  hypertrophy 
to  which  the  name  "  macroglossia  "  is  sometimes  applied,  in  which  the 
tongue  becomes  so  large  that  the  child  cannot  close  his  jaws  or  talk  in- 
telligibly, and  which  requires  the  removal  of  the  central  part  of  the 
tongue  by  amputation  and  the  formation  of  side-flaps  which  are  to  be 
brought  together  to  form  a  more  convenient  organ,  an  operation  usually 
attended  with  great  success.^ 

Congenital  Tumor. — Another  congenital  afiection  of  the  tongue  is  a 
fibroid  tumor  which  sometimes  grows  from  the  tongue,  and  which  may 
be  quiescent  at  first  and  then  increase  at  a  later  period  of  life  and  require 
removal.^ 

Nsevi  also  are  found,  but  very  rarelj',  on  the  tongue.  They  ma}^  be 
treated  by  electrolysis,  the  actual  cautery,  or  some  of  the  potential  cau- 
teries, or  even  by  excision,  or  the  ligature,  should  that  be  necessary, 
which,  however,  is  seldom  the  case,  since  these  ntevi  more  commonly 
prove  quite  innocuous. 

Ichthyosis  of  the  epidermis  on  the  dorsum  linguae  is  spoken  of  by  Mr. 
Fairlie  Clarke,"  and  a  model  of  this  affection  exists  in  the  Museum  of  the 
Royal  College  of  Surgeons. 

Finally,  there  are  sometimes  found  imbedded  in  the  substance  of  the 
tongue  fibrous  or  other  innocent  tumors,  which  may  in  some  cases  require 
removal. 

DISEASES    OF   THE    PHARYNX    AND    OESOPHAGUS. 

The  aff"ections  of  the  pharynx  need  not  detain  us  long.  Acute  inflam- 
mation is  constant  in  sore  throat  of  all  kinds,  in  inflammation  propagated 
from  the  spine,  and  in  erysipelatous  affections  spreading  inwards.  But 
in  all  these  cases  the  condition  of  the  pharynx  itself  is  of  minor  impor- 
tance. The  two  former  classes  of  cases  have  been  spoken  of  along  with 
the  affections  of  the  mouth  and  of  the  spine.     The  main  importance  of 

>  The  leading  cases  of  this  disease  will  be  found  reported  by  Dr.  Humphry,  Mr. 
Hodgson,  and  Mr.  Teale,  in  the  36th  vol   of  the  Med.-Chir.  Trans. 
2  See  Mason,  Path.  Soc.  Trans.,  vol.  xv,  p.  216. 
•''  Diseases  of  the  Tongue,  p.  97. 

39 


610  DISEASES    OF    THE    (ESOPHAGUS. 

the  erysipelatous  aftections,  besides  the  ordinary  dangers  of  erysipelas, 
consists  in  the  risk  of  spasm  of  the  glottis,  which  is  peculiarly  liable  to 
complicate  these  cases,  and  which  will  be  treated  of  in  the  chapter  on 
Diseases  of  the  Larynx. 

Tumor!<  sometimes  arise  in  the  pharynx,  as  in  the  remarkable  instance 
which  Mr.  Holt  has  recorded,^  in  a  man  eighty  years  of  age.  Here  a  large 
pendulous  fatt}^  tumor  springing  from  the  wall  of  the  pharynx  extended 
nine  inches  down  the  oesophagus.  It  had  been  growing  certainly  more 
than  twelve  years,  and  occasionally  caused  s^'mptoms  of  suffocation.  At 
last,  under  some  circumstances  not  fully  explained,  it  suddenly  obstructed 
the  upper  opening  of  the  larynx  and  at  once  caused  death.  In  cases  such 
as  this,  where  a  tumor  of  the  pharj'ux  is  pedunculated,  there  is  no  doubt 
that  it  should  be  removed.  The  patient  should  be  brought  fully  under 
antesthesia,  the  mouth  widely  opened  by  a  gag,  the  tumor  drawn  fairly 
into  reach  by  a  vulsellum  ;  then,  if  the  neck  is  at  all  broad,  or  if  there  is 
any  reason  to  apprehend  haemorrhage  from  its  division,  it  should  be  per- 
forated b}"  a  stout  double  ligature  and  firmly  tied.  Or  else  the  tumor 
should  be  simply  removed,  tlie  actual  or  potential  cautery  being  at  hand 
for  use  if  necessary',  and  the  surgeon  should  be  prepared  for  the  necessity 
of  laryngotomy. 

3Ia {formations  of  the  pharynx  and  oesophagus  are  not  common.  There 
are  cases  in  which  the  pharynx  is  congenitally  obstructed,  and  in  which 
it  opens  into  the  larynx ;  but  they  are  only  of  scientific  interest,  as  the 
infant  is  not  viable.  More  interesting  in  the  surgical  point  of  view  is  the 
pouched  condition  of  the  phar3'nx  or  oesophagus  '^  which  is  sometimes 
found,  probabl}'  either  as  a  congenital  defect  or  as  the  result  of  some 
atrophy  and  yielding  of  its  muscular  walls.  A  large  pouch  extends  some 
distance  down  the  tube,  and  the  continuation  of  the  oesophagus  appears 
as  an  opening  some  distance  above  the  bottom  of  the  pouch.  The  result 
is  that  the  food  collects  in  the  pouch,  and  is  often  rejected  afterwards, 
producing  a  suspicion  of  stricture.  On  passing  a  bougie  it  is  liable  to  be 
arrested  in  the  pouch  instead  of  finding  its  way  down  the  oesophagus. 
The  case  from  which  Mr.  Pollock's  drawing  is  taken  was  believed  during 
life  to  be  one  of  stricture,  nor  is  the  diagnosis,  easy ;  but  the  patient  will 
probably  be  able  sometimes  to  swallow,  the  surgeon  may  happen  some- 
times to  hit  the  natural  opening,  and  the  symptoms  will  probably  not  be 
so  urgent  as  in  stricture,  so  that  a  conjecture  as  to  the  nature  of  the  case 
may  perhaps  be  formed.  No  treatment  is  applicable — the  course  of  the 
disease  will  to  an  attefitive  surgeon  contraindicate  the  use  of  bougies, 
which,  indeed,  after  the  first  exploration  can  only  do  harm. 

Stricture  of  the  oesophagus  is  one  of  the  most  terrible  diseases  which 
afflict  humanity.  It  occurs  "  as  the  result  of  several  distinct  conditions  : 
folds  of  the  mucous  membrane;  cicatrices  after  injury;  pressure  occa- 
sioned b}'  neighboring  tumors  ;  thickening  and  contraction  of  its  walls; 
or  lastly,  and  most  frequently,  cancerous  affections  of  the  tube " 
(Pollock). 

Little  can  be  hoped  from  surgical  treatment  in  these  cases.  It  is,  there- 
fore, of  very  great  importance  to  distinguish  between  organic  stricture  or 
obstruction  from  tlie  causes  above  enumerated  and  the  somewhat  common 
affection  called  hysterical  strictui'e  of  the  oesophagus,  or  nervous  dyspha- 
gia, which  simulates  the  graver  malad}'. 

'  Path.  Soc.  Trans  ,  vol.  v,  p.  123. 

'  A  beautiful  illu-tration  of  this  pouchod  condition  will  be  found  in  Mr.  Pollock's 
essay  in  Syst.  of  Surg.,  2d.  ed.,  vol.  iv,  p.  487. 


NERVOUS    DYSPHAGIA.  611 

NervoKs  dj/spharpa  is  more  common  in  women  than  in  men  ;  it  often  is 
conjoined  with  symptoms  clearly  h^^sterical ;  the  patient,  in  spite  of 
alleged  long-continned  inability  to  swallow,  is  in  good  health  and  general 
condition  ;  the  dysphagia  is  not  constant ;  frequently  he  feels  less  diffi- 
culty in  taking  solids  than  fluids,  and  sometimes  the  jjatient  can  be  proved 
to  be  able  to  swallow  quite  well  when  no  one  is  looking.'  Such  cases, 
like  cases  of  nervous  disease  in  other  organs,  require  judicious  manage- 
ment more  than  medical  or  surgical  treatment. 

The  symptoms  produced  by  stricture  of  the  oesophagus  may  be  summed 
np  in  two  words, — dysphagia  and  emaciation.  The  patient  is  at  first  able 
to  take  small  quantities  of  solid  food  when  well  chewed  and  lubricated, 
then  he  is  gradually  conscious  of  increasing  difficulty,  and  sometimes  the 
oesophagus  rejects  the  food  which  it  cannot  drive  down  ;  then  he  is  re- 
stricted to  fluids,  and  soon  he  sinks  from  exhaustion,  if  not  cut  off  by 
some  of  the  local  consequences  of  ulceration  about  the  stricture. 

It  is  by  no  means  easy  to  distinguish  the  various  forms  of  stricture 
from  each  other.  Those  which  proceed  from  cicatrization  will  be  known 
by  their  history,  if  the  accident  which  caused  them  is  remembered,  but 
this  may  not  be  the  case.  The  malignant  will  differ  from  the  innocent 
stricture  by  occurring  generally  later  in  life,  by  the  implication  of  the 
glands  of  the  neck,  b}^  the  more  rapid  cachexia,  and  by  the  tendency  to 
implication  of  the  larj'nx  and  neighboring  organs.  Obstruction  from  a 
tumor  is  generally  caused  by  aneurism  of  the  aorta  (at  least  when  caused 
by  a  tumor  of  any  other  nature  the  cause  is  usually  obvious),  and  it  there- 
fore occurs  always  at  the  part  where  the  aorta  is  in  contact  with  the 
oesophagus,  so  that  the  difficulty  is  referred  to  the  upper  part  of  the  chest. 
In  such  cases  very  careful  examination  is  necessary  before  the  diagnosis 
is  made,  and  above  all  before  a  bougie  is  passed.  Cases  are  known  in 
which  the  instrument  has  perforated  the  aneurism  and  produced  instan- 
taneous death.  Careful  auscultation  and  percussion  of  the  chest,  and  the 
examination  of  the  pulse  in  both  wrists  by  the  sphygmograph,  if  availa- 
ble, are  indispensable ;  and  it  should  be  ascertained  whether  any  of  the 
other  symptoms  of  aneurism  are  present — the  ringing  cough,  the  pain  in 
the  back,  the  so-called  rheumatic  pains  about  the  neck,  etc. 

The  innocent  forms  of  stricture  are  fatal  only  by  starvation;  but 
malignant  disease  very  commonly  produces  death  by  spreading  into  the 
larynx^  or  into  one  of  the  great  vessels. 

It  is  justifiable  and  indeed  necessary  in  the  first  instance  to  pass  a 
bougie,  except  in  advanced  stages  of  cancer,  in  winch  case  no  mechanical 
interference  is  justifiable,  since  the  bougie  has  often  passed  through  the 
softened  tissue  of  the  cancer  into  the  pleura,  pericardium,  or  great  vessels. 
When  the  seat  of  the  obstruction  has  been  ascertained  the  next  question 
is,  whether  the  stricture  can  be  treated.  If  it  is  clearly  cicatricial,  the  cica- 
trix might  be  divided  by  either  external  or  internal  incision,  certainly 
not  without  very  great  danger  ;  but,  under  circumstances  such  as  these, 
danger  would  justifiably  be  incurred.  The  objection  would  be  the  great 
difficulty  of  maintaining  the  opening.     I  do  not  know  that  the  attempt 

1  Sir  J.  Paget  in  his  interesting  little  essay  on  Stammering  with  other  Organs  than 
those  of  Speech  (Clin.  Lectures,  p.  82),  has  pointed  out  that  the  difficulty  of  swallow- 
ing may  in  many  of  these  cases  be  analogous  t<>  that  in  stammering,  viz.,  an  inability 
from  mental  causes  to  co-ordinate  the  various  muscular  actions  which  are  necessary 
to  deglutition.  If  the  patient  knows  he  is  being  watched,  or  directs  his  mind  too 
anxiously  to  what  he  has  to  do,  he  cannot  swallow,  whilst  if  he  is  easy  and  uncon- 
cerned he  feels  no  difficulty.     In  some  cases  the  patient  also  stammers  in  speaking. 

*  Or  it  may  be  itself  an  extension  from  the  larynx,  though  this  seems  less 
common. 


612 


DISEASES    OF    THE    INTESTINES. 


has  ever  been  made.  Billroth  has  attempted  the  extirpation  of  a  can- 
cerous deposit  in  the  oesophagus,  but  the  operation  is  not  usuall}^  re- 
garded as  justifiable.  I  have  alluded  to  the  possibility,  in  cases  of 
stricture  not  obviously  malignant,  of  preserving  life  by  gastrotomy  (page 
239) ;  and  though  the  attempt  has  hitherto  failed,  it  is  worth  making. 
Failing  these  means,  the  only  thing  that  can  be  done  is  to  keep  the 
passage  open  by  means  of  bougies  ;  and  in  spite  of  the  known  and  ad- 
mitted dangers  of  the  treatment,  I  cannot  but  think  that  it  is  the  best 
course  for  the  patient,  unless  the  cancerous  symptoms  are  so  urgent  as 
to  deter  the  surgeon  from  fear  of  rupturing  the  oesophagus.  If  the 
bougie  can  be  passed  the  patient  will  be  able  to  swallow,  and  so  will  be 
kept  free  from  the  tei-rible  pangs  of  starvation  for  a  time.  If  nothing 
else  can  be  done,  the  prospects  connected  with  the  operation  of  opening 
the  stomach  should  be  explained  to  him,  and  at  his  request  the  operation 
should  be  undertaken. 


Fi6.  275. 


AFFECTIONS    OF   THE    INTESTINAL   TUBE. 

Internal  Strangulation. — The  strangulation  of  a  portion  of  the  intestines 
inside  the  abdomen  is  an  even  graver  evil  than  its  strangulation  in  a 
hernial  sac,  since  though  it  is  not  so  rapidly  fatal  (perhaps  because  usu- 
ally' not  so  acute),  it  is  much  less  susceptible  of  relief.  The  causes  are 
vQvy  numerous,  and  by  no  means  easy  to  diagnose.  A  common  one  is 
the  formation  of  adhesions  from  previous  peritonitis.  Such  adhesions 
sometimes  unite  with  an  appendix  epiploica  or  the  edge  of  the  mesentery 
to  form  a  ring  passing  round  one  of  the  coils  of  bowel,  and  the  contrac- 
tion of  the  material  which  forms  this  ring,  or  the  accidental  enlargement 
of  the  contents  of  the  bowel,  seems  to  cause  the  constriction.  At  other 
times  the  constricting  agent  is  formed  by  a  mere  band  passing  from  one 
coil  of  intestine  to  another,  and  pressing  the  bowel  against  the  wall  of 
the  bell}'  behind ;  or  the  bowel  may  be  bent  or  twisted  on  itself  (volvulus), 
and  thus  the  passage  of  fueces  through  it  may  be  stopped  ;  or  the  pres- 
sure of  tumors  in  its  neighbor- 
hood, or  stricture  of  its  walls  may 
produce  the  same  result ;  or,  fin- 
ally, a  portion  of  bowel  may  slip 
into  the  tube  below,  just  as  the 
finger  of  a  glove  maj^'  be  shortened 
by  slipping  one  part  of  it  over  the 
other  —  intussusception  —  a  con- 
dition which  sometimes  producses 
strangulation,  but  not  always.  In- 
tussusception must  be  spoken  of 
by  itself.  The  other  conditions 
are  indistinguishable  from  each 
other  unless  the  cause  which  pro- 
duces them  is  within  the  reach  of 
the  hand.  The  great  point  is  to 
distinguish,  if  possible,  the  part 
of  the  bowel  affected,  in  order  to 
determine  whether  a  surgical  oper- 
ation for  its  relief  is  feasible. 
Tiie  main  diagnostic  symptoms 
are  these  :  Strangulation  produces 
at  first  constipation,  then   vomit- 


Internal  strangulation  of  a  eoil  of  intcstin(>  l)y  a 
band  of  peritoneal  adhesion,  which  passes  on  to  the 
surface  and  mesentery  of  a  neighlioriiif;  coil  of  gut. 
The  band  has  been  displaced  from  the  groove  which 
it  has  worked  upon  the  strangulated  bowel,  in  order 
to  show  the  extent  to  whicii  the  latter  is  constricted. 
— St.  George's  Hospital  Museum,  Ser.  i.\,  No.  15.3. 


IMPACTION    OF    F^CES.  613 

ing,  which  afterwards  becomes  fecal.  The  liigher  the  obstruction  is  situ- 
ated in  the  intestine  the  sooner  will  the  vomiting  commence;  but  if  the 
obstruction  is  high  up  it  will  not  rapidly  become  ftecal.  The  amount  of 
nourishment  which  the  patient  has  taken  will,  however,  influence  this 
to  some  degree.  Usually  he  is  both  unwilling  and  unable  to  take  any- 
thing ;  but  if  the  diet  has  not  been  restricted  so  that  the  stomach  and 
upper  part  of  the  bowel  are  filled,  vomiting  will  probably  (;omraence 
earlier  than  would  have  been  the  case  under  more  judicious  treatment. 
All  the  symptoms  are  more  acute  when  the  obstruction  is  high  up. 
When,  on  the  contrary,  it  is  seated  in  the  large  intestine  or  close  to  the 
end  of  the  small,  the  belly  will  sometimes  continue  to  swell  gradually' 
without  any  vomiting  for  several  weeks,  and  the  i)atient  sutlers  little 
except  the  loss  of  appetite  consequent  on  repletion  and  constipation. 
Another  most  important  diagnostic  sign  is  the  quantity  of  water  which 
can  be  injected  into  the  bowel.  If  the  obstacle  is  situated  at  the  sigmoid 
flexure  of  the  colon  it  is  rarely  possible  even  with  the  utmost  gentleness 
to  inject  more  than  about  a  pint  and  a  half  before  it  is  expelled,  and 
usually  with  some  force.  The  higher  up  the  obstacle  is  situated  the 
larger  is  the  quantity  which  will  pass  in  ;  and  if  the  small  intestine  is  the 
part  affected,  a  very  large  quantity  of  fluid  may  be  passed  up,  especially 
if  the  patient  is  under  chloroform,  and  will  at  first  run  out  quite  gently 
until  the  bowel  is  roused  to  expulsive  action.  Palpation  of  the  abdomen 
is  of  course  useful,  and  it  is  said  that  auscultation  while  the  fluid  is  being 
injected  ma}^  sometimes  give  valuable  information  of  the  position  of  the 
obstacle,  but  I  have  never  been  able  to  realize  this. 

Imjjaction  of  Faeces. — During  the  constipation  much  may  be  done  to 
alleviate  the  patient's  sufferings.  The  first  question  is,  whether  the  con- 
stipation depends  on  a  real  organic  obstacle  or  merely  on  impaction  of 
faeces,  which  will  produce  the  same  symptoms  if  long  neglected.  Such 
masses  of  impacted  faeces  are  comparatively  often  mistaken  for  tumors. 
The  distinction  is  made  b}'  observing  that  though  there  may  be  a  good 
deal  of  swelling  around  the  bowel,  the  substance  is  to  some  extent  soft 
and  will  take  the  impression  of  the  fingers;  that  its  size  has  been  known 
to  vary  with  the  state  of  the  bowels  ;  and  that  there  is  the  history  of 
neglected  constipation.  If  the  mass  is  situated  within  reach  of  the  anus 
it  should  be  broken  down  with  a  scoop,  otherwise  free  purgation  and 
injections  should  be  employed. 

Treatment  of  Obstruction. — But  when  an  invincible  obstacle  has  been 
pi'oved  to  exist,  the  first  rule  of  practice  is  to  abstain  from  irritating  the 
bowels  with  purgatives,  to  give  nourishment  in  the  fluid  form  only,  and 
in  the  smallest  possible  quantities  at  a  time,  and  to  soothe  the  patient's 
sufferings  with  opium,  subduing  thirst  with  small  pieces  of  ice  kept  in 
the  mouth.  As  to  surgical  operations  they  are  directed  either  to  relieve 
the  strangulation  or  to  give  an  artificial  exit  to  the  faeces  above  it.  The 
former  can  only  be  used  in  cases  of  strangulation  by  adhesions.  It  was 
successfully'  carried  out  by  Mr.  Br^'ant,^  in  a  case  in  which  thei'e  was  a 
hernial  sac,  but  no  strangulation,  and  where  the  band  was  reached  by 
carrying  the  incision  which  had  been  made  into  the  sac  a  little  upwards. 
Mr.  Bryant  thinks  that  such  bands  are  more  common  when  there  has 
been  hernia,  so  that  the  existence  of  a  hernia  may  encourage  the  surgeon 
to  attempi  the  operation.  In  the  only  case  where  I  have  mj-self  operated 
I  found  a  band  crossing  the  lower  part  of  the  ileum  (a  very  common 
situation),  and  divided  it,  but  the  operation  had  been  put  ott'  too  long, 

1  See  Bryant,  Med. -Chir.  Trans.,  1867. 


614  DISEASES    OF    THE    INTESTINES. 

and  the  bowel  gave  wa}'  on  the  division  of  tlie  band,  having  been  pre- 
A'iously  ahnost  perforated  by  the  constriction. 

Goiotomy  may  be  practiced  on  either  side  when  the  seat  of  obstruction 


is  dearly  localized  in  the  large  intestine.  Jt  is  more  commonl}-  practiced 
on  the  left  side  (descending  colon)  in  obstruction  and  other  affections  of 
the  rectum,  and  is  more  promising  than  on  the  other  side,  partly  because 
the  descending  colon  is  less  often  provided  with  a  mesentery  than  the 
ascending,  but  chiefly  because  affections  of  the  rectum  exhaust  the  patient 
less,  and  are.  more  easily  diagnosed,  and  therefore  more  promptly  treated, 
than  those  situated  higher  up.  When  the  obstruction  is  complete,  and 
the  flank  is  distended  by  the  swollen  intestine,  the  operation  is  an  easy 
one  ;  but  when  performed  for  the  relief  of  cancer  or  other  aflfections  which 
do  not  produce  coniplete  obstruction,  and  the  gut  happens  to  be  collapsed, 
it  is  sometimes  very  difficult.  A  free  transverse  incision  is  to  be  made 
midwa}'  between  tlie  .ilium  and, last  rib,  and  the  edge  of  the  erector  spinse 
is  to  be  sought.  The  fascia  which  bounds  this  muscle  (fascia  himborum) 
is  then  to  be  fully  opened,  and  the  fascia  covering  the  intestine  to  be 
sought  through  the  fat  which  surrounds  it.  The  peritoneum  may  be 
distinguishable  from  this  fascia,  but  it  generally  is  not  so.  If,  however, 
the  bowel  is  much  distended  there  is  little  risk  of  opening  the  peritoneum. 
When  much  difficulty  exists  in  finding  the  intestine  the  lower  end  of  the 
kidney  forms  the  surest  guide.  The  bowel  is  sure  to  be  found  just  below 
and  in  front  of  the  kidney,  on  careful  search.  It  is  then  to  be  drawn  up 
to  the  surface,  stitched  to  the  two  edges  of  the  wound,  and  opened  be- 
tween the  stitches  to  an  extent  sufficient  to  admit  the  end  of  the  finger, 
after  which  the  mucous  membrane  of  the  bowel  is  to  be  carefull}'^  attached 
to  the  skin  around  the  whole  circumference  of  the  opening.  It  is  well 
not  to  make  the  opening  too  large,  as  the  posterior  wall  of  the  intestine 
is  sure  to  protrude  from  it  afterwards.  The  intestine  will  become  adherent 
to  the  wound  before  the  sutures  have  come  out,  and  after  all  has  been 
consolidated  and  the  patient  has  got  up,  a  plug  of  ivory  or  glass  can  be 
fitted  on  to  the  opening  and  fixed  by  an  elastic  bandage.  The  bowels 
will  very  often  regulate  themselves,  so  that  the  action  will  occur  usually 
at  stated  periods  and  the  patient  be  quite  clean  and  comfortable. 

The  operation  on  the  riglit  side  is  performed  in  exactly  the  same  way. 
The  horizontal  incision  (Amussat's)  is  certainl}-  preferable  to  Callisen's 
plan  of  making  a  vertical  incision  at  the  outer  border  of  the  erector  spinte. 
Mr.  Bryant  has  proposed  cutting  obliquely,  at  an  angle  of  45*^,  as  less 
likel}^  to  injure  the  vessels  and  nerves  of  the  part. 

Gatiirolomy. — When  the  surgeon  has  made  up  his  mind  to  look  for  the 
seat  of  strangulation  inside  the  peritoneum  (an  operation  often  descrilied 
by  the  name  Gastrotomy,  see  page  238)  he  usually  makes  an  incision 
through  the  linea  alba  below  the  umbilicus,  as  in  ovariotomy,  long  enough 
to  get  the  fingers  in,  feels  for  the  seat  of  stricture  b,y  tracing  down  the 
distended  l)owel,  passes  a  director  under  the  adhesion  when  found,  and 
divides  it  with  a  liernia  knife. 

LHlre\s  Operntioii. — Another  plan  which  is  sometimes  justifiable  is  to 
make  an  incision  on  the  distended  intestine  wherever  it  happens  to  be 
perceptible  and  attach  it  to  the  skin  (Littre's  operation),  so  as  to  make 
an  artificial  anus  in  the  small  intestine.  This  is  best  done  in  the  groin, 
when  possilile. 

/»/«.s>-i'/.'<r'r'p/?o??, or  invagination,  is  very  much  more  common  in  cliildhood 
than  in  adult  life  ;  it  occurs  more  frequent!}'  in  the  small  intestine  than  in 
the  large,  though  eitlier  may  be  affected.  Sometimes  it  proceeds  to  a  very 
great  extent,  so  that  the  inverted  ileociecal  valve  has  often  been  known  to 


INTUSSUSCETTION. 


615 


Fig.  276. 


protrude  from  the  anus.  It  occurs  in  two  main  forms, — chronic  and  acute. 
In  the  chronic  form  there  is  often  no  complete  stoppage,  but  the  invagi- 
nated  intestine  becomes  more  and  more  , 

matted  to  that  into  which  it  is  thrust, 
the  passage  of  faeces  through  it  be- 
comes shiggish,  pain  comes  on  from 
the  local  inflammation,  vomiting  sets 
in  and  becomes  constant ;  tlie  patient 
loses  appetite  and  strength,  and  must 
inevitably  ultimately  sink.  In  the  acute 
form  there  is  considerable  pain  from 
the  first,  with  complete  obstruction, 
straining  to  pass  faeces,  but  only  a 
little  bloody  fluid  passing ;  a  sausage- 
shaped  tumor  can  often  be  felt  in  the 
part  to  which  the  pain  is  referred,  the 
neck  of  the  invaginated  portion  is 
acutely  constricted,  ulceration  sets  in, 
the  intussuscepted  part  is  detached  and 
drops  loose  into  the  bowel.  Frequently 
this  is  accompanied  by  perforation  and 
fatal  extravasation  of  fjeces  into  the 
peritoneal  cavit}^,  but  in  many  cases 
the  intussuscepted  portion  has  been 
passed  per  anum,  and  a  natural  cure 
has  thus  been  effected. 

The  diagnosis  is  difficult  in  some 
cases,  clear  enough  in  others,  when 
either  the  intussuscepted  portion  can 
be  seen  or  felt  from  the  anus,  or  when 
the  sudden  accession  of  obstruction, 
with  the  straining  to  pass  a  little  bloody 
fluid,  and  the  painful  sausage-shaped 
tumor  point  almost  unmistakably  to  the 
nature  of  the  disease. 

The  treatment  consists  (1)  in  endeav- 
oring to  disengage  the  invaginated  in- 
testine, or  (2)  to  support  the  patient 
through  the  period  required  for  its 
natural  separation.  There  can  be  no 
question  that  in  many  cases  the  infla- 
tion of  the  intestine  by  air  or  water 
pumped  into  the  anus  has  been  followed 
by  the  complete  subsidence  of  the 
symptoms   and    recovery.     It  is  quite 

true  tliat  the  air  or  water  cannot  pass  the  ileocecal  valve,  and  there- 
fore it  is  difficult  to  see  how  any  good  can  result  if  the  intussusception 
be  seated,  as  it  generally  is,  in  the  small  intestine.  But  then,  again, 
no  harm  will  be  done,  and  the  attempt  seems  worth  making,  especially 
by  insufflation  ;  but  to  be  effectual  it  should  be  done  early.  Kneading 
the  abdomen  has  sometimes  succeeded.  These  milder  measures  failing, 
it  is  best  in  acute  cases  to  endeavor  to  support  the  patient's  strength  by 
nutrient  enemata,  very  small  quantities  of  concentrated  food  and  stimu- 
lants, and  administer  opium  liberally,  in  order  to  give  him  the  chance  of 
spontaneous  cure.     Mr,  Hutchinson  lately  succeeded  in  a  very  remarkable 


IntiLSSiisception. — From  a  preparation  in 
the  Museum  of  St  George'.s  Hospital. 


616  DISEASES    OF    THE    INTESTINES. 

case  in  cutting  into  the  linea  alba  and  drawing  out  au  intussusception  so 
largo  thai  the  ilioctv^cal  valve  protruded  from  the  anus  ;  the  intussuscep- 
tion had  lasted  some  weeks;  the  patient,  an  infant,  recovered;'  and  Mr. 
Howard  Marsh  has  lately'  operated  in  a  similar  case  with  equal  success. 
These  cases  certainly  show  that  in  the  chronic  form  of  intussusception 
adhesion  does  not  (at  least  does  not  always)  occur  earl}^,  and  justify  the 
repetition  of  the  attempt  at  relief  in  such  circumstances,  since  the  disease 
must  otherwise  end  in  death.  But  success  cannot  be  often  anticipated 
even  in  chronic  cases,  and  in  the  acute  I  have  no  doubt  that  the  patient 
has  a  better  chance  from  the  natural  cure.- 

Umhilical  Fistula. — I  ought,  perhaps,  to  mention  the  rare  cases  of  dis- 
charge from  the  navel.  This  discharge  ma}'  be  of  various  kinds  and 
arise  from  very  different  causes.  In  childhood  a  small  vascular  protru- 
sion is  found  occasionall}'  at  the  navel,  which  may  grow  to  some  size  and 
then  become  irritable  and  bleed  or  suppurate.  This  pi'otrusion  is  con- 
genital, and  is  somehow  connected  with  the  ligature  of  the  umbilical 
cord.  All  that  is  necessary  is  to  pass  a  ligature  firmly  round  its  base, 
after  having  carefully  ascertained  the  absence  of  any  hernia. 

Again,  fiecal  or  biliary  fluid  is  sometimes  discharged  from  the  umbili- 
cus. Such  discharges  are  connected  with  some  malformation  of  the  ora- 
phalo-mesenteric  duct,  and  are,  as  far  as  I  have  seen,  incurable.  Two 
cases  have  come  under  my  observation,  in  one  of  which  the  fluid  appeared 
to  be  pure  bile;  in  the  other  it  was  mixed  witli  the  contents  of  the  intes- 
tine and  portions  of  the  food,  as  the  pips  of  fruit,  would  occasionally  ap- 
pear in  it. 

In  other  cases  the  discharge  seems  merely  purulent,  and  connected 
with  an  abscess  in  the  parietes  or  subperitoneal  tissue  which  has  found 
its  exit  through  the  umbilicus  and  become  sinuous.  The  best  way  to 
treat  such  cases,  I  think,  is  to  dilate  the  opening  as  much  as  possible 
with  sea-tangle  tents  and  wash  out  the  cavit}^  with  carbolic  lotion.  I 
have  latel}'  treated  a  case  of  this  kind  in  this  manner  witli  rapid  success. 

Finally,  there  are  cases  (especially  in  very  fat  persons)  in  which  dis- 
charge from  the  umbilicus  is  produced  merely  b}'  heat  and  cutaneous 
irritation.  These  cases  must  be  treated  like  intertrigo — of  which,  indeed, 
they  are  the  sequelae — by  great  cleanliness  and  keeping  the  parts  from 
rubbing  against  each  other  by  dusting  the  skin  with  oxide  of  zinc,  and 
inserting  tents  steeped  in  tannin  or  nitrate  of  silver  lotion. 

ParacenteaiH  Abdominis. — The  operation  of  paracentesis  is  required, 
in  cases  of  ascites  and  ovarian  dropsy,  to  relieve  the  patient  from  the 
distress  caused  by  distension.  It  is  performed  by  preference  in  the 
linea  alba,  about  lialf-way  between  the  umbilicus  and  pubes,  though  in 
rases  of  encysted  dropsy  it  may  l)ecome  necessary  to  tap  wherever  the 
fluid  is  found,  care  being  taken  to  avoid  the  course  of  the  epigastric 
artery.''     If  the  patient  has  not  made  water  lately  he  should  be  instructed 

^  Mcd.-Chir.  Trans.,  vol.  Ivii. 

"^  Yery  useful  information  may  sometimes  be  obtained  in  pelvic  and  abdominal 
diseases  and  tumors  by  passini^  the  whole  band  into  the  bowel,  which  may  be  accom- 
plished under  an?esthesia  bj-  iijradually  dilating  the  anus  with  the  fingers  pressed  to- 
gethi!!'  in  a  conical  form.  The  hand  may  then  be  buried  in  the  bowel  as  far  as  the 
wrist,  and  the  parts  examined  about  as  high  as  the  kidney,  between  the  hand  in  the 
bow(!l  and  the  one  outside,  much  more  siitisfactorily  than  liy  any  other  method  of 
exploration.  The  stretching  of  the  anus  leaves  some  inconlincsnce  of  faeces,  but  only 
for  a  few  days.  Care  must,  of  course,  be  exercised  not  to  dilate  the  parts  too  raj)idly, 
and  not  to  rupture  the  wall  of  the  bowel. 

'  I  have  known  a  case  in  which  this  artery  was  punctured  and  fatal  haimorrhage 


HERNIA.  617 

to  do  so,  or  the  emptiness  of  the  bladder  should  be  ascertained  by  per- 
cussion. It  used  to  be  usual  to  tap  in  the  sitting  posture,  but  it  is  far 
less  convenient  than  the  recumbent.  The  patient  is  brouglit  to  the  edge 
of  the  bed  and  turned  on  his  side,  so  tliat  tlie  prominent  abdomen  pro- 
jects beyond  the  edge  of  tlie  bed.  Then  the  operator,  having  ascertained 
by  percussion  that  the  place  at  which  he  proposes  to  tap  is  perfectly  dull, 
and  that  the  fluctuation  is  plainl_y  perceptible  there,  makes  a  small  punc- 
ture with  a  lancet,  if  the  patient  is  at  all  stoat,  and  introduces  iiis  trocar 
and  canula.  A  piece  of  tubing  may  be  applied  on  the  canula,  so  as  to 
obviate  wetting  the  bed  with  any  of  the  fluid,  or  the  same  end  may  be 
obtained  bj-  holding  something  under  the  mouth  of  the  canula  to  direct 
the  fluid  into  a  pail  on  the  floor.  No  compression  or  disturbance  of  the 
abdomen  of  any  kind  is  needed,  the  fluid  is  emptied  by  atmospheric  pres- 
sure, and  when  it  ceases  to  flow  the  puncture  is  to  be  closed  with  a  piece 
of  strapping,  and  a  pad  and  a  bandage  applied.  I  have  never  seen  any 
harm  Id  this  little  operation,  but  no  doubt  the  bowel  has  been  wounded 
from  a  too  free  thrust  of  the  trocar.' 

Paracentesis  is  also  used  in  hydatid  tumors  of  the  liver.  1  hardly 
think  this  the  place  for  discussing  the  diagnosis  or  treatment  of  these 
cases.  They  have  been  successfully  dealt  with  b}'  electrolysis,  by  inci- 
sion, and  free  washing  out  of  the  cyst,  and  by  keeping  several  catheters 
in  the  opening,  and  constantly  washing  out  the  cavity  through  the  cathe- 
ters, the  original  opening  being  dilated  by  passing  fresh  catheters  along 
the  side  of  those  previously  introduced.  I  would  recommend  the  reader 
to  study  the  papers  by  Dr.  John  Harlej^,  in  the  49th  vol.  of  the  3led.- 
Chir.  Trans.,  and  by  Mr.  Hilton  Fagge  and  Mr.  Durham,  in  the  .54th 
vol.  of  the  same  series. 


CHAPTER  XXXII. 

HERNIA. 

The  term  hernia  is  sometimes  applied  in  surgical  language  to  the  pro- 
trusion of  any  of  the  internal  parts  through  their  coverings.  Thus  we 
have  spoken  of  hernia  cerebri,  hernia  of  the  lung,  etc.  But  it  is  far  more 
commonly  applied  to  the  protrusion  of  one  of  the  abdominal  viscera 
through  the  parietes,  and  when  used  alone  it  is  always  in  this  sense.  The 
hernia  generally  takes  place  through  one  of  the  natural  '•  rings  "  in  the 
abdomen,  the  inguinal,  femoral,  or  umbilical,  and  the  part  protruding 
is  generally  the  bowel  (enterocele),  or  the  omentum  (epiplocele),  or  both 
(entero-epiplocele).  I  shall  first  speak  of  the  general  characters  common 
to  all  forms  of  hernia  before  speaking  of  its  special  anatomical  varieties. 

A  hernia  is  at  first  almost  always  reducible — i.  e.,  the  protruding  viscera 
can  be  passed  bacli  into  the  belly.     It  consists  of  a  sac,  formed  of  the 

produced  by  a  surgeon  making  a  puncture,  as  he  thought,  in  the  middle  line,  not 
having  noticed  that  the  belly  was  unequally  distended. 
1  Gay,  Path.  Trans.,  vol.  ii,  p.  203. 


618  HERNIA. 

peritoneum,  and  its  contents.  The  sac,  in  most  cases,  is  a  new  formation, 
a  protrusion  of  a  portion  of  the  peritoneum  whicli  naturall}'  ouglit  not  to 
exist;  but  there  are  hernitx?  which  protrude  into  a  diverticulum  of  the 
peritoneum  existing  naturally  in  the  foetal  state,  which  should  be  closed 
at  birth,  but  remains  on  the  contrar}',  congenitall,y  open.  Such  hernise, 
depending  as  the^^  do  on  a  congenital  condition,  are  therefore  called  "  con- 
genital ;"  not  that  the  hernia  itself  is  necessaril}^  congenital,  for  in  some 
cases  it  does  not  appear  till  adult  life,  but  that  the  state  which  produces 
it  is  so.  Such  are  the  congenital  inguinal  and  the  congenital  umbilical 
hernia.  The  non-congenital  herni;e  occur  in  consequence  of  a  weakness 
of  the  abdominal  wall  at  the  seat  of  protrusion,  and  possibly  also  in  con- 
sequence of  an  elongated  state  of  the  mesenteries  of  the  viscera.  The 
pressure  of  the  viscera  gradually  pushes  the  peritoneum  thi-ough  the  wall 
of  the  abdomen,  and  as  it  advances  it  contracts  adhesions  to  the  parts 
covering  it;  and  when  it  has  emerged  from  the  cavit}^  of  the  abdomen  it 
swells  out  into  a  pear-shaped  tumor,  the  constricted  part  communicating 
with  the  general  cavity  being  its  neck^  the  dilated  part  the  fundus.  At 
first  there  is  nothing  perceptible  except  a  little  fulness  and  weakness  of 
the  abdominal  wall,  with  unnatural  impulse  on  coughing.  Then  there  is 
a  distinct  tumor,  which,  however,  vanishes  at  once  when  the  patient  lies 
down,  or  when  pressure  is  made  on  it;  but  when  the  tumor  has  become 
more  developed  and  of  larger  size  more  manipulation  is  necessary  to 
press  it  back  again.  The  sac  of  course  remains,  and  the  viscera  imme- 
diately reprotrude  when  the  patient  stands  up  or  coughs  or  exerts  him- 
self. A  hernia  is  never  transparent,  as  a  hydrocele  is ;  it  has  almost 
always  an  impulse  on  coughing,  which  is  communicated  to  it  tlirough  the 
contents  of  the  bowels  acted  on  by  the  muscles  of  the  abdomen,  and  it  is 
traced  up  to  and  along  the  canal  leading  into  the  abdomen,  and  by  these 
signs  and  its  reducibility  a  hernia  is  immediatel}'  recognized  in  general. 
But  if  the  contents  of  the  sac  have  from  any  cause  become  adherent  to 
its  interior  it  ceases  to  be  reducible,  and  is  then  called  irreducihle  ov  incar- 
cerated ;  and  if  besides  this,  the  herniated  viscera  are  constricted,  so  that 
the  circulation  of  the  contents  of  the  intestines  is  suspended,  it  is  said 
to  be  strangulated. 

PJach  of  these  conditions  is  marked  b}^  symptoms  which  it  is  of  great 
Importance  clearly  to  recognize  ;  and  when  the  hernia  has  lost  its  reduci- 
bility, one  of  the  main  diagnostic  signs  being  no  longer  applicable,  such 
symptoms  become  valuable  evidence  of  the  nature  of  the  tumor.  The 
history  also  ought  in  such  cases  to  be  carefully  investigated,  for  the  fact 
that  the  patient  has  for  some  time  been  able  to  push  back  the  tumor  at 
will,  or  that  the  tumor  has  made  its  appearance  quite  suddenly,  are  verj- 
strong  proofs  that  it  is  a  hernia. 

Irreducible  Hernia. — When  a  hernia  is  merely  irreducible,  but  not 
strangulated,  the  impulse  on  coughing  usually  remains,  and  the  neck  of 
the  sac  can  be  traced  up  to  its  exit  from  the  abdomen.  The  gurgling  of 
the  air  in  the  intestine  can  often  be  felt  on  pressure,  for  the  tumor  when 
irreducible  is  iVequently  of  large  size  and  contains  much  bowel ;  and  in 
such  cases  there  may  be  perceptible  resonance  on  percussion,  which  is  a 
valuable  diagnostic  sign.  There  is  often  more  or  less  of  ol)struction  to 
the  passage  of  matters  through  the  bowel  contained  in  the  sac,  occasion- 
ing constipation  and  vomiting,  a  condition  bordering  on  and  nearly  re- 
sembling that  of  strangulation,  but  distinguislicd  from  it  by  the  absence 
of  those  more  urgent  symptoms  now  to  be  described. 

8lran(julaHon  is  marked  by  total  and  usually  sudden  constipation,  ur- 
gent vomiting,  at  first  merely  of  food,  then  of  bile  stained  matter,  next 


TREATMENT.  619 

of  the  contents  of  the  small  intestines,  and  finally  of  feces.  Tliere  is 
great  distress  and  pain  usually  in  the  tumor,  and  almost  always  in  the 
neighborhood  of  the  umbilicus,  frequent,  irritable  pulse,  dry  and  brown 
tongue,  tympanitis,  and  often  considerable  tenderness  of  the  abdomen 
and  distress  of  countenance.  As  the  vomit  becomes  more  and  more 
faecal,  tiie  tongue  becomes  drier,  hiccough  comes  on,  and  tlie  patient 
sinks  into  a  state  of  exhaustion,  of  which  he  dies,  if  unrelieved,  usually 
in  from  ten  days  to  a  fortnight.  The  tumor  when  strangulated  becomes 
hard,  })ainful,  often  inflamed  on  the  surface,  loses  it5  impulse  more  or 
less  entirely  according  to  the  tightness  of  the  stricture,  and  the  neck  is 
sometimes  so  constricted  that  it  can  no  longer  be  traced  along  the  ab- 
dominal ring.  The  strangulation,  even  of  the  omentum  only,  produces 
symptoms  identical  in  kind  with  those  of  strangulated  bowel,  though 
possibly  not  so  severe,  a  fact  which  I  find  it  difficult  to  account  for  on 
purely  mechanical  principles,  especially  as  the  omentum,  when  exposed 
in  the  operation  for  hernia,  is  constantly  tied  tightly  in  order  to  remove 
portions  of  it,  with  complete  impunity.  A  strangulated  hernia  is  generall}'' 
too  tightly  bound  down  to  permit  of  any  correct  opinion  being  formed  by 
palpation  or  percussion  as  to  the  nature  of  its  contents. 

Inflamed  Hernia. — Strangulation  is  to  be  distinguished  from  mere 
incarceration  partly  by  the  pain  in  the  sac  and  around  the  umbilicus, 
parti}'  by  the  greater  urgenc}^  of  the  vomiting,  partly  by  the  constitutional 
disturbance  which  accompanies  strangulation  ;  but  when,  as  sometimes 
happens,  the  hernia,  as  well  as  being  incarcerated,  is  also  inflamed,  the 
distinction  becomes  very  difficult.  If  the  symptoms  of  strangulation  are 
not  very  urgent,  but  the  parts  are  much  inflamed,  the  hernia  often  be- 
comes reducible,  after  the  application  of  leeches  to  the  hernial  tumor, 
with  hot  baths  and  free  fomentation  ;  and  in  such  conditions  the  admin- 
istration of  euemata,  or  even  of  a  purgative,  seems  often  very  beneficial. 

Gangrene. — A  most  formidable  complication  is  gangrene  of  the  con- 
tents of  the  tumor,  an  event  which  is  often  preceded  by  a  cessation  of 
the  pain  which  the  patient  was  sutfering,  with  a  continuance  or  increase 
of  the  lovv  fever,  with  dry  brown  tongue,  small  wiry  pulse,  hiccough,  and 
slow  sinking  into  a  state  of  collapse,  with  cold,  livid  extremities.  The 
coverings  of  the  tumor  are  often  edematous  and  inflamed.  When  gan- 
grene is  suspected  no  farther  interference  with  the  tumor  is  justifiable. 
It  must  be  at  once  laid  open  and  dealt  with  according  to  the  state  in 
which  its  contents  are  found. 

Ulceration  and  Perforation. — Another  almost  surely  fatal  lesion  is  the 
ulceration  of  tiie  bowel  in  the  line  of  the  stricture.  Under  continued 
pressure  (especially  in  femoral  hernia  from  the  sharp  edge  of  Gimbernat's 
ligament)  the  mucous  coat  of  the  bovvel  becomes  ulcerated,  and  this 
ulceration  gradually  extends  to  the  serous  or  outer  coat.  Thus  the  faeces 
may  find  their  wa}'  into  the  i)eritoneal  cavity.  No  symptoms  are  known 
to  mark  the  occurrence  of  this  ulceration.  If  perforation  occurs  before 
operation  the  faeces  almost  inevitably  find  their  way  into  the  peritoneal 
cavit}',  a  catastrophe  marked  by  intense  pain  in  the  abdomen,  followed 
by  rapid  and  fatal  collapse.  In  some  rare  cases  the  feces  have  been  en- 
cysted in  an  abscess  external  to  the  general  cavity  of  the  peritoneum  and 
the  patient  has  recovered.  After  operation  this  perforation  sometimes 
leads  to  faecal  fistula,  which  is  not  necessarily  fatal  nor  even  permanent. 

Treatment. — The  treatment  of  most  cases  of  hernia  is  extremely  simple, 
consisting  merely  in  reducing  the  herniated  viscera  into  the  abdomen 
and  keeping  them  so.  The  first  indication  is  fulfilled,  when  necessary, 
by  manipulation,  technically  called  "the  taxis,"  the  second  by  the  appli- 


620 


HERNIA. 


Fig.  277. 


Ccation  of  a,  truss.  If  the  hernia  does  not  slip  up  of  itself,  or  under  the 
patient's  own  manipulation,  it  is  necessary  for  the  surgeon  to  reduce  it, 
and  it  is  most  important  that  he  should  be  familiar  with  the  way  of  doing 
this  and  with  the  signs  by  which  it  may  be  known  that  it  has  really  been 
accomplished.  It  often  happens  that  herniae  of  which  a  portion  is  irre- 
ducible (probably  from  the  adhesion  to  the  sac  of  a  piece  of  omentum 
imi)licating  perhaps  some  of  the  bowel)  are  diminished  in  size  by  the 
reduction  of  the  rest  of  their  contents ;  and  the  irreducible  part  being 
overlooked,  a  truss  is  applied  which  cannot  be  worn  on  account  of  the 
pain  it  produces,  or  which  aggravates  the  mischief  by  pressure  causing 
increased  adhesion.  A  still  graver  error  is  when  the  surgeon,  in  apply- 
ing taxis  for  a  strangulated  hernia,  forces  a  small  tumor  somewhat  higher 
up  the  canal  and  leaves  it  still  strangulated  in  the  abdominal  parietes, 
thinking  all  the  time  he  has  reduced  it. 

The  Taxis. — In  applying  the  taxis  the  surgeon  should  keep  in  mind 

the  causes  which  oppose 
reduction.  They  are  the 
tension  of  the  abdominal 
rings,  the  sudden  increase 
in  the  bulk  of  the  contents 
of  the  herniated  bowel,  the 
implication,  or  folding  in, 
of  the  contents  into  each 
other,  and  adhesions  be- 
tween the  contents,  or  of 
the  contents  to  the  sac. 
The  latter  is  of  course  in- 
superable, except  b}^  a  cut- 
ting operation. 

In  order-  to  obviate  the 
tension  of  the  rings  the 
patient  is  to  be  placed  in 
such  a  position  that  the 
abdominal  parietes  may  be 
relaxed,  b}^  bending  the 
thigh  on  the  abdomen  and 
abducting  it  a  little  so  as 
to  relax  Poupart's  liga- 
ment and  the  fibrous  struc- 
^,  ^    ,  .,,,.,.  ,        . ,,      tures    connected    with    it. 

The  sac  of  a  large  congenital  hernia,  showing  rupture  of  the 
sac  hy  forcible  taxis.    The  hernia  had  been  operated  on  fifteen     I  hlS    may    be    doUC    by    an 
years  previously.    It  descended  again  four  days  before  the  pa-    assistant  Or  HUrse.^      Then 
tient's  admission,  and  was  reduced,  but  appeared  again  next    ^j^g     g^^^    ^g    ^^    j^g     crentlv 
day,  when  forcible  taxis  was  unsuccessfully  used.    On  his  ad-     -.  ^  ,  ■.       '^ 

mission  the  scrotum  was  purple  from  extravasation.  The  oper-  Clrawn  ClOWnwarClS,  SO  aS 
ation  was  performed  at  once,  but  he  died  next  day  from  peri-  tO  untold  itS  COUtCntS  aS 
toijitis.  The  sac  was  found  to  have  been  torn,  and  was  full  of  f^^  r^g  i)racticable  and  tO 
coagulated  blood ;  the  mesentery  of  the  herniated  bowel  had  y^^     ^j  .ggg^,;  ^^    ^Ct 

also  been  lacerated.  » 

a  shows  the  opening  made  at  the  operation.    The  testicle  is    directly  tOWards   the    ring, 
situated  near  this  opening,  but  is  not  visible  in  this  aspect  of 
the  preparation. 

6  shows  the  rent  in  the  sac  extending  into  the  cellular  tissue 
of  the  scrotum. — St.  George's  Hospital  Museum,  Ser.  ix,  No.  95. 


This  being  done  with  the 
fingers  of  the  left  hand, 
gentle   pressure    is    made 


'  Some  surgeons  believe  that  an  advantage  is  gained  by  inverting  the  position  of 
the  body,  thi;  polvi.s  being  raisod  morn  or  less  above  the  head.  There  is  no  objection 
to  maUiiig  a  trial  in  this  position  if  tho.sc  in  the  usual  one  have  failed,  but  it  does  not 
seem  tliat  mucli  importance  is  to  be  attached  to  it. 


REPETITION    OF    TAXIS. 


621 


with  those  of  the  right  on  the  more  prominent  part  of  the  tumor,  so  as 
to  empty  if  possible  some  of  the  air  or  fluid  in  the  gut  into  the  abdominal 
cavity.  When  this  has  been  done  the  contents,  so  reduced  in  bulk,  gen- 
erally yield  easily  to  the  kneading  movement  which  is  now  gently  applied 
to  the  hernia,  and  the  protruded  viscera  return  into  the  peritoneal  cavity. 
This  return  takes  place  in  a  very  characteristic  manner.  The  hernia  does 
not  recede  gradually,  but  it  vanishes  at  once,  generally  with  a  perceptible 
snap,  or  with  a  gurgle  of  air  and  fluid  ;  and  if  there  remains  on  the  mind 
of  the  surgeon  the  least  doubt  whether  reduction  is  complete,  he  should 
not  be  satisfied  without  putting  his  finger  fairly  through  the  ring,  and 
ascertaining  by  a  comparison  of  the  two  sides  that  no  unnatural  fulness 
is  left. 

Dangers  of  too  Forcible  Taxis. — The  process  of  reduction  is  materially 
facilitated  by  anassthesia,  which  neutralizes  the  resistance  that  the  patient 
can  otherwise  hardly  help  making  when  there  is  any  serious  difficulty,  and 
accordingly  a  hernia  should  not  be  regarded  as  irreducible  until  the  taxis 
has  been  tried  under  anjesthesia.  It  is  a  very  grave  and  often  fatal  error  to 
use  too  much  force  in  applying  the  taxis.  Our  hospital  museums  contain 
a  ghastly  array  of  preparations  showing  the  bowel  or  its  mesentery  or  the 

Fig.  278. 


The  gut,  with  its  mesentery,  from  the  same  preparation  as  last  figure,  showing  a  rent  (a)  in  the  por- 
tion of  mesentery  connected  with  the  attached  border  of  the  gut. — St.  George's  Hospital  Museum,  Ser. 
ix,  No.  96. 

hernial  sac  ruptured  by  forcible  taxis,  and  we  have  only  too  frequent 
opportunities  in  operating  for  hernia  of  seeing  the  traces  of  minor  violence 
in  extravasations  on  the  bowel  or  omentum,  bloody  fluid  in  the  sac,  and 
other  lesions,  which  though  not,  perhaps,  in  themselves  fatal,  yet  add  to 
the  dangers  of  the  case  and  increase  the  inflammation  set  up  by  the  state 
of  the  parts. 

Bepetition  of  the  Taxis. — If  reduction  has  failed  it  must  be  left  to  the 
discretion  of  the  surgeon  whether  to  repeat  it  or  not,  looking  at  the  symp- 
toms of  the  case  and  the  nature  of  the  tumor.  There  are  some  hernife 
where  the  constriction  is  so  very  tight  that  the  surgeon  at  once  feels  con- 
vinced that  nothing  except  the  division  of  the  stricture  can  avail  to  re- 
duce the  hernia ;  and  there  are  some  cases  in  which  the  symptoms  when 
first  seen  are  so  urgent  that  even  a  single  application  of  the  taxis  would  be 
improper,  since  the  bowel  may  be  gangrenous  or  so  nearly  perforated  by 
ulceration  that  the  least  pressure  would  rupture  it.     In  either  case  the 


622  HERNIA. 

operation  must  be  performed  at  once.  But  the  indications  are  usually 
less  clear,  and  it  is  difficult  to  lay  down  any  general  rule,  as  to  when  the 
repetition  of  tlie  taxis  is  inadmissible,  which  shall  not  be  liable  to  fre- 
quent excejitions.  The  one  whicli  appears  the  best,  and  which  is,  I  be- 
lieve, usually  adopted  in  the  hospitals  of  this  city,  is  this  :  when  symptoms 
of  strangulation  are  decided  and  the  vomit  is  beginning  to  be  tinged 
with  the  contents  of  the  small  intestine  (i.  e.,  is  turning  from  mere  bilious 
fluid  to  a  dark  color  and  somewhat  offensive  odor),  do  not  put  off'  the 
operation  longer,  after  a  final  gentle  trial  under  anaesthesia.  The  means 
which  used  formerly  to  be  employed  in  order  to  facilitate  reduction,  such 
as  the  warm  bath,  tobacco  enemata,  and  bleeding,  are  no  longer  used, 
being  superseded  by  anaesthetics.^  But  in  voluminous  herniae,  in  which 
the  svmptoras  of  strangulation  are  mild,  or  which  are  merely  irreducible, 
the  application  of  ice  appears  to  be  serviceable.  And  irreducible  herniae 
sometimes  become  reducible  after  prolonged  rest  in  bed,  in  aid  of  which 
saline  purgatives  appear  valuable. 

Treatment  of  Irreducible  Hernia. — Mr.  Langton,  in  an  interesting 
paper  in  the  second  volume  of  the  St.  Bartholomew'' s  Hospital  Reports.^ 
points  out  how  much  benefit  may  be  obtained  in  such  cases  as  have  re- 
sisted the  above  treatment  by  constant  and  well-graduated  pressure. 
Tills  is  effected  by  an  "  accurately  fitting  bag  which  should  be  capable  of 
being  laced  tightly  by  means  of  a  running  tape,  so  as  to  follow  the  de- 
creasing size  of  the  protrusion.  The  bag  may  be  supported  by  a  cup- 
shaped  truss,  or  a  ball-and-socket  truss  may  be  placed  over  the  neck  of 
the  tumor,  and  the  taxis  may  be  employed  occasionally,  as  the  size  of 
the  tumor  lessens."  Pure  epiploceles  may  of  course  be  treated  more 
freel}'  than  those  tumors  which  contain  intestine.  For  further  details 
and  for  some  interesting  examples  of  the  success  of  the  treatment  the 
reader  is  referred  to  Mr.  Langton 's  paper. 

Accidents  in  Taxis. — The  chief  accidents  which  are  known  to  take 
place  in  taxis  are  rupture  of  the  bowel  and  "  reduction  en  masse.''''  The 
minor  lesions  above  alluded  to,  of  bruising,  etc.,  may  be  suspected  when 
injudicious  violence  has  been  used,, but  can  hardly  be  recognized.  "  The 
indications  of  burst  bowel,"  says  Mr.  Birkett,^  "are  very  characteristic. 
The  hernia  glides  awa}'^  from  the  pressure  of  the  finger,  and  consequently 
the  tumor  disappears.  This  is  not,  however,  accompanied  with  that  sud- 
den and  peculiar  sensation  which  the  replacement  of  an  unburst  bowel 
within  the  peritoneal  cavity  produces.  The  patient  immediately  com- 
plains of  some  pain  in  the  abdominal  region  ;  vomiting  ceases,  but  pain 
and  hiccough  may  arise  instead  ;  collapse  rapidly  supervenes,  and  death 
closes  the  scene  in  a  few  hours."  Mr.  Birkett,  however,  adds  that  in 
I'are  cases  the  ruptured  part  has  been  closed  off'  from  the  general  peritoneal 
cavit,y  by  inflammation,  abscess  has  ensued,  and  tlie  patient  has  recovered 
with  an  artificial  anus. 

'"'Reduction  en  masse.,''''  or  "en  bloc,^^  is  the  term  which  is  used  to  de- 
scribe the  accident  in  which  the  hernia  is  pushed  away  from  the  external 
surface  of  the  bod}'  and  nothing  is  left  perceptible  except  an  ill-defined 


1  "  I  am  speaking  here  of  the  praqtice  which  is  pursued  at  the  hospital  to  which  I 
am  myself  attached.  But  the  warm  bath  is  used  at  other  institutions.  Sir  J.  Paget 
lays  much  stress  on  its  employment,  and  says  that  it  sliould  be  used  in  all  cases  which 
ai'c  not  very  bad,  unless  in  old  and  feeble  persons,  whom  it  would  depress  too  much, 
and  in  whom  fomentations  or  hot  poultices  should  be  substituted  ;  and  he  adds  that  in 
many  cases  where  the  warm  bath  does  not  make  the  hernia  reducible  at  once,  it  be- 
comes so  after  a  few  hours'  rest  in  bed  " — Clin.  Lectures,  p.  119. 

2  Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p.  008. 


REDUCTION    EN    MASSE. 


623 


fulness  in  the  canal,  but  the  strangulation  is  not  liberated.  It  seems 
that  this  may  be  effected  in  at  least  one  of  two  ways:  I.  The  old  idea 
was  that  in  these  cases  the  whole  of  the  sac  (neck  and  fundus)  had  been 
detached  from  the  tissues  around  it  and  pushed  into  the  canal,  or  even 
througli  the  canal  into  the  subperitoneal  tissue,  leaving  the  gut  still 
strangulated  by  the  neclc  of  the  sac.  That  this  does  occur  in  some  cases 
there  is  anatomical  evidence.^  (Fig.  279.)  But  it  appears  to  be  more 
common  for  the  sac  to  be  lacerated,  although  in  these  cases  its  neck  may 
also  be  displaced  and  separated  from  its  cellular  connections.  The 
laceration   sometimes   involves   the   whole  sac,  in  which  case  the  neck 

Fig.  279.  Fig.  280. 


Fig.  279. — Diagram  of  reduction  en  masse.  The  whole  sac  and  its  contents  (6)  separated  from  the  parts 
investing  it,  and  pushed  up  into  the  cellular  tissue ;  the  gut  still  strangulated  at  the  neck  of  the  sac  (a). 

Fig.  280. — Reduction  en  masse.  The  hernial  sac  torn  at  h,  and  the  bowel  <c)  pushed  through  the  rent 
into  the  subperitoneal  ti.ssue,  but  still  strangulated  at  a,  the  neck  of  the  sac. 

of  the  sac  constricting  the  gut  is  pushed  up  the  canal  and  lies  in  the 
subperitoneal  tissue.  Or  the  posterior  part  of  the  sac  may  be  lacerated 
and  the  gut — still  constricted  by  the  neck  of  the  sac,  or  the  tissues  around 
it — ma}'  be  pushed  through  the  rent  and  doubled  up  in  the  subperitoneal 
tissue  under  the  upper  part  of  the  sac.^     (Fig-  280.) 

The  accident  appears  to  be  not  very  uncommon  when  much  violence  is 
used.  Its  occurrence  should  always  be  suspected  when,  after  forcilde  taxis, 
the  symptoms  are  not  relieved,  and  the  surgeon  may  be  almost  certain  that 
it  has  occurred  when  there  has  not  been  the  usual  characteristic  sensa- 
tion of  the  reduction  of  bowel  (which  I  have  called  above  a  "  snap  "),  and 
especially  if  some  ill-defined  fulness  is  still  left  on  that  side  of  the  ab- 
domen, yet  the  still  graver  symptoms  enumerated  above  as  characteristic 
of  rupture  of  the  bowel  are  not  present.     The  accident  occurs  both  in 


'  See  especially  the  cases  related  by  Mr.  Avery,  in  the  Path.  Soc.  Trans.,  vol.  iii, 
p.  97,  and  by  Mr.  Bryant  in  his  work  on  the  Practice  of  Surgery,  p.  349.  Both  were 
cases  of  femoral  hernia. 

'■^  See  Dr.  Broadbent's  case,  Path.  Soc.  Trans.,  vol.  xii,  p.  97  ;  Mr.  Morris's,  ibid., 
vol.  xxii,  p.  148;  Birkett,  Syst.  of  Surg.,  vol.  iv,  p.  703,  2d.  ed. 


624 


HERNIA. 


femoral  ami  inguinal  hernia?,  but  seems  more  liable  to  happen  in  the 
latter,  probably  on  account  of  the  greater  length  of  the  sac.  Its  treat- 
ment should  be  by  immediate  operation,  as  will  be  more  full}^  described 
in  the  section  treating  of  Herniotomy. 

TrjKs.sT.s. — In  all  cases  in  which  a  patient  is  discovered  to  be  ruptured, 
after  the  hernia  is  fairly  reduced  he  should  not  be  allowed  to  resume  his 
ordinary  avocations  without  a  truss.  If  the  hernia  has  been  strangulated 
he  should  not  even  be  permitted  to  walk  to  the  instrument-maker's  shop 
without  having  the  reprotrusion  of  the  hernia  prevented  by  a  carefully 
adjusted  pad  and  bandage.  In  no  case  of  reducible  hernia  should  the 
continual  support  of  a  truss  be  omitted.  An  impression  prevails  that  an 
infant  may  be  too  3'oung  to  wear  a  truss  ;  but  no  error  can  be  more  unfor- 
tunate. It  is  true  that  in  .young  infants  there  is  much  more  difficult}^  in 
adjusting  a  truss,  and  in  keeping  it  worn  without  ulceration  of  the  skin, 
inasmucli  as  the  child  is  in  constant  motion,  and  the  truss  will  be  con- 
stautl}'  fouled  with  urine  and  faeces.  The  parent  or  nurse  should,  there- 
fore, be  provided  with  more  than  one  well-fitting  truss,  which  should  be 
covered  witli  oiled  silk  and  changed  when  necessary,  and  all  possible  care 
should  be  given  to  see  that  the  truss  fits  and  to  pad  it  with  cotton-wool 
wherever  it  threatens  to  chafe.  But  so  far  from  letting  an  infant  with 
hernia  dispense  with  a  truss,  it  should,  on  the  contrary,  be  worn  night 
and  day.  For  the  hernia  is  usually  of  the  congenital  form,  and  the  ring 
will  probably  close,  if  the  gut  be  kept  out  of  it,^  to  which  end  the  nurse 
should  be  instructed  to  keep  her  finger  applied  carefully  to  the  ring  even 
while  washing  the  child. 

A  single  truss  is  a  spring  surrounding  the  abdomen  just  above  the 
spines  of  the  ilia,  terminating  at  one  end  in  a  pad  and  at  the  other  in  a 
strap  with  l)uttonholes.     A  button  is  attached  on  the  back  of  the  pad  to 


Fig.  281. 


Fig.  282. 


Plight  inguinal  truss. 


Left  inguinal  truss. 


whicli  the  strap  is  secured,  and  the  truss  is  prevented  from  displacement 
by  a  straj)  fastened  to  its  l)ack  i)art,  Ijrought  under  the  thigh,  and  also 
buttoned  on  the  pad  (Figs.  281,  282).     If  the  ring  is  very  large  a  tail- 

'  Opinions  seem  to  differ  as  to  the  probability  of  the  cure  of  a  hernia  by  the  pressure 
exercisod  by  11  truss  on  the  ring,  but  no  one  questions  its  possibility ;  and  as  to  its 
occasional  occurrence,  at  any  rate  in  early  life,  I  think  I  can  testit'y  from  my  own 
experience. 


TRUSSES. 


625 


piece  is  attached  to  the  pad,  to  make  the  pressure  over  a  larger  area  (Fig. 
283).  When  there  is  hernia  on  both  sides  the  spring  has  a  pad  at  each 
end,  and  they  are  l<ept  in  position  by  a  strap  passing  from  one  to  the 
other  (Fig.  284).  Tlie  essential  requisites  of  a  good  truss  are  that  it 
should  fit  easily  round  the  bod_y,  that  its  pressure  should  be  directed 
properly,  and  should  be  great  enough  to  prevent  the  descent  of  the  hernia 
without    being  so    great    as 

either  to  be  painful  to  the  pa-  ^"'-  '^^^■ 

tient  or  to  cause  absorption 
of  the  parietes,  whereby  the 
ring  would  be  further  weak- 
ened. 

Except  in  the  case  of  infants 
the  truss  is  only  to  be  worn 
in  the  daytime,  though,  if  the 
hernia  descends  very  readily, 
the  patient  may  be  instructed 
to  apply  it  before  he  gets  up. 

The  object  of  a  truss  is  to 
exert  such  an  amount  of  pres- 
sure upon  the  ring  through 
which  the  hernia  has  de- 
scended that  its  renewed  de- 
scent shall  be  prevented  in  all 

positions  of  the  body  and  during  au}'^  exertion  which  the  patient  may 
make.  For  the  attainment  of  this  object  it  is,  of  course,  necessary,  in  the 
first  place,  that  the  hernia  should  be  completely  reduced.  This  essential 
precaution  is  too  often  neglected  b}'  ignorant  persons,  and  it  is,  therefore, 
the  surgeon's  duty  to  explain  fully  to  the  patient  how  important  it  is  to 
make  sure  of  the  complete  reduction  of  the  hernia  before  he  applies  the 
truss,  and  also  to  show  him  the  signs  by  which  he  may  make  sure  that 
the  hernia  is  really  reduced.  The  next  point  to  which  attention  should 
be  paid  is  the  choice  of  the  form  of  truss  which  is  to  be  recommended  for 

Fig.  284. 


Left  scrotal  truss. 


Double  inguinal  truss. 

the  special  case  in  hand.  It  would  be  highly  undesirable,  as  well  as 
unnecessary,  to  speak  in  this  place  of  the  inventions  of  different  instru- 
ment-makers or  surgeons.  Each  has  its  own  advantages,  when  con- 
structed on  sound  mechanical  principles,  but  those  in  common  use  and  of 

40 


626 


HERNIA. 


cheaper  construction  answer  all  ordinary  purposes  well  enough.  They 
may  be  divided  into  three  classes :  1.  Those  in  which  the  pad  which 
covers  the  hernial  aperture  is  supported  and  kept  in  place  by  a  spring 
surrounding  the  pelvis.  2.  Those  in  which  the  pad  is  kept  in  place  by 
counter-pressure  applied  to  the  loins.  3.  Those  in  which  the  pad  is  sup- 
ported on  a  lever-spring  attaclied  to  a  soft  girth  or  belt. 

The  common  truss  is  the  best  example  of  the  first  class  (Figs.  281-284). 
The  spring  encircles  the  whole  body  just  below  the  hips,  i.  e.,  the  iliac 
spines,  is  prevented  from  "riding"  or  slipping  upwards  by  a  strap  pass- 
ing from  back  to  front  between  tlie  thighs  and  buttoned  on  to  the  pad  in 
front.  If  there  is  a  double  rupture,  both  ends  of  the  spring  carry  a  pad, 
and  both  pads  are  secured  b}'  a  strap  besides  being  attached  to  each 
other  (Fig.  284). 

In  the  spiral-spring  truss  (Fig.  285)  the  pad  has  a  spiral  spring  coiled 
in  it,  and  tlie  body-spring  does  not  encircle  the  pelvis,  but  terminates  in 

Fig.  2So. 


Spiral-spring  truss. 


a  larger  pad  on  the  loins,  in  which  also  a  spiral  spring  is  coiled,  and 
which  is  attached  to  the  pad  by  a  strap  passing  round  the  sound  side  of 
the  body.  In  the  double  truss  the  two  pads  are  buttoned"  together,  and 
the  two  back  pads  are  hinged  together  or  made  into  one  ellipitical  hinged 
piece. 

The  ball-and-socket  truss  (Figs.  286,  287),  (or  Salmon  and  Ody's),  is  a 
modification  of  this,  in  which  the  pad  is  mounted  on  a  ball-and-socket,  or 
universal  joint,  and  in  the  single  form  the  sprint;  encircles  the  sound  side 
of  the  body,  crossing  in  front  of  the  pubes,  so  as  to  direct  the  pressure 
of  tlie  pad  up  the  inguinal  canal. 

The  moc-main  lever  truss  (Fig.  288)  derives  its  peculiar  designation 
from  the  Indian  name  of  the  silk-cotton  tree,  from  the  pith  of  which  its 
pad  is  formed.  But  the  main  peculiarity  of  its  construction  is  that  all 
encircling  springs  are  dispensed  with.  A  soft  belt  encircles  the  body, 
and  to  this  the  pad  is  attached,  carrying  a  horizontal  lever-spring  which 
passes  across  to  the  opposite  end  of  the  belt.  It  is  comfortable,  but 
cannot  be  trusted  to  when  anytiiing  like  forcible  pressure  is  required. 

In  applying  a  truss  the  first  thing  is  to  take  an  accurate  measurement 
of  the  patient's  body  by  a  tape  carried  from  the  centre  of  the  hernial 
opening  to  a  point  just  below  the  anterior  superior  spine  on  that  side, 
thence  horizontally  round  the  back  to  the  same  point  on  the  opposite 


TRUSSES. 


627 


side,  and  so  back  to  the  starting-point.  Tlie  length  of  the  horizontal 
line  which  joins  the  two  anterior  snperior  spines  in  front,  and  the  vertical 
distance  of  the  centre  of  the  liernial  opening  from  that  line  shonld  also 
be  noted,  and  if  the  patient  is  unusually  fat,  so  that  the   abdominal 


Fig.  286. 


Fig.  287. 


Fig.  286. — Ball-and-socket  truss.    (Salmon  and  Ody.) 
Fig.  287. — Double  truss.    (Salmon  and  Ody.) 

parietes  are  very  oblique,  it  is  desirable,  as  Mr.  Wood  suggests/  to  note 
the  horizontal  distance  of  the  hernial  aperture  from  a  plumb-line  let  fall 

Fig.  288. 


Moc-main  lever  truss. 


from  the  line  which  joins  the  anterior  superior  spines.     In  city  practice 
all  this  is  left  to  the  instrument-maker,  but  the  surgeon  ought  himself 

1  A  paper  by  Mr.  J.  Wood  on  this  subject,  in  the  Brit.  Med.  Journal,  Oct.  14, 
1871,  will  well  repay  attentive  perusal. 


628  HERNIA. 

to  see  that  the  truss  which  has  been  supplied  answers  its  purpose  in  all 
respects. 

The  following  are  the  main  qualities  of  a  good  truss  :  1.  It  should  lie 
comfortably  in  the  hollow  between  the  buttock  and  loins,  and  should  be 
so  closely  applied  to  the  hips  as  not  to  shift  in  the  movements  of  the 
patient's  body,  yet  the  spring  should  not  be  so  tight  as  to  gall  the  skin, 
nor  should  the  end  of  the  spring  project  agaiust  the  wall  of  the  bell_v.  2. 
Its  pad  should  cover  the  whole  hernial  aperture  and  the  abdominal  wall 
for  at  least  half  an  inch  around  it.  In  large  scrotal  herniiie  a  tail-piece  to 
the  pad  is  almost  essential  in  order  to  prevent  the  hernia  from  slipping 
down  under  the  lower  end  of  the  pad  (Fig.  283).  3.  The  pressure  should 
be  sufficient  to  prevent  the  descent  of  the  rupture  in  any  exertion  which 
the  patient  may  be  called  on  to  make,  but  should  not  be  so  severe  as  to 
cause  the  absorption  of  the  abdominal  wall  and  so  enlarge  the  aperture 
of  the  hernia.  Certain  it  is  that  many  patients  notice  the  hernia  get 
gradually  larger  as  the  truss  is  worn,  and  find  that  the  pad  has  to  be 
gradually  increased  in  size  in  order  to  keep  up  the  rupture.  Mr.  Wood 
attributes  this  to  the  shape  of  the  pad,  which  is  generally  made  convex, 
and  for  that  purpose  prefers  flat  pads,  believing  that  the  convex  pads 
press  the  structures  inwards  which  support  the  abdominal  wall  behind, 
and  so  destroy  their  valve-like  arrangement.  This  may  fairly  be  doubted, 
and  it  seems  to  me  that  the  convex  shape  of  the  pad  is  really  better,  since 
it  buries  itself  in  the  skin  and  fat  (beyond  which  no  effect,  I  think,  is  pro- 
duced by  the  shape  of  the  surface),  taking  a  better  hold  of  the  parts,  and 
so  saving  force  in  the  spring.  But  whatever  shape  of  pad  is  adopted  it 
ought  to  be  supported  with  the  least  force  possible,  in  order  to  prevent 
the  escape  of  the  rupture,  otherwise  not  only  will  its  application  be  irk- 
some, but  the  ring  will  certainl}^  be  enlarged.  As  it  is  almost  impossible 
to  calculate  the  variations  which  may  be  occasioned  in  the  outward  pres- 
sure of  the  rupture  by  the  jDatient's  circumstances,  those  who  are  liable 
to  be  called  on  for  extra  exertions  at  stated  times  are  sometimes  usefully 
provided  with  two  trusses,  one  for  rest,  the  other  for  exercise.^  An 
instrument  has  been  devised  by  Mr.  Wood  for  the  purpose  of  measuring 
the  resistance  of  a  rupture. 

Finally,  the  direction  in  which  the  pressure  is  made  must  correspond 
to  that  of  the  hernial  canal.  Direct  inguinal  hernia  comes  straight  for- 
ward out  of  the  belly,  and  its  neck  is  very  short.  Oblique  inguinal 
hernia,  on  the  contrary  (unless  it  has  been  long  neglected,  in  which  case 
the  neck  is  shortened  and  the  enlarged  rings  are  brought  almost  into  a 
line,  giving  it  much  resemblance  to  the  direct  form),  has  a  long  neck 
running  ol)liqucly  upwards  and  outwards,  and  the  pressure  must  be 
made  in  this  direction,  and  in  such  a  manner  that  the  pad  may  bring  the 
walls  of  the  spermatic  canal  into  contact  and  press  on  the  situation  of 
the  internal  inguinal  ring.  Femoral  hernia,  again,  has  a  short  neck 
terminating  at  a  ring  which  in  tlie  erect  position  is  nearl}^  horizontal,  so 
that  the  pressure  is  most  effectively  directed  upwards,  Ininging  the  pad 
to  bear  directly  on  Gimbernat's  ligament.  If  tlie  rupture  lias  been  ope- 
rated on,  the  corresi)onding  ring  is  often  enlarged  and  weakened,  and 
more  than  common  attention  must  be  bestowed  to  see  that  the  pad  is 
large  enough  and  makes  pressure  in  the  proper  direction. 

The  above  has  reference  to  inguinal  and  femoral  ruptures  only.     Um- 

'  Persons  who  arc  iuldictcd  to  swimming  must  have  a  special  truss  for  the  purpose, 
covered  with  india-rubber  material. 


RADICAL,    CURE.  629 

bilical  and  ventral  hernias  are  treated  by  a  belt  round  the  abdomen,  the 
belt  being  laced  behind,  and  provided  by  elastic  sides.  This  belt  carries 
a  pad  corresponding  to  the  position  of  tlie  hernial  opening,  and  so  made 
that  its  surface  is  accurately  adapted  to  the  shape  of  the  wall  of  the  belly 
and  its  outline  overlaps  the  opening  on  all  sides.  The  common  i)ractice 
in  umbilical  rupture  in  childhood  of  putting  a  nipple-shaped  pad  into  the 
orifice  seems  to  me  bad,  as  tending  to  dilate  the  opening;  at  the  same 
time  the  tendenc}^  to  natural  cure  is  so  great  that  as  a  rule  no  harm 
follows. 

"  Radical  Cure''''  of  Hernia. — The  wearing  of  a  truss  may,  it  has  been 
said,  prove  curative,  but  tliis  is  certainly  exceptional.  On  the  other 
hand,  there  are  cases  in  which  the  ring  is  so  large  that  there  is  much 
ditficulty  in  applying  a  truss ;  and  in  all  cases  a  hernia  is  a  grave  infirm- 
ity, and  exposes  the  patient  to  constant  danger.  This  danger,  however, 
is  extremely  slight,  if  proper  care  be  given  to  the  management  of  the 
truss.  The  chief  inconvenience  of  an  ordinary  reducible  hernia  is  that 
it  debars  the  patient  from  the  safe  or  comfortable  pursuit  of  various 
athletic  sports,  and  that  it  constitutes  a  bar  to  his  entrance  into  the 
public  services. 

For  one  or  other  of  these  reasons  the  patient  often  seeks  for  a  radical 
cure,  and  man}'  have  been  the  operations  proposed  for  this  object.  And 
I  think  it  ma}'  be  said  of  all  of  them,  even  those  most  recently  devised 
and  most  carefully  thought  over,  that  they  usuall}'  fail  in  their  object, 
unless  assisted  by  the  pressure  of  the  truss,  that  is  to  say,  that  they  are 
not  really  "radical  cures,"  as  they  are  generally  called.  Nor  is  this  sur- 
prising. The  object  of  the  operation  is  to  close  the  abdominal  ring. 
Now,  this  can  only  be  eflTected  in  umbilical  hernia,  for  in  inguinal  hernia 
an  attempt.absolutely  to  close  the  ring  would  certainly  involve  the  scrotal 
cord,  and  in  femoral  hernia,  the  femoral  vein.  In  femoral  hernia,  how- 
ever, the  operation  is,  I  believe,  too  dangerous  to  be  justifiable.  One 
fatal  case  attracted  some  attention  a  few  years  since,  in  which  the  bowel 
was  perforated  in  an  attempt  to  close  the  femoral  ring,  and  I  am  not 
aware  that  the  operation  has  been  repeated.  In  umbilical  hernia  the 
radical  cure  is  rarely  attempted,  since  the  congenital  form  usually  disap- 
pears in  after-life,  and  the  acquired  form  occurs  generally  in  elderly 
stout  people  who  are  not  fit  subjects  for  surgical  operation  nor  given  to 
active  pursuits,  and  the  local  conditions  are  also  usually  very  unfavor- 
able. The  operation  is,  therefore,  in  practice,  restricted  to  inguinal 
herniae  in  the  male  sex,  and  I  think  it  ought  never  to  be  performed  ex- 
cept upon  patients  who  either  (by  themselves  or  their  parents)  have  been 
properly  informed  of  its  dangers,  and  who  deliberately  choose  to  incur 
them  in  order  to  get  quit  of  the  inconvenience.  The  methods  of  Wiitzer 
and  others,  though  much  vaunted  at  the  time,  are  now,  I  believe,  ad- 
mitted to  be  nearly  universally  failures.  I  need  only  describe  the  plan 
devised  by  Mr.  John  Wood.  In  this  operation  an  assistant  reduces  the 
hernia,  and  keeps  it  most  carefully  reduced  the  whole  time,  keeping  two 
fingers  pressed  above  the  internal  ring,  so  that  there  ma}'  be  no  chance 
of  the  operator's  needle  injuring  the  gut.  The  instruments  required  ai'e 
a  stout  unyielding  needle,  in  a  handle  with  a  peculiar  curve  adapted  to 
the  shape  of  the  finger,  and  a  piece  of  stout  copper  wire  silvered,  about 
two  feet  long.  Great  care  must  be  taken  to  see  that  the  wire  is  properly 
flexible  and  free  from  kink.  An  incision  is  made  through  the  skin  of 
the  scrotum,  about  an  inch  long,  so  as  to  expose  the  fascia  covering  the 


630  HERNIA. 

hernial  sac,  the  skin  and  fascia  are  then  separated  for  about  an  inch  all 
round  the  aperture.  The  finger  is  pushed  up  along  the  face  of  the  cord, 
pushing  the  fascia  and  sac  in  front  of  it  until  it  is  fairly  within  the 
spermatic  canal  and  feels  the  internal  pillar  of  the  internal  abdominal 
rin^j-;  the  conjoined  tendon  is  then  recognized  and  carefully  taken  up  on 
the  needle,  which  is  tlien  made  to  traverse  the  superficial  parts  obliquel}^, 
upwards  and  inwards.  The  skin  is  now  drawn  upwards  and  inwards, 
and  the  needle  is  pushed  through  it.  One  end  of  the  wire  is  then  hooked 
into  the  needle's  eye  and  the  latter  is  witiulrawn,  carrying  the  wire  along 
with  it.  Then  the  needle  is  disengaged  from  the  wire  and  carried  again 
alono'  the  finger  to  the  outer  side  of  the  ring;  here  it  is  thrust  through 
the  tissues  at  the  outer  side  of  the  internal  aperture  of  the  hernia  ("  the 
anterior  aponeurosis,  close  to  Poupart's  ligament,"  as  Mr.  Wood  de- 
scribes it),  and  then  the  skin  is  brought  over  so  that  the  needle  emerges 
at  the  former  punctures.  The  other  end  of  the  wire  is  now  hooked  into 
the  needle's  eye,  and  the  latter  is  withdrawn  and  disengaged,  leaving  a 
loop  of  wire  emerging  from  the  skin  of  the  groin,  and  two  ends  which 
embrace  more  or  less  completely  tlie  internal  orifice  of  the  hernial  sac. 
Tlie  next  step  is  to  pinch  up  the  hernial  sac  and  the  fascia  covering  it, 
between  the  finger  and  thumb,  opposite  the  scrotal  opening  of  the  hernia, 
the  spermatic  cord  being  slipped  awa_y  from  their  grasp,  as  in  the  opera- 
tion for  varicocele.  The  needle  is  then  made  to  take  up  all  the  tissues 
which  lie  in  front  of  the  cord  (i.e.,  the  whole  circumference  of  the  ex- 
ternal ring  or  its  neighborhood),  and  it  is  made  to  enter  and  emerge  from 
either  corner  of  the  scrotal  wound.  The  extensibilit}'  of  the  scrotal  tis- 
sues renders  this  generally  easy.  One  end  of  the  wire  (either  end  will 
do,  but  Mr.  Wood  prefers  tliat  which  has  been  passed  through  the  con- 
joined tendon,  i.e.,  inside  the  internal  ring)  is  then  hooked  into  the  eye 
of  the  needle  and  brought  down.  Tlius,  one  of  the  ends  of  wire  is  left 
possibl}'  iyi"g  behind,  but,  as  Mr.  Wood  points  out,  more  probably  in 
most  cases  passing  through  the  tissues  of  the  sac,  and  embracing  its 
lower  orifice,  while  the  other  end  simply  traverses  the  inguinal  canal  and 
one  of  the  pillars  of  the  internal  ring.  The  two  ends  are  now  drawn 
down,  straightened  and  stretched  till  the  loop  comes  close  to  the  skin, 
where  it  is  held  by  an  assistant,  while  the  surgeon  twists  together  the 
two  ends  (counting  the  number  of  twists  wliich  he  gives,  in  order  that 
he  may  know  how  to  untwist  them  afterwards),  and  by  this  twisting  the 
tissues  around  tlie  external  ring  are,  of  course,  twisted  along  with  the 
wire.  Now  the  loo[)  is  drawn  forcibly  upwards,  so  as  to  invaginate  these 
twisted  tissues  firml}'  into  the  inguinal  canal.  Then  the  two  ends  of  the 
loop  are  twisted  a  certain  number  of  times,  so  as  to  have  a  firmly  twisted 
stalk,  but  with  still  a  loop  at  its  end;  and,  finally,  the  two  free  ends  of 
the  wire  are  passed  through. this  loop  aiid  made  fast  around  a  pad  of  lint 
which  presses  over  the  inguinal  canal.  The  patient  is  placed  in  bed,  with 
the  testicles  supported  and  the  abdominal  parietes  relaxed.  The  wire  is 
generally  left  till  about  the  eighth  or  tenth  day,  when  it  is  untwisted,  and 
is  removed  about  the  fourteenth.  8up[)uratiou  usually  lasts  for  some 
time  in  the  track  of  the  wires.  The  operation  for  inguinal  hernia  in  the 
female  is  exactly  the  same  in  principle. 

The  patient  must  not  leave  his  bed  till  the  parts  are  sufficiently  con- 
solidated to  bear  a  [)ad  and  bandage,  and  n)ust  wear  a  truss  afterwards. 

Hcrinotomij. — The  operation  for  strangulated  hernia  (called  sometimes 
Herniotomy  or  Kelotoiny)  differs  l)ut  slightly  in  the  different  forms  of 
hernia.     \n  many  particulars  it  is  the  same  in  all  forms. 


HERNIOTOMY 


631 


Fig.  289. 


Tlie  onl}^  special  instruments  required  in  an  operation  for  hernia  be- 
sides the  ordinary  contents  of  the  pocket-case,  and  an  extra  pair  of 
forceps  with  a  ver}'  fine  bite,  are  tlie  liernia  knife 
and  hernia-director.  The  knife  lias  a  probe-point, 
and  only  a  very  short  cutting  edge,  so  as  to  endanger 
the  bowel  as  little  as  possible.  It  is  made  either 
straight  or  curved,  the  latter  being  the  most  gener- 
ally convenient  shape,  especially  for  deepseated  con- 
strictions. The  hernia-director  as  usually  made  is 
merely  a  common  director  much  broader  than  usual. 
The  object  of  this  breadth  is  to  push  away  the  bowel 
from  the  edge  of  the  knife  when  the  latter  is  passed 
under  the  stricture.  Sometimes  the  director  is  pro- 
vided with  wings  for  the  same  purpose.  It  is  also 
advisable  to  have  a  stout  double  ligature  ready  on  a 
curved  needle  in  any  case  where  the  sac  may  contain 
much  omentum. 

A  free  incision  is  made  over  the  tumor  by  innch- 
ing  up  a  fold  of  skin  and  subcutaneous  tissue  and 
dividing  it.  Then  the  surgeon  cuts  down  with  care  on 
to  the  sac  which  invests  the  hernia.  This  is  usuall}^ 
done  by  i)inching  up  the  successive  layers  of  fascia, 
making  a  small  hole  in  tliem,  and  dividing  them  on 
a  director  to  tiie  extent  of  the  original  wound. 
When  the  sac  is  fairly  exposed  the  surgeon  may  ex- 
amine the  structures  around  its  neck  carefully,  pass  Hernia  knife. 
his  director  under  any  of  them  which  seem   to  be 

constricting  the  hernia,  make  a  sufficient  incision  into  them  with  the 
hernia  knife,  and  then  try  to  reduce  the  hernia.  This  will  often  succeed 
when  the  stricture  is  entirely  external  to  the  sac.  The  hernia  being  re- 
duced, the  wound  is  sewn  up.  But  if  this  attempt  has  failed,  or  if  from 
whatever  cause  the  surgeon  is  unwilling  to  try  it,  the  sac  is  next  to  be 
divided.  This  should  be  done  with  all  imaginable  care.  If  the  tension 
is  not  very  great  it  is  better  to  pinch  up  a  fold  and  divide  it  with  the  edge 
of  the  knife  turned  horizontally',  so  as  not  to  endanger  the  gut,  much  in 
the  same  way  as  the  sheath  of  an  artery  is  opened.  When  the  sac  is  too 
tense  to  permit  this  it  must  be  gently  scratched  through  till  the  fluid  or 
gut  underneath  is  reached.  In  the  great  majority  of  cases  there  is  some 
fluid  in  the  sac,  the  escape  of  which  gives  conclusive  proof  that  the  sac 
has  been  opened,  but  in  some  instances  the  gut  and  the  sac  are  completely 
in  apposition,  and  if  the  greatest  care  be  not  used  the  bowel  may  be 
wounded,  as  has  often  happened.  The  little  hole  in  the  sac  is  enlarged 
on  a  director  freely  enough  to  allow  a  complete  view  of  the  whole  con- 
tents of  the  sac.  The  surgeon  passes  his  finger  along  the  gut  or  omen- 
tum to  the  ring,  and  then  feels  the  stricture  with  his  nail.  He  carries 
the  hernia  director  along  his  nail  under  the  stricture,  and  then  insinuates 
the  cutting  edge  of  the  hernia-knife  beneath  the  constricting  band,  and 
divides  it  to  a  ver}-  slight  extent.  If  this  does  not  allow  the  easj'  reduc- 
tion of  the  hernia,  another  little  nick  must  be  made  in  the  same  or 
another  part  of  the  stricture,  so  that  the  l)Owel  can  be  reduced  without 
dangerous  violence.  Finally,  the  reality  of  the  reduction  must  be  put 
beyond  doubt  l>y  passing  the  finger  through  into  the  peritoneal  cavity, 
and  then  the  wound  is  to  be  sewn  up  and  a  pad  and  bandage  applied. 

Every  step  in  the  operation  thus  summarily  described  has  its  own  diffl- 


632  HERNIA. 

culties  and  clangers,  and  presents  many  points  for  observation.  I  will  try 
briefly  to  indicate  those  which  are  most  important. 

In  tlie  first  place,  with  reference  to  cutting  down  upon  the  sac.  It  is  a 
matter  of  great  consequence  for  the  rapid  and  satisfactory  performance 
of  the  operation  to  be  able  clearly  to  recognize  the  sac  from  the  mem- 
branes which  surround  it,  nor  is  this  at  all  easy.  The  subperitoneal  fat 
often  so  closely  resembles  the  omentum  that  the  operator  is  tempted  to 
think  that  he  has  opened  the  sac  without  knowing  it.  But  on  trying  to 
pass  his  finger  round  the  supposed  omentum  and  up  into  the  peritoneal 
ring,  he  will  find  that  he  cannot  do  so,  and  the  error  will  be  manifest. 
Much  time  is  sometimes  lost  in  carefully  dealing  with  membranes  taken 
for  the  sac  which  are  merely  the  investing  fascifE  or  the  membraniform 
layers  of  the  common  cellular  tissue.  But  the  sac  is  usually  recognized 
by  its  more  distinctly  fibrous  appearance,  and  bj^  the  color  of  the  fluid 
which  is  seen  through  it. 

Comparison  of  the  Extra-  and  Intra  peritoneal  Ojjerations. — The  parts 
constricting  the  hernia  external  to  the  sac  are  usuall}^  very  perceptible 
when  the  operation  without  incision  of  the  sac  is  indicated,  and  in  ordi- 
nary cases  of  strangulation  I  can  see  no  motive  for  exposing  the  perito- 
neal cavit3\  It  is  true  that  the  statistics  of  the  two  operations  do  not 
show  any  such  striking  differences  in  rate  of  mortality  as  to  be  decisive 
of  the  question,  for  allowing,  as  Mr.  Bryant's  ^  figures  show,  that  the  death- 
rate  is  lower  after  the  operation  performed  external  to  the  sac,  yet  it 
seems  probable  if  not  certain  that  the  cases  were  more  favorable.  But 
common  sense  (which  I  hold  to  be  a  better  guide  than  statistics)  appears 
to  me  to  be  in  favor  of  leaving  the  sac  untouched  if  possible.  A  surgeon 
attempts  to  reduce  a  hernia  by  taxis  ;  failing  in  this,  he  thinks  it  neces- 
sary to  operate.  If  he  could  reduce  the  hernia  without  cutting  the  skin 
he  would  be  well  pleased,  for  experience  will  have  taught  him  that  death 
is  excessively  rare  after  successful  taxis.  Surely,  then,  we  may  argue,  if 
it  could  be  conceived  that  the  mere  division  of  the  skin  could  make  the 
hernia  reducible  he  would  not  incise  the  deeper  parts  ;  if  the  mere 
division  of  superficial  bands  of  fascia  would  make  it  reducible  he  would 
not  expose  the  sac.  Similarly,  if  the  division  of  the  constriction  above 
the  sac  cnal)les  him  to  reduce  the  hernia,  why  should  he  open  the  peri- 
toneum ?  The  only  conceivable  motive  is  in  order  to  obtain  a  view  of  the 
hernial  contents,  in  case  it  should  prove  unadvisable  to  attempt  their  re- 
duction, and  therefore  it  ma}^  be  admitted  that  in  cases  where  the  taxis 
is  contraindicated  (see  p.  621)  the  sac  should  alvva3S  be  opened  at  once. 
And,  of  course,  if  no  constriction  can  be  found  external  to  the  sac,  and 
the  surgeon  is  clear  that  the  neck  of  the  sac  forms  the  stricture,  no  good 
can  be  done  (and  some  harm  perhaps  ma}')  by  trying  in  vain  to  reduce 
the  gut  after  having  divided  some  structures  which  are  not  really  on  the 
stretch.  But  when  any  definite  stricture  external  to  the  sac  can  be  made 
out  it  should  be  incised.  I  have  often  reduced  herniaj  by  this  operation,'^ 
and  have  never  had  to  regret  it. 

Seat  of  Stricture. — The  seat  of  stricture  varies  much  for  diflferent  kinds 

1  Practice  of  Surgorj',  p.  348. 

2  I  may  perhaps  ineiUinn  Unit  an  erroneous  idea  prevails  that  tlie  operation  exter- 
nal to  the  sac  is  not  practiced  at  St.  George's  Hospital.  Po.ssibiy  we  may  not  form  so 
high  an  opinion  of  its  advantages  as  some  do,  and  may  not  therefore  attempt  it  so 
frequently,  but  it  is  certainly  u--ed  in  all  the  cases  wiiich  seem  to  the  operator  appro- 

Sriate.     The  reader  may  refer  to  Sir  J.  Paget's  Clin.  Lect  ,  p.  127,  and  Mr.  Howard 
[arsh's  note  on  that  passage;  also  to  u  paper  by  myself  in  the  3d   vol.  of  the  St. 
George's  Hospital  Reports,  p.  322. 


HERNIOTOMY. 


633 


Fig.  290. 


of  hernia.  In  those  forms,  as  the  femoral,  which  are  surrounded  by  very 
tight  fibrous  structures,  these  are  very  liable  to  be  the  agents,  or  at  least 
the  chief  agents,  of  constriction,  while 
in  other  cases  the  sac  itself  is  alone  con- 
cerned iu  producing  the  strangulation, 
which  will  last  even  when  the  sac  and 
its  contents  have  been  liberated  from  all 
the  surrounding  parts,  as  in  reduction 
en  masne.  This  is  partly  illustrated  by 
the  accompanying  case  and  drawing. 
In  such  cases  it  is  evident  that  the  con- 
striction cannot  be  relieved  without 
opening  the  sac,  and  in  many  cases 
where  the  main  agent  of  strangulation 
is  anatomicall}^  external  to  the  sac, 
such  as  the  deep  crural  arch  or  Gimber- 
nat's  ligament  in  femoral  hernia,  yet  it 
has  become  so  buried  in  and  incorpo- 
rated with  the  neck  of  the  sac  that  prac- 
tically it  is  impossible  to  divide  it  ex- 
ternal to  the  tumor. 

Inspection  of  Contents  of  Sac. — When 
the  sac  is  opened  the  nature  of  the  fluid 
which  it  contains  should  be  noticed,  in 
respect  of  prognosis.  If  it  be  merely 
thin  serum  it  is  so  far  favorable.  Flakes 
of  lymph  speak  of  commencing  inflam- 
mation of  the  bowel;  ^  blood,  of  bruis- 
ing by  taxis  or  unusual  congestion  from 
tight  stricture;  a  dark,  sanious,  fetid 
condition,  of  commencing  gangrene; 
and  bubliles  of  gas,  of  perforation  of  the 
bowel,  which,  if  not  gangrenous,  is  rup- 
tured or  ulcerated,  and  should  be  care- 
fully examined  in  order  to  detect  the 
spot. 

Now,  the  stricture  being  divided,  the  condition  of  the  sac  and  of  the 
hernia  absorbs  the  most  careful  attention  of  the  operator.  If  there  is  both 
omentum  and  gut  in  the  sac  the  first  point  will  be  so  to  disengage  them 
from  each  other  that  the  latter  can  be  sei)arately  returned.  In  some 
cases  the  whole  sac  is  closely  lined  with  omentum,  and  when  this  is  the 
case  there  is  the  strongest  reason  for  apprehending  that  it  is  a  case  of 
what  Mr.  Hewett  has  so  well  described  as  "an  omental  sac,"  in  which 
the  bowel  descends  into  the  centre  of  a  mass  of  omentum,  and  is  con- 
stricted within  the  sac  so  formed,  by  the  thickening  of  the  tissue  at  its 
neck.  This  may  happen  in  any  form  of  hernia,  though  it  is  most  com- 
mon, I  think,  in  the  umbilical.  In  such  cases  the  omentum  must  be  care- 
fully torn  or  scratched  through  until  the  bowel  is  found  inside,  when  the 
finger  must  be  passed  along  the  bowel,  the  director  inserted  below  the 
ring  of  the  omentum,  and  the  constriction  incised  just  sufficiently  to  ad- 


Strangulation  of  a  hernial  tumor  by  the 
neck  of  the  sac,  at  the  internal  abdominal 
ring.  This  preparation  was  taken  from  the 
l)ody  of  a  patient  who  was  admitted  with  a 
strangulated  hernia,  the  size  of  a  man's  fist. 
Attempts  at  reduction  were  made  in  vain; 
then  the  patient  was  put  into  a  warm  bath, 
and  Iresh  attempts  were  no  doubt  made,  as  the 
tumor  suddenly  disappeared,  although  at  the 
time  the  hernia  was  said  to  have  disappeared 
without  being  touched.  The  man  died  six 
and  a  half  hours  afterwards,  unoperated  on. 
The  hernial  tumor  was  found  to  be  entirely 
within  the  inguinal  canal,  the  external  ring 
being  quite  free. 


^  As  a  surgical  curiosity  I  may  mention  the  presence  of  a  loose  body  in  the  hernial 
sac,  an  example  of  which  is  related  in  Path.  Trans.,  vol.  xv,  p.  96.  These  loose  bodies 
bear  considerable  resemblance  to  the  loose  cartilages.  They  are  formed  by  aggrega- 
tions of  lymph  and  fibroid  tissue,  often,  as  it  seems,  in  appendices  epiploicse,  which 
then  become  detached  ;  sometimes,  perhaps,  as  the  result  of  contusion. 


634 


HERNIA. 


mit  of  the  return  of  the  bowel.     Of  course,  in  so  dealing  with  a  vascular 

structure  like  the  omentum 
h.neraorrhage  may  be  caused, 
but  unless  the  omentum  be 
divided  the  relief  of  the 
strangulation  is  impossible. 
Treatment  of  the  Sli-angu- 
lated  Bowel. — The  omentum 
being  unravelled,or  if  neces- 
sary divided,  the  bowel  is 
exposed  ;  or  if  there  be  no 
omentum  in  the  sac  the  gut 
comes  into  view  at  once,  and 
the  surgeon  has  to  decide 
what  to  do  with  it.  In  all 
ordinary  cases  the  decision 
is  instantaneous  and  the  gut 
is  reduced  at  once,  for  it  is 
important  not  to  expose  it 
to  the  air  a  moment  longer 
than  is  necessary.  But  it 
is  by  no  means  easy  to  re- 
duce a  large  tense  mass  of 
bowel  even  when  one  has  it 
in  one's  hands,  and  much 
patience  and  care  is  neces- 
sary to  avoid  bursting  it.  In 
dealing  with  a  large  mass  of 
bowel  the  operator  should 
try  to  pass  one  end  back  at 
a  time  (and  if  the  upper  end 
can  be  distinguished  from 
tlie  lower  he  -had  better  be- 

An  "omental  sac,"  from  a  case  in  which   the  stricture  was  gi'^     ^ji^h     that)     by     gently 

relieved  hy  operation,  the  omentum  being  divided  in  order  lo  pressing  the  COllteutS  of  the 

reach  the  howel.    a  points  to  a  dense  fibrous  membrane,  ap-  \)owel     into     the     abdominal 

parently  a  condensation  of  the  different  fascise  and  neigh-  (.jj^y||;,y  ^(.W^  DUSllino"   tlie  o-nt 

boring  areolar  tissue,    b  to  tlie  peritoneal  sac  ;  c,  the  external  ^^      '' . ^      _  K\  "  ^? 

surface  of  the  omentum,  which  is  spread  out  over  the  interior 


after   it    with   a    kneading 


of  the  whole  of  the  hernial  sac;  d,  the  wound  made  in  the    motion    of     the    twO    liauds. 

operation ;  e,  the  testicle.  ^Yn    assistant    steadies   the 

This  preparation  is  from  one  of  tlie  cases  referred  to  by  Mr-  ^      r.,,       i  i         i  <•  n 

Ilew.tt  in  Med.-Chir.Trans.,vol  xxvii,  and  is  in  the  Museum    IGSt  of  the  bowel  and  follows 

oi  St.  George's  Hospital.  the  movements  of  the  sur- 

geon. When  once  a  part  of 
the  gut  is  redu(;ed  the  rest  soon  follows.  0|ierators  have  even  found  it 
necessary  in  cases  of  extreme  distension  of  the  bowels  to  prick  them  in 
one  or  two  places  with  a  needle  and  evacuate  tlie  air  from  them.  As  the,y 
collapse  and  the  three  coats  slide  on  each  other  the  punctures  in  thein  no 
longer  correspond,  so  that  no  extravasation  of  fseces  follows.  But  this 
cannot  be  necessary  except  in  very  rare  cases. 

If  the  bowel  is  found  ruptured  by  previous  taxis,  or  if  it  gives  way 
during  the  efforts  at  reduction,  yet  is  tolerably  healthy,  the  rent  should 
be  sewn  up  with  the  continuous  suture,  and  the  bowel  returned,'  and  the 

1  For  a  case  in  which  this  was  done  with  perfect  succos.s,  see  a  paper  entitled  Re- 
marks on  two  Cases  of  Strangulated  Uerniu,  in  the  St.  George's  Hospital  Keports, 
vol.  iii. 


TREATMENT  OF  STRANGULATED  OMENTUM.      635 

same  course  should  be  followed  in  case  of  an  accidental  wound  or  punc- 
ture with  the  knife. 

Ulceration. — The  bowel  may  be  ulcerated  at  the  seat  of  stricture, 
though  healthy  in  other  parts.  This  ulceration  begins  on  the  mucous 
surface,  and  is  always  seen  to  be  more  extensive  on  the  inner  than  the 
outer  face  of  the  bowel,  even  when  it  has  penetrated  all  the  coats  of  the 
gut.  It  may,  therefore,  be  going  on  without  i)eing  at  all  perceptible  ex- 
ternally ;  and  for  this  reason,  and  also  because  traction  on  the  weakened 
bowel  ma}'  break  it  down,  while  it  otherwise  might  recover,  I  think  the 
advice  generally  given  to  draw  the  herniated  bowel  down  so  as  to  exam- 
ine the  part  constricted  and  ascertain  the  absence  of  such  ulceration,  is 
mistaken,  and  1  would  only  do  so  if  the  escape  of  air  shows  that  perfora- 
tion has  occurred  somewhere.  The  reduction  of  a  bowel  in  which  such 
ulceration  is  impending  is  by  no  means  necessarily  fatal.  I  have  seen 
many  cases  in  which  after  a  few  days  faecal  fistula  has  followed  in  all 
probability  from  this  cause,  yet  the  patient  has  completely  recovered. 
The  ulcerated  part  has  been  shut  off  from  the  general  peritoneal  cavity 
bj'  inflammatory  effusion  before  perforation  has  occurred.  Tliese  tistuloe 
sometimes  remain  permanent,  but  more  frequently  contract  and  ultimately 
heal. 

Reduction  of  Inflamed  Bowel. — In  all  states  of  inflammatory  degenera- 
tion short  of  gangrene  I  think  the  counsel  given  by  Aston  Key  to  reduce 
the  bowel  into  the  peritoneal  cavity  is  judicious.  It  is  more  likel}'  to 
recover  itself  there  than  if  left  protruding,  and  if  it  does  not  do  so  fjecal 
extravasation  into  the  peritoneal  cavity  is  by  no  means  common.  On 
this  subject,  however,  every  operator  must  follow  his  own  judgment. 
There  is  no  question  that  a  gangrenous  bowel,  including  one  in  which 
gangrene  though  possibly  not  present  is  absolutel}^  commencing,  should 
be  left  in  the  sac,  the  stricture  having  been  freely  divided.  And  it  is 
better,  I  think,  to  lay  the  gut  open  and  attach  it  round  the  wound,  not 
because  there  is  any  chance  of  its  receding  into  the  belly — for  it  is  glued 
to  the  neck  of  the  sac  by  inflammatory  adhesions — but  in  order  that  the 
rest  of  the  wound  may  be  united  and  a  free  exit  left  for  fieces  at  the 
artificial  anus.  Gangrene  of  the  gut,  if  complete,  is  unmistakable  :  its 
earlier  stages  are  marked  by  mottled  greenish  discoloration  of  the  bowel, 
loss  of  lustre,  and  formation  of  blebs  under  its  serous  coat,  as  well  as  by 
the  before-mentioned  characters  of  the  serum  in  the  sac. 

Treatment  of  Strangulated  Omentum. — The  practice  of  different  sur- 
geons differs  in  dealing  with  the  omentum,  when  in  a  morbid  state,  eitlier 
from  bruising  or  inflammation.  At  St.  George's  Hospital  our  practice  is 
to  surround  it  at  its  neck  with  a  stout  double  ligature  and  cut  it  off, 
leaving  the  ends  of  the  ligature  projecting  out  of  the  wound,  and  this 
seems  as  successful  as  an}'  other  plan.  Others  prefer  simply  to  leave  it 
in  the  wound,  a  plan  which  has  the  assumed  advantage  that  the  omentum 
becomes  consolidated  to  the  ring  and  may  act  as  a  plug,  preventing  the 
return  of  the  hernia;  but  it  has  the  drawback  of  prolonged  suppuration 
in  the  unhealthy  mass,  and  possible  imperfect  closure  of  the  ring,  so  that 
instead  of  being  obstructed  it  may  be,  on  the  contrary,  kept  permanently 
open.  Others  again  having  cut  off'  the  omentum  tie  each  vessel  which 
they  find  bleeding  in  it.  If  this  plan  is  adopted  it  is  best  to  secure  the 
neck  with  a  clamp  before  cutting  the  mass  away.  The  objection  to  it  is 
that  vessels  which  do  not  show  while  exposed  may  bleed  on  being  re- 
turned into  the  abdomen.  On  the  whole,  I  liave  seen  no  reason  to  try  any 
other  than  the  first  method.  When  the  omentum  adheres  to  the  sac  it 
should  be  removed. 


636  HERNIA. 

If  the  gut  be  adherent  to  the  sac  it  is  probable  that  the  adhesions  will 
be  too  extensive  to  be  separated  ;  at  least  it  has  been  so  in  the  instances 
which  I  have  seen,  and  it  is  necessary  to  leave  the  bowel  where  it  is,  after 
dividing  the  stricture  freely.'  But  it  is  a  very  unfavorable  element  in  the 
prognosis. 

Operation  in  CaKS  of  Reduction  en  masse. — In  cases  of  suspected  re- 
duction en  masse  the  opei'ation  is  of  much  more  complicated  and  difficult 
character.  The  external  opening  must  be  made  ver}'  free,  and  the  ring 
must  be  clearh^  exposed.  In  cases  of  inguinal  hernia  an  incision  is  made 
on  a  director  up  the  spermatic  canal,  and  the  surgeon  feels  with  his 
finger  for  the  sac  or  the  bowel  as  the  case  may  be.  When  this  has  been 
found  it  is,  if  possible,  to  be  exposed  by  incision  ;  in  any  case  it  must  be 
drawn  gently  down  till  the  parts  are  fairly  in  sight.  Then  the  sac,  if  un- 
opened, is  to  be  freely  incised,  and  the  dissection  conducted  along  the 
bowel  till  the  seat  of  stricture  is  reached  and  the  constricting  tissue  so 
fully  divided  that  the  finger  can  be  passed  along  the  bowel  without  re- 
sistance into  the  peritoneal  cavity  ;  and  not  till  he  is  perfectly  satisfied 
that  no  further  constriction  exists  should  the  surgeon  try  to  reduce  the 
intestine.  In  cases  of  femoral  hernia  the  position  of  the  sac  is  prol)ably 
less  deep,  but  care  must  be  taken  to  avoid  injuring  the  femoral  vein. 

When  the  operation  is  completed  the  wound  is  to  be  carefully  adjusted 
and  dressed,  and  then  it  is  usual  to  put  on  pressure  with  pad  and  band- 
age. This  is  perhaps  a!)Solutely  necessary  only  when  the  patient  is 
troubled  with  cough,  in  which  case  the  gut  might  certainly  reprotrude ; 
and  I  liave  seen  it  do  so  even  under  the  pad,  requiring  the  wound  to  be 
laid  open  and  the  gut  reduced  afresh.  Under  ordinary  circumstances 
the  bowel  would  probably  remain  in  place  without  any  special  dressing; 
but  the  pad  does  no  harm,  and  gives  some  support  to  the  wound.  It 
need  not  be  used  after  the  first  dressing.  The  spica  bandage  is  put  over 
the  pad,  as  figured  in  the  chapter  on  Minor  Surgery. 

After  treatment. — The  after-treatment  of  cases  of  hernia  which  go  on 
favorably  is  generally  very  simple.  No  length  of  constipation  is  now  held 
to  necessitate  a  resort  to  purgatives,  so  long  as  there  are  no  symptoms 
calling  for  their  administration.  Cases  do  perfectly  well  in  which  the 
bowels  do  not  act  for  a  fortnight,  and  even  a  longer  period.  And  it  seems 
most  rational  to  avoid  any  disturbance  of  an  intestine  which  has  just 
undergone  so  serious  an  ordeal  as  exposure  and  operative  reduction 
involves.  Yet  the  indiscriminate  resort  to  opium  and  the  extreme  horror 
of  purgatives  which  some  operators  display  appear  to  me  unnecessary. 
Unless  there  is  some  special  indication  from  pain  or  restlessness,  or  some 
threatening  of  peritonitis,  I  see  no  reason  for  administering  opium,  unless 
perhaps  a  single  dose  or  a  single  subcutaneous  injection  to  pi-ocure  tran- 
quil sleep  after  the  operation.  And  wiien  the  abdomen  is  l)ecoming  dis- 
tended from  constipation  much  relief  will  be  found  from  evacuation  of  the 
bowels  by  an  enema ;  or  if  there  is  also  a  foul  state  of  the  tongue,  by  a 
gentle  purgative. 

Seqnehi-  of  Strangulation. — A  few  other  points  deserve  notice  in  speak- 

1  English  surgeons  are,  I  think,  Onanimous  in  reconnmending  the  reduction  of  the 
gut,  uniifT  filmost  all  circumstiinees.  Yet  some  French  surgeons  advocate,  on  the 
contrary,  "  kelotoniy  without  reduction  "  as  theuniversal  practice.  This  proceeding 
is,  I  think,  only  justifiable  when  the  surgeon  cannot  reduce  the  herniated  gut  with- 
out dangerous  violence.  It  loses  the  gn-at  advantage  r)!'  the  immediate  closure  of  the 
parts  about  the  nock  of  the  sac  after  operation,  whereby  the  peritoneal  cavity  is  at 
once  isolated,  instead  of  being  kept  in  open  communication  with  a  suppurating  sac. 


SEQUELS    OF    STRANGULATION. 


637 


ing  of  the  phenomena  of  strangulation,  and  of  the  operation  for  its  relief. 
In  the  first  place,  I  would  observe  that 

although   the    taxis    if    successful   in  fig.  292. 

wholly  reducing  the  bowel  is  hardly 
ever  followed  by  any  symptoms  what- 
ever (so  that  the  patient  is  at  once  re- 
stored to  his  usual  health),  yet  this  is 
not  always  the  case.  I  have  seen  two 
or  three  cases,  in  the  course  of  an  ex- 
perience of  about  a  quarter  of  a  cen- 
tury, in  which  peritonitis  has  persisted 
after  the  reduction  of  the  bowel,  and 
has  proved  fatal.'  And  a  case  lately 
occurred  under  my  care  in  which  after 
the  reduction  of  the  herniated  intestine 
it  sloughed,  and  the  patient  died  about 
ten  days  after  the  reduction  with  very 
obscure  symptoms,  which  afterwards 
were  found  to  depend  on  gangrene  of 
the  bowel  formerly  contained  in  the 
sac,  without  any  general  peritonitis. 

The  bowel  after  strangulation,  though 
neither  ulcerated  nor  gangrenous,  is 
■often  so  inflamed  as  to  be  unable  to 
resume  its  functions  at  once.  Thus, 
even  after  the  complete  reduction  of 
the  bowel,  constipation  and  vomiting 
not    unfrequently   continue ;    in    fact, 


Contraction  of  the  bowel  after  strangulation. 
The  portion  wliich  has  been  in  the  hernial  sac 
is  so  contracted  that,  at  the  time  of  exami- 
nation, water  would  hardly  flow  through  it. 
The  bowel  above  is  much  dilated,  that  below  is 
of  the  natural  calibre.  The  contraction  is  due 
to  induration  and  thiekeningof  all  the  coats  of 
the  bowel.  The  patient,  a  woman,  had  been 
operated  on  for  femoral  hernia.  At  the  operar 
tion  the  bowel  was  found  considerably  inflamed. 
She  went  on  pretty  well  for  a  time,  complain- 
,.       ,.  .,,         ,  .,.  ,  .     ing,  however,  occasionally  of  griping  and  con- 

constipation  without  vomiting  almost  stipation.  The  wound  healed,  and  a  truss  was 
invariably  follows  strangulation,  and  is  fitted  about  a  month  after  the  operation,  but 
no    doubt    salutary,    as    providing    rest    the  griping  and  constipation  became  worse,  and 

fo.l         .    .  1     •    ._      i-  -r>    J.  about  eight  weeks  after  the  operation  she  died 

_r    the    injured    intestine.       But    some-    quUe  suddenly,  as  if  from  perforation  of  the 

times  it  appears  as  if  the  bowel  were  bowel.  On  post-mortem  examination,  how- 
more  permanently  injured,  as  it  was  in  ever,  no  perforation  was  found,  nor  anyperi- 
4-i,„  ,  „  ^  1  •  I  4.1  „>„.  .,„;.,™  tonitis,  but  the  bowel  was  much  ulcerated  on 
the  case  from  which  the  accompanying  it,  „,„;ous  surface.-St.  George's  Hospital  Mu- 

figure  was  taken,  in  wiiich  the   bowel   seum,  Ser.  ix,  No.  84  c. 
which    has    been   strangulated  is  seen 

much  thickened,  narrowed,  and  obviously  incapable  of  the  natural  action, 
and  the  distension  of  the  bowel  above  the  seat  of  stricture  is  considera- 
ble. The  history  shows  this  to  have  been  the  result  of  the  inflammation 
caused  by  the  stricture. 

Peritonitis  after  the  operation  for  hernia  is  a  very  common  cause  of 
death,  being  sometimes  connected  with  inflammation  of  the  bowel ;  at 
others  with  inflammation  spreading  from  the  wound.  It  must  be  treated 
by  free  leeching,  if  the  symptoms  are  those  of  the  acute  form  of  the  dis- 
ease, fever,  rapid  and  hard  pulse,  great  pain  in  the  belly,  with  frequent 
vomiting  and  tympanitis.  After  the  leeches  bleeding  should  be  en- 
couraged by  warm  fomentations,  and  the  addition  of  mercury  to  the  opium, 
which  is  indicated  in  all  forms  of  traumatic  peritonitis,  ma}'  be  useful. 
The  low  form  of  peritonitis  is  even  more  fatal,  in  which  there  is  little  pain, 
and  a  low  irritable  pulse,  with  dry  brown  tongue,  the  nature  of  the  affec- 
tion being  marked  rather  by  vomiting  and  tympanitis  than  by  any  other 
more  definite  symptoms.    In  such  cases  the  peritoneal  cavity  will  be  found 


1  One  of  these  cases  is  reported  in  the  St.  George's  Hospital  Reports,  vol.  iii,  p.  326. 


638 


HERNIA. 


filled  with  puiiilont  serum,  and  there  will  most  likely  be  pus  diffused 
amono-  the  meshes  of  the  subperitoneal  tissue.  Here  reliance  must  be 
placed  mainly  on  opium,  stimulants,  and  fomentations,  all  depressing 
measures  be  avoidcil ;  but  the  treatment  is  rarely  successful. 

ArtifivioJ  AnuK. — Two  different  conditions  lead  to  the  discharge  of 
fa?ces  from  the  wound  after  operation,  which  ought  to  be  distinguished 
from  each  other  by  aiipropriate  names.  They  are,  however,  usually  con- 
founded under  the  common  designation  of  "  artificial  anus,"  which  is  only 
appropriate  to  one  of  tliem.  The  one,  which  should  be  Qii\\Q(\  fsecal  fis- 
tula^ depends  on  the  ulceration  of  the  bowel  in  the  course  of  the  stricture 
al)()ve  described.  A  portion  of  the  f^ces  passes  from  the  wound,  but 
another  portion  usually,  if  not  always,  is  voided  by  the  natural  passage. 
In  this  case,  as  the  ulceration  has  made  its  way  from  the  interior  or  mu- 
cous surface,  it  has  caused  a  limited  inflammation  of  the  serous  coat  by 
which  the  ulcerated  portion  of  the  bowel  has  been  glued  to  the  parietal 
peritoneum  coating  the  wound,  the  discharge  from  the  bowel  is  directed 
externall}-,  and  thus  extravasation  of  fteces  into  the  peritoneal  cavity  is, 
under  ordinary  circumstances,  prevented.  If  this  should  not  be  the  case 
profound  collapse  occurs,  speedily  followed  by  death.  More  commonl}", 
however,  there  is  no  very  great  inconvenience  connected  with  this  acci- 
dent beyond  the  appearance  of  faeces  in  the  discharge,  an  event  which 


Fig.  293. 


A,  the  internal,  and  B,  Uie  external,  views  of  a  preparation  showing  the  state  of  parts  in  artificial 
anus  after  an  operation  for  femoral  hernia. 

In  the  first  figure  may  be  seen  the  largersize  of  the  coil  of  intestine  (a),  which  Is  nearer  the  stomach 
and  has  transmitted  the  ficces,  in  comparison  with  that  of  the  lower  coil  (6),  the  very  acute  angle  at 
which  they  join,  and  the  small  extent  of  the  union  of  their  internal  or  peritoneal  surfaces.  In  b  may 
be  seen  the  aspect  of  the  opening  on  the  skin,  and  the  projecting  septum  (eperon  of  Dupuytren),  which 
divides  it  into  two  parts,  and  which  must  be  destroyed,  in  order  that  ficeal  matter  can  pass  from  the 
upper  to  the  lower  iiart  of  the  l)owel.  The  projection  of  this  septum  would  doubtless  have  increased 
had  the  patient  lived  longer.  She  was  pregnant,  and  died  after  miscarriage  about  three  weeks  from 
the  date  of  the  operation. — St.  George's  Hospital  Museum,  Ser.  ix.  No.  102. 

may  be  apprehended  when  the  gut  has  been  seen  at  the  time  of  operation 
to  be  much  inflamed,  and  when  (with  or  witliout  i)reliminary  pain  in  the 
wound)  the  discharge  has  been  noticed  to  be  foul  and  offensive.  I  have 
seen  many  such  cases  terminate  in  complete  recovery,  the  fiieces  passing 
by  the  anus  in  gradually  increasing  quantity  until  the  fistula  has  been 
soundly  healed.     J3eyond  rest  in  bed  and  the  avoidance  of  constipation  I 


ARTIFICIAL     ANUS. 


639 


do  not  know  any  treatment  which  can  be  adopted,  nor  in  cases  where  the 
fistula  lias  remained  permanent  have  I  ever  heard  any  surgical  measures 
proposed. 

But  the  condition  to  which  the  name  of  artificial  anus  is  appropriate,  and 
to  which  it  should  be  restricted,  is  that  which  is  shown  by  the  annexed  illus- 
trations (Fig.  293).  It  is  caused  by  gangrene  of  a  considerable  portion 
of  the  wall  of  the  gut,  leading  to  a  state  of  parts  which  can  only  be  reme- 
died by  a  surgical  operation.  Whilst  the  gangrenous  part  of  the  bowel 
has  been  separating,  the  living  portions  have  been  contracting  adhesions 
to  the  parietal  peritoneum,  and  the  bowel,  l)ent  at  an  angle,  is  found  (as 
in  Fig.  a)  adherent  to  the  wall  of  the  belly  all  round.  Tlie  superficial  gan- 
grenous portion  of  the  knuckle  of  intestine  having  come  away,  a  large 
orifice  is  left  (as  shown  in  Fig.  b),  in  which  the  upper  and  lower  coil  are 
seen  to  open,  much  like  the  muzzle  of  a  double-barrelled  gun,  except  that 
one  is  larger  than  the  other,  especially  after  a  time.  For  the  lower  coil 
of  intestine  (6),  as  it  no  longer  transmits  any  faeces,  shrinks  up  and  be- 
comes smaller  than  the  upper,  sometimes  obliterated  and  cord-like.  The 
septum  betvveen  the  two  orifices,  called  by  Dupuytren  the  eperon,  or  spur, 
on  account  of  its  prominence,  is  formed  by  the  posterior  wall  of  the  intes- 
tine at  the  junction  of  the  two  coils,  and  it  is  projected  forward  by  the 
bowels  which  lie  in  the  receding  angle  be- 
tween the  two.  Tiie  angle  of  junction  is  ^"^■-  -^*- 
generally  very  acute,  and  this  spur  is  some- 
times of  considerable  length.  It  is  this  pro- 
jection which  diverts  the  faeces  from  the 
upper  bowel  through  the  skin  wound  and 
prevents  them  from  passing  into  the  lower 
part  of  the  bowel.  Tiierefore,  so  long  as  this 
spur  remains  the  condition  is  incurable,  and 
the  first  step  in  the  surgical  treatment  of 
artificial  anus  is  so  far  to  destroy  the  Eperon 
as  to  permit  the  passage  of  fteces  directly 
from  the  upper  Into  the  lower  bowel.  This 
is  efiTected  by  the  gradual  pressure  of  Du- 
puytren's  enterotome.  One  blade  being 
passed  up  each  of  the  coils  of  bowel  as  high 
as  is  deemed  necessary,  they  are  connected 
together  and  are  brought  into  close  contact 
b}'  means  of  the  screw.  This  is  twisted 
tighter  and  tighter  as  ma}'  be  necessary  until 
the  instrument  ulcerates  through  the  walls 
of  both  intestines  and  drops  oflT.  While  this 
ulceration  is  in  progress,  the  peritoneal  sur- 
faces of  the  two  coils  of  intestine  pour  out 
lymph  and  adhere  together  all  round  the  portion  included  in  the  blades 
of  the  enterotome.  This  prevents  any  efiTusion  of  fteces  into  the  peritoneal 
cavity.  The  contents  of  the  upper  bowel  (a)  now  pass  freely  into  the 
lower  bowel  (6)  within  the  peritoneal  cavity,  the  eperon  withers  avvay,  and 
the  wound  contracts.  It  may  possibly  heal  of  itself.  If  not  its  edges 
must  be  cautiously  refreshed  and  a  piece  of  skin  be  transplanted  into  the 
opening,  if  the  orifice  is  too  large  to  admit  of  the  edges  being  brought 
into  direct  contact. 

The  dangers  connected  with  this  operation  are  mainly  two.  One  is  that 
a  coil  of  bowel  may  lie  in  the  receding  angle  betvveen  the  two  coils  a  and 
6,  Fig.  A,  and  this  may  be  caught  or  bruised  by  the  enterotome.  To  avoid 


Dupuytreu's  enterotome. 


040  HERNIA. 

this  all  imaginable  care  sbonld  be  taken  to  examine  well  with  the  two 
forefingers  in  order  to  make  sure  that  there  is  nothing  except  the  walls 
of  the  bowel  between  the  blades  of  the  instrument.  The  other  danger  is 
that  the  adhesions  may  not  form  sutRciently,  and  that  the  faeces  may 
escape  into  the  peritoneal  cavity. 

I  ought  not  to  quit  the  subject  without  adding  that  there  are  cases  in 
which  the  sloughing  of  a  considerable  portion  of  bowel  may  take  place, 
and  yet  no  permanent  artificial  anus  may  result.  Thus  Mr.  Hey  relates 
an  instance  from  Sir  A.  Cooper's  practice  in  which  the  bowel,  in  an  opera- 
tion for  femoral  hernia,  was  found  extensively  mortified;  an  incision  an 
inch  and  a  half  long  was  made  in  it,  and  its  contents  evacuated.  The 
mortified  portion  of  intestine  separated  by  sloughing,  and  from  the  length 
of  the  incision  it  seems  certain  that  it  must  liave  comprised  the  whole  cir- 
cumference of  the  bowel ;  yet  soon  afterwards  the  faeces  passed  naturally 
and  the  wound  ultimately  healed,  the  patient,  a  woman,  passing  through 
the  efforts  of  parturition  afterwards  without  ill  effects.  In  such  cases 
some  accidental  adhesion  probably  has  prevented  the  two  coils  of  bowel 
from  becoming  bent  at  an  angle  with  each  other,  and  has  thus  hindered 
the  formation  of  the  projection  of  the  posterior  wall  of  the  bowel  which 
directs  the  faeces  out  of  tlie  wound. 

We  must  now  speak  of  the  various  anatomical  forms  of  hernia,  and  of 
the  treatment  appropriate  to  each,  and  first  of  inguinal  hernia. 

Inguinol  hernia  is  divided  into  two  varieties,  according  to  the  position 
of  the  neck  of  the  sac  with  regard  to  the  epigastric  artery.  If  the  neck  of 
the  sac  be  internal  to  the  artery  it  is  called  a  direct  or  an  internal  hernia; 
if  external,  an  oblique  or  external  hernia.  The  latter  is  much  the  more 
common.  The  oblique  variety  passes  out  through  the  internal  or  deep 
abdominal  ring,  traverses  the  spermatic  canal,  appears  below  the  skin 
through  the  external  or  superficial  ring,  and  then  drops  into  the  scrotum. 
Its  coverings,  therefore,  will  be  the  skin,  subcutaneous  tissue  and  super- 
ficial fascia,  the  intercoluranar  fascia,  the  cremaster  muscle,  the  infundi- 
buliform  fascia,  the  subperitoneal  cellular  tissue,  and  the  peritoneal  sac. 

Different  Forms. — There  are  numerous  forms  of  oblique  inguinal  hernia. 
The  first  is  the  congenital^  in  which  the  internal  abdominal  ring  and  the 
infundil)uliform  process  of  the  peritoneum  liave  never  been  obliterated, 
but  the  general  peritoneal  cavity  communicates  freely  with  the  cavity  of 
the  tunica  vaginalis.  When  this  communication  is  of  very  small  size  no 
symptoms  need  be  caused  by  it.  It  is  recorded  that  in  the  post-mortem 
examination  of  Sir  A.  Cooper's  body  a  minute  canal  was  discovered  lead- 
ing from  the  internal  ring  to  the  tunica  vaginalis  on  both  sides;  yet  lie 
never  suffered,  as  far  as  is  known,  from  either  hydrocele  or  hernia.  When 
too  small  to  allow  the  passage  of  the  bowel  or  omentum  it  may  give  rise 
to  hydrocele.  Larger  communications  will  give  rise  to  hernia.  An  exam- 
ple is  figured  below  (Fig.  295),  in  which  this  communication  existed  on 
both  sides,  and  will  serve  to  illustrate  the  state  of  parts  which  predis- 
poses to  congenital  hernia.  Such  a  state  of  parts  may,  however,  long  con- 
tinue before  the  hernia  actually  makes  its  appearance.  I  have  known  the 
hernia  to  show  itself  for  the  first  time  after  tlie  age  of  forty,  and  even  later 
periods  have  been  recorded.  By  congenital  hernia,  tlierefore,  is  meant 
in  surgical  language  not  precisely  a  hernia  originating  at  or  before  birth, 
but  a  hernia  which  takes  place  through  a  congenital  ojjening.  The  pecu- 
liarity of  congenital  inguinal  hernia  is  that  the  gut  and  testicle  are  in  con- 
tact.    When  fully  formed  and  large  the  testicle  is  buried  in  the  bowels 


HERNIA    AND    RETAINED    TESTIS. 


641 


instead  of  being  below  or  behind  the  tumor,  as  in  ordinary  inguinal 
hernia;  but  it  is  impossible  without  operation  to  do  more  tlian  surmise 
the  precise  nature  of  the  hernia  apart  from  a  trustworthy  history.  At  the 
operation  the  presence  of  the  testicle  in  the  sac  is  conclusive.  Congenital 
hernia  may  be  known  in  the  infant  from  congenital  hydrocele  by  its  want 
of  transparency,  the  hydrocele  being  always  quite  transparent,  and  also 
by  the  feeling  of  gurgling  in  the  bowel,  which  is  rarely  absent. 

Retaiyied  Testis. — There  are  other  congenital  conditions  which  may  in- 
volve the  existence  of  inguinal  hernia.  Of  these  the  most  frequent  is  the 
retention  of  the  testis  in  the  inguinal  canal.  This  keeps  the  internal 
ring  patulous,  and  a  hernia  may  easily  come  down  which  usually  adheres 
to  the  testicle,  but  which  may  pass  beyond  it  even  into  the  scrotum. 
The  annexed  engraving  (Fig.  296)  illustrates  this.     It  shows  the  testicle, 

Fig.  295.  Fio.  296. 


Fig.  295.— Non-clos\ire  of  the  pouch  of  the  tunica  vaginalis,  from  a  case  in  which  this  state  of  things 
existed  on  both  sides.  On  this,  the  right  side,  there  was  no  hernia,  the  ring  not  being  sufficiently  dis- 
tended. But  on  the  opposite  side  a  hernia  existed  which  was  strangulated  and  was  operated  on  with  a 
fatal  result.    The  patient  was  five  mouths  old.— St.  George's  Hospital  Museum,  Ser.  ix.  No.  82. 

Fig.  296.— Retained  testicle  and  sac  of  congenital  hernia,  seen  from  the  abdomen.  The  testis  is  the 
globular  body  with  a  narrow  neck  seen  on  the  left  side  of  the  drawing,  the  more  cylindrical  tumor  to 
the  right,  and  behind  it  is  the  hernial  sac. 

The  scrotal  cord  is  attached  to  the  testicle  and  descends  beyond  it  through  the  inguinal  canal,  and 
the  gubernaculum  is  plainly  shown  in  the  preparation  attached  to  the  testis.  The  retained  testis  is 
healthy  and  natural  in  character,  as  determined  by  the  microscope ;  the  spermatic  cord  and  the  testicle 
are  adherent  to  the  abdominal  aspect  of  the  internal  inguinal  ring.— St.  George's  Hospital  Museum, 
Ser.  ix.  No.  91. 


which  is  adherent  to  the  internal  inguinal  ring,  along  with  the  spermatic 
cord,  and  has  evidently  been  occasionally  in  the  canal  and  at  other  times 
in  the  abdomen.  Connected  to  the  testicle  is  a  hernial  sac,  which  can 
travel  independently  of  the  testicle,  outside  the  inguinal  ring. 

In  all  cases  of  hernia  it  is  most  necessary  to  examine  the  scrotum  care- 
fully, and  if  it  is  found  that  the  testicle  has  not  descended  on  that  side, 
then  a  very  careful  examination  of  the  inguinal  canal  should  be  instituted, 
in  order  to  see  whether  the  testicle  is  detained  there,  and  if  any  bowel 
can  be  felt  to  adhere  to  it,  or  to  move  independently  of  it.  The  mere 
retention  of  the  testis  in  the  canal,  together  with  some  accidental  lesion, 
will  produce  pain  and  vomiting ;  and  if  constipation  be  also  accidentally 
present,  I  have  more  than  once  seen  it  mistaken  for  strangulated  hernia. 

41 


642 


HERNIA. 


When  the  nature  of  the  case  is  plain,  if  sj-mptoms  of  strangulation  be 
present,  the  operation  should  be  at  once  performed  ;  and  it  is  better,  I 


Fig.  299. 


Fig.  297. — Diagram  of  congenital  inguinal  hernia.  The  process  of  peritoneum  which  passes  down 
■with  the  cord  (funicular  process)  remains  freely  open  ;  the  general  cavity  of  the  peritoneum  is,  there- 
fore, identical  with  that  of  the  tunica  vaginalis  testis  forming  the  hernial  sac,  the  bowel  contained  in 
which  is  in  direct  contact  with  the  testicle. 

Fici.  298. — Diagram  of  the  (assumed)  condition  of  the  parts  in  an  infantile  hernia.  The  tunica  vagi- 
nalis (1)  is  closed  above,  at  or  near  the  external  inguinal  ring,  but  its  funicular  portion  is  open.  The 
bowel  in  the  hernial  sac  lies  behind  this  funicular  portion,  and  is  represented  in  the  diagram  as  having 
made  its  way  between  the  funicular  process  and  the  cord.  The  relation  of  the  sac  to  the  cord  seems, 
however,  to  be  variable.  The  bowel  is  covered  in  cutting  down  from  the  skin  by  three  layers  of  peri- 
toneum, viz.,  1  and  2,  the  opposite  surfaces  of  the  funicular  process,  and  3  the  anterior  layer  of  the 
peritoneal  hernial  sac. 

Fig.  299. — Another  variety  of  infantile  hernia  (the  encysted  form).  The  bowel  instead  of  passing 
behind  the  closed  funicular  process  has  distended  the  membrane  which  closes  its  upper  end,  and  has 
pushed  itself  into  the  funicular  process,  the  upper  or  back  wall  of  which  envelops  it.  In  this  case, 
therefore,  the  hernial  sac  is  furnished  by  the  funicular  process  itself,  and  only  two  layers  of  peritoneum 
cover  the  intestine. 

think,  to  remove  the  misplaced  testicle.  Such  testicles  are  constant 
sources  of  trouble,  and  it  seems  very  dubious  whether  they  are  of  any 
real  use. 


Fig.  300. 


Fig.  301. 


Fh..  :iiii). — Diagram  of  the  common  scrotal  hernia.  The  tunica  vaginalis  is  seen  behind  and  below^ 
and  is  represented  as  distended  with  a  certain  amount  of  hydrocele  fluid,  but  quite  distinct  from  the 
hernial  sac. 

Fig.  301. — Diagram  of  partial  obliteration  of  the  funicular  process,  to  illustrate  the  formation  of  the 
hernia  "en  bissac  "  and  of  cysts  in  the  cord  (encysted  hydrocele  of  the  cord).  The  cavity  of  the  tunica 
vaginalis  testis  is  closed  at  c ;  the  funicular  process  is  also  separated  from  the  peritoneal  cavity  at  a, 
the  situation  of  the  aMominal  ring.  Tliere  is  also  another  septum  at  h.  When  one  or  more  of  these 
septa  are  absent  or  imperfect  various  conditions  occur,  as  explained  in  the  text. 

Fig.  302. — Diagram  of  the  (ormation  of  the  "hernia  into  tlic  funicular  process  of  the  peritoneum" 
of  Hirkett  and  i)f  tlie  "hernie  en  bissac"  of  French  authors.  Keferring  to  the  diagram.  Fig.  301,  the 
septum  or  obliteration  at  c  is  supposed  to  be  absent, so  that  the  tunica  vaginalis  is  open  as  high  as  the 
septum,  b,  whicli  is  in)perfect,  or  has  given  way  from  some  accidental  cause.  In  the  diagram  the  septum 
at  the  external  abdominal  ring,  a,  is  drawn  as  being  widely  open,  but  strangulation  may  occur  either 
in  this  septum  or  at  b,  somewhat  lower  down,  or  at  both. 


BUBONOCELE.  643 

If  the  hernia  be  not  strangulated  the  question  of  wearing  a  truss  oc- 
curs. Whenever  a  truss  can  be  tolerated  it  should  be  worn,  irrespective 
of  the  probabilit}^  of  atrophy  of  the  testis  from  its  pressure.  For  the 
disuse  of  the  truss  certainly  entails  risk  of  increase  of  the  hernia  and  of 
strangulation  ;  while,  if  the  testis  is  incapable  of  secreting  (as  most  of 
these  retained  testes  seem  to  be)  its  atrophy  is  a  matter  of  no  conse- 
quence. Generally,  however,  the  organ  is  too  sensitive  to  bear  the  pres- 
sure, and  then  a  suspensory  bandage,  or  a  concave  pad,  must  be  fitted. 
If  the  testicle  is  liable  to  frequent  attacks  of  inflammation  it  may  be 
worth  the  patient's  wliile  to  submit  to  its  removal,  in  which  case  care 
must  be  taken  not  to  wound  the  hernial  sac. 

The  next  form  of  oblique  hernia  is  that  described  b}^  Mr.  Hey  under 
the  name  of  hernia  infantilis,  and  which  is  also  called  encysted  hernia. 
In  this  form  the  communication  between  the  peritoneal  cavity  and  the 
infundibuliform  process  leading  into  the  tunica  vaginalis  is  obstructed  at 
or  about  the  external  (or  superficial)  ring,  but  the  process  itself  is  not 
obliterated,  so  that  the  cavity  of  the  tunica  vaginalis  extends  up  to  the 
external  ring.  Then  a  hernia  comes  down  and  generally  slips  behind 
this  upper  prolongation  of  the  tunica  vaginalis  (Fig.  298) ;  but  the  her- 
niated bowel  ma}'  bury  itself  in  the  upper  end  of  the  infundibuliform 
process  and  thus  be  encysted  by  it  (Fig.  299).  This  may  occur  in  con- 
sequence of  adhesions  having  obstructed  the  neck  of  the  infundibuliform 
process  and  formed  a  membrane.  This  membrane,  being  distended  by 
the  protruding  bowel,  forms  a  hernial  sac  for  it. 

It  seems  certain  also  that  there  ma}-  be  two  other  forms  of  congenital 
inguinal  hernia,  viz.,  one  where  the  funicular  process  is  obliterated  at  its 
lower  part,  so  that  it  is  not  in  communication  with  the  tunica  vaginalis, 
but  the  upper  end  and  body  of  this  process  is  not  obliterated,  so  that 
the  peritoneal  cavity  extends  down  to  the  testicle.  This  remains  usually 
without  any  hernia  till  the  commencement  of  adult  life,  when  in  some 
violent  effort  a  hernia  suddenly  comes  down  and  is  often  acutely  strangu- 
lated. Or  the  state  of  parts  maj'  have  been  that  which  has  just  been 
described  as  the  initial  stage  in  the  formation  of  infantile  or  encysted 
hernia,  i.  e.,  the  upper  end  of  the  funicular  process  may  have  been  ob- 
structed, and  this  obstructing  medium  may  have  given  way,  causing  a 
hernia,  which  now  is  reall}'  one  of  the  congenital  form,  and  which  also 
will  probably  be  acutely  strangulated.  It  is  in  this  way  that  Mr.  Birkett 
explains  the  indubitable  fact  of  the  frequent  occurrence  of  acutely  stran- 
gulated inguinal  hernite,  in  some  of  which  the  testicle  is  found  in  the  sac, 
and  not  in  others.  Hey,  in  describing  his  infantile  hernia,  has  pointed 
out  that  the  membrane  which  shuts  off  the  cavity  of  the  peritoneum  from 
the  expanded  or  infantile  tunica  vaginalis  (Fig.  298)  may  give  way  again 
and  admit  a  hernia  into  the  cavity  containing  the  testicle,  the  hernia 
being  therefore  of  the  congenital  form,  though  it  does  not  occur  congeni- 
tally  nor  from  congenital  patency  of  the  funicular  process ;  and  he  cites 
a  passage  in  which  William  Hunter  had  pointed  out  the  possibility  of 
this  event,  though  he  had  never  seen  a  case  (Hey's  Pract.  Obs.  in  Sur- 
gery, p.  229). 

The  other  forms  of  inguinal  hernia  are  acquired,  i.e.,  they  form  slowly, 
the  inguinal  canal  being  in  the  condition  natural  to  the  adult  (Fig.  300). 

Bubonocele. — The  peritoneum,  containing  omentum,  gut,  or  both,  is 
slowly  projected  at  the  internal  ring  down  the  scrotal  canal.  If  the 
hernial  tumor  has  not  reached  the  external  ring  the  disease  is  termed 
bubonocele.     It  presents  a  small  rounded  swelling,  traceable  to  the  inter- 


64-4 


HERNIA. 


iial  ring,  where  it  becomes  lost  without  an^'  neck,  very  little  movable,  with 
an  impulse  on  coughing,  and  reducible  under  ordinary  circumstances. 
Its  diagnosis  is  sometimes  difficult,  the  affections  with  which  it  is  most 
liable  to  be  confounded  being  enlarged  inguinal  glands  and  encysted 
hydrocele  of  the  cord.  Neither  mistake  is  possible,  however,  when  the 
bubonocele  is  completely  reducible,  and  presents  a  distinct  impulse.  If 
the  symptoms  of  strangulation  should  be  present  they  are  always  a  suffi- 
cient reason  for  treating  the  disease  as  a  hernia  and  cutting  down  on  the 
tumor,  though  there  is  no  doubt  that  a  cyst  lying  high  up  in  the  cord 
ma}'  so  for  simulate  a  bubonocele  as  to  deceive  the  best  surgeons,  the 
symptoms  having  depended  on  the  strangulation  of  some  small  deep- 
seated  hernia  (such  as  obturator  hernia)  or  on  strangulation  of  the  bowel 
inside  the  peritoneal  cavity  (see  Figs.  275,  p.  612,  and  308,  p.  651).  Usu- 
all}^  however,  a  cyst  in  the  cord  or  an  enlarged  gland  can  be  pulled  down 
sufficiently  to  convince  the  surgeon  that  it  is  separate  from  the  internal 
ring.  Besides  which  the  cyst,  if  it  is  at  all  large,  will  show  its  character- 
istic transparency  on  very  careful  examination,  and  the  position  of  the 
inguinal  glands  is  not  exactlj'  that  of  inguinal  hernia.  However,  when 
any  doubt  exists  and  the  symptoms  of  strangulation  are  present,  it  is 
far  more  prudent  to  ascertain  the  nature  of  the  case  by  an  exploratory 
operation. 

The  common  external  or  oblique  hernia  forms  a  large  tumor  which  lies 
generally  above  or  in  front  of  the  testicle,  with  a  long  neck  reaching  up 

Fig.  303. 


An  oblique  inguinal  hernia.  The  sac  contains  a  large  amount  of  omentum.  The  testicle  is  seen  at 
its  lower  part.  Running  round  the  neck  of  the  sac  and  close  to  the  inner  border  of  the  ring  may  be 
seen  the  epigastric  artery  (a),  the  position  of  which  and  of  the  internal  ring,  concealed  here  by  the 
omentum  in  the  sac,  arc  indicated  by  dotted  lines. 

to  the  position  of  the  internal  ring,  the  cord  being  generally  behind  it, 
though  instances  are  not  wanting  in  which  the  cord  is  spread  over  the 
front  of  the  tumor,  or  in  which  the  elements  of  the  cord  are  separated 


OBLIQUE    INGUINAL    HERNIA. 


645 


and  lie  on  either  side  of  the  neck  of  the  sac.  The  abdominal  muscles 
are  tightly  spread  over  the  upper  part  of  the  neck  of  the  sac  in  the 
canal ;  and  I  have  met  with  several  cases  iu  which  strangulation  has  been 
produced  by  tight  bands  running  across  it,  probably  portions  of  the  ten- 
don of  the  external  oblique,  on  the  division  of  which  the  hernia  was  at 
once  reduced.  The  neck  of  the  sac  is  often  most  tightly  constricted  at 
the  internal  ring  (see  Fig.  290,  p.  633),  and  this  lies  at  a  very  great  depth 
when  there  is  a  large  hernial  tumor,  besides  which  there  are  often  one  or 
more  minor  constrictions  in  the  course  of  the  canal  which  must  be  di- 
vided before  the  operator  arrives  at  the  ring.  So  that  the  operation  is 
often  both  severe  and  troublesome.^  The  epigastric  artery  lies  close  to 
the  inner  margin  of  the  ring  (Fig.  303)  and  at  its  lower  border.     The 


The  same  hernia  seen  from  the  outside. — St.  George's  Hospital  Museum,  Ser.  ix,  No.  72. 

incision  into  the  neck  of  the  sac  should  therefore  be  directed  upwards. 
When  the  hernia  is  of  gradual  formation  and  old  standing  the  neck  be- 
comes much  more  oblique  and  relatively  shorter,  so  that  its  month  is 
more  easily  reached.  Such  herniae,  also,  are  far  more  likely  to  be  stran- 
gulated external  to  the  sac,  and  to  be  susceptible  of  relief  by  the  extra- 
peritoneal operation. 

The  operation  for  bubonocele  is  of  the  same  nature  as  that  for  scrotal 
hernia.  In  both  an  incision  is  to  be  made  along  the  long  axis  of  the 
tumor,  which  is  most  conveuiently  done  by  pinching  up  a  fold  of  skin 
transversely'  and  transfixing  it,  the  incision  being  made  of  sufficient 
length  to  give  easy  access  to  the  neck  of  the  sac  at  tlie  internal  ring. 
The  various  layers  of  fascia  having  been  divided  successively^  (on  a 
director,  if  they  are  tense),  the  surgeon  may  examine  for  anj'^  bands 
which  he  can  feel  constricting  the  tumor  external  to  the  sac  and  divide 


^  Such  constrictions  sometimes  form  real  double  sacs,  as  would  be  the  case  in  Fig. 
301,  if  the  septa  a  and  c  were  imperfect,  and  the  hernia  after  passing  through  them 
had  become  enlarged  or  the  septa  had  contracted  so  that  the  gut  were  strangulated 
at  both  points. 


646  HERNIA. 

tliem  by  passing  a  probe-pointed  bistoury  beneath  them.  If  the  hernia 
is  still  irreducible  the  sac  must  be  opened  and  the  neck  of  the  tumor 
traced  up  into  the  peritoneal  cavity,  in  doing  which  the  seat  of  strangu- 
lation will  be  met  with.  In  a  voluunnous  tumor,  with  a  tight,  deep- 
seated  stricture,  much  care  is  needed  (especiall}'  with  an  inexperienced 
assistant)  to  keep  the  bowel  out  of  harm's  way  while  incising  the  stric- 
ture. It  is  of  no  use  to  commence  the  reduction  of  the  bowel  until  the 
stricture  has  been  so  thoroughly  divided  that  the  finger  passes  easil}'' 
into  the  cavity  of  the  peritoneum  and  it  is  of  course  necessary  to  have 
the  bowel  and  omentum  freed  from  an}-  entanglement  with  each  other, 
and  to  ascertain  the  absence  of  adhesions. 

Direct  inguinal  hernia  is  far  less  common  than  oblique.  It  does  not 
occur  congenitally  in  the  male  sex  at  least.  The  bowel  protrudes  in  the 
space  denominated  the  triangle  of  Hesselbach,  which  is  bounded  exter- 
nally by  the  epigastric  artery  and  internally  by  the  sheath  of  the  rectus 
muscle,  Poupart's  ligament  forming  its  base.  Two  varieties  of  this  hernia 
are  described  in  the  anatomical  theatre  as  occurring  in  cases  where  the 
obliterated  h^ypogastric  artery  divides  Hesselbach's  triangle  into  two 
parts.  In  the  ordinary  state  of  parts  it  seems  more  common  for  the 
course  of  this  obliterated  vessel  to  correspond  pretty  nearl}'  with  that  of 
the  epigastric.  Its  projection  inwards  throws  the  peritoneum  into  two 
fosstB,  the  bottom  of  the  internal  fossa  being  at  the  external  or  super- 
ficial ring,  while  the  bottom  of  the  external  fossa  will  lie  at  the  internal 
or  deep  ring  when  the  course  of  the  hypogastric  and  epigastric  vessels 
corresponds,  but  will  be  internal  to  the  deep  ring  when  the  obliterated 
arter}-  runs  across  the  triangle ;  and  in  the  latter  case  the  hernia  will 
push  before  it  the  wall  of  the  spermatic  canal,  and  pass  down  a  portion 
of  that  canal  before  reaching  the  superficial  ring.  This  causes  a  slight 
diflerence  in  the  coverings  of  these  two  forms  of  hernia.  The  common 
form  of  direct  hernia  is  covered  by  the  skin,  subcutaneous  tissue  or 
superficial  fascia,  intercolumnar  fascia,  conjoined  tendon,  transversalis 
fascia,  and  subperitoneal  tissue,  while  the  less  usual  form  has  the  cre- 
master  muscle  or  fascia  in  place  of  the  conjoined  tendon.  This  is  not  a 
matter  of  any  consequence  ;  in  fact,  it  could  only  be  demonstrated  by 
very  careful  dissection  ;  what  is  of  more  sui-gical  importance  is  to  re- 
raemljer  that  the  neck  of  the  sac  may  be  very  close  to  the  epigastric 
artery.  In  the  ordinary'  form  the  epigastric  artery  is  at  such  a  distance 
as  to  be  quite  out  of  the  way  in  an  operation.  In  all  cases,  therefore,  it 
is  belter  to  incise  the  neck  of  the  sac  directly  upwards.  Direct  inguinal 
hernia  passes  at  once  into  the  scrotum,  and  its  diagnosis  is  not  usually  a 
matter  of  any  ditticulty.  The  neck  of  the  sac  is  more  superficial  than  in 
oblique  hernia,  and  the  operation  is  therefore  simpler,  but  is  the  same  in 
principle  and  in  most  of  its  details. 

Inguinal  hernia  occurs  also  in  females,  and  a  certain  amount  of  pro- 
trusion at  the  external  ring  and  into  the  top  of  the  labium  is  very  com- 
mon in  female  infants — congenital  hernia — which  as  a  rule  graduall}"^ 
disai)i)ears  without  any  treatment,  but  if  unusually  large  requii'es  the 
constant  a[)pli('ation  of  a  truss  just  as  congenital  hernia  does  in  the  male. 
A  congenital  hydrocele  (hydrocele  of  the  round  ligament)  also  occurs  in 
females,  and  may  be  mistaken  for  iiernia,  though  the  disease  is  a  rare 
one.  In  infancy  I  am  not  aware  that  the  difliculty  occurs,  but,  in  the 
adult,  cases  have  been  recorded  in  which  an  operation  has  been  necessary 
in  order  to  settle  the  diagnosis.  The  tense  nature  of  the  tumor,  the  want 
of  impulse  on  coughing,  and  in  some  cases  its  translucency,  are  the  chief 


FEMORAL    HERNIA. 


647 


diagnostic  marks ;  but  in  tliis,  as  in  all  other  embarrassments  of  diag- 
nosis, when  the  symptoms  are  sufficiently  urgent  to  justify  it,  an  explora- 
tory' operation  should  be  early  performed.  The  inguinal  hernia  of  later 
life  in  females  is  of  the  acquired  form  and  usually  direct.  No  special 
directions  are  necessary  for  the  operation  in  cither  form. 

Femoral  l^ernia  occurs  more  commonly  in  the  female  than  in  the  male 
sex,  although  it  is  by  no  means  rare  in  men.  The  hernia  is  never  of  the 
congenital  form,  and  therefore  occurs  very  rarely  in  childhood.  There 
seems  no  doubt  that  pregnancy  and  parturition  predispose  to  it.  The 
neck  of  the  sac  is  at  the  crural  ring,  which  is  tightly  constricted  at  its 
inner  and  upper  part  by  tlie  deep  crural  arch,  the  upper  cornu  of  the  falci- 
form opening  and  Gimbernat's  ligament.  The  pressure  of  these  dense 
unyielding  structures  often  causes  very  acute  strangulation,  in  which  cir- 
cumstances the  symptoms  are  urgent  and  taxis  unsuccessful.     The  neck 

Fig.  305. 


Femoral  hernia.  External  view.  Tlie  internal  view  of  this  preparation  is  .shown  as  Fig.  306. 
a  shows  the  sac  ;  b  the  omentum  contained  in  it.  The  femoral  vessels  are  seen  on  the  interior  of  the 
sac  displaced  outwards,  so  as  to  be  tlirown  into  a  curve.  The  mouth  of  the  circumflex  iliac  artery  is 
shown  passing  outwards,  and  that  of  a  large  vein  is  seen  close  to  the  outer  border  of  the  hernial  sac. 
— St.  George's  Hospital  Museum,  Ser.  ix,  No.  84  a. 

of  the  sac  can  be  traced  below  Poupart's  ligament,  though  its  fundus,  or 
the  bod}'  of  the  tumor,  in  many  cases  rises  up  into  the  abdomen,  lying 
upon  that  ligament.  The  coverings  of  a  femoral  hernia  are  the  skin,  the 
subcutaneous  tissue  and  superficial  fascia,  the  cribriform  fascia,  the  sheath 
of  the  vessels,  the  crural  septum,  and  the  subperitoneal  tissue.  The 
crural  ring,  or  the  mouth  of  the  sac,  has  on  its  outer  side  the  femoral 
vein,  and  the  epigastric  vessels  lie  a  little  above  it ;  but  it  has  usually  no 
important  vessels  at  its  inner  and  upper  angle,  where  the  incision  is 
made  to  relieve  strangulation.  The  anastomosing  artery  between  the 
epigastric  and  obturator  passes  around  the  ring,  and  its  size  varies  con- 
siderably, so  that  sometimes  free  bleeding  occurs  in  this  incision,  and  in 
fact  I  have  known  such  hgemorrhage  prove  fatal  in  a  case  where,  the 
vessels  being  uninjected,  no  conspicuous  artery  could  be  detected  at  the 


648 


HERNIA. 


post-mortem  examination.  But  in  cases  of  anomalous  origin  of  the 
obturator  artery  tlie  trunk  of  this  A'essel  may  entirely  encircle  the  ring, 
so  as  to  be  in  danger  of  being  divided  at  the  operation.  This  is  not 
ordinaril}' the  ease  even  when  the  obturator  comes  off  from  the  epigastric, 
for  the  anomalous  artery  usually  takes  its  course  towards  the  obturator 
foramen  on  the  outer  side  of  the  sac,  as  shown  in  Fig.  306,  and  is  quite 

Fig.  30G. 


Irregular  distribution  of  tlie  obturator  vessels  iu  a  case  of  femoral  hernia.  The  obturator  artery 
arises  from  the  external  iliac  close  to  the  origin  of  the  epigastric  ;  the  vein  opens  into  the  epigastric 
vein.  As,  however,  they  lie  on  the  outside  of  the  hernial  sac,  the}'  could  he  in  no  danger  in  an  opera- 
tion ;  a,  the  hernial  sac,  on  the  inner  side  of  which  the  Incision  would  be  made  in  case  of  strangula- 
tion ;.  6,  its  contents;  c.  the  obturator  vessels;  d,  the  epigastric  vessels.  This  is  the  internal  view  of 
the  preparation  in  Fig.  305. 

out  of  harm's  way.     But  when,  as  in  Fig.  307,  the  obturator  vessels  pass 
around  the  neck  of  the  sac  the}''  are  liable  to  be  wounded  in  dividing  the 

Fig.  807. 


A  specimen  of  femoral  hernia  in  which  the  obturator  vessels  given  off  from  the  epigastric  encircle 
the  neck  of  the  sac.  a  shows  the  artery  curving  over  the  inner  side  of  the  sac,  and  just  above  the 
letter  a  dark  space  is  seen,  which  is  an  extension  from  the  wound  of  the  operation.  The  vein  (cut 
sli(irt)  in  marked  by  the  letter  fc.— St.  George's  Hospital  Museum,  Ser.  ix,  No.  84. 


FEMORAL    HERNIA.  649 

stricture,  although  they  may  accidentally  escape.  In  the  instance  from 
which  that  figure  was  drawn  it  seemed  probable  that  the  vein  was 
wounded  at  time  of  the  operation,  but  the  artery  escaped,  though  it  gave 
way  afterwards.  There  was  considerable  venous  haemorrhage  at  the  time 
of  the  operation  ;  but  this  was  supi)ressed  by  pressure.  A  good  deal  of 
omentum  which  was  in  the  sac  was  left  in  the  wound.  Sloughing  at- 
tacked the  wound,  and  then  arterial  hsemorrhage  took  place,  the  source 
of  which  could  not  be  discovered.  It  recurred  two  or  three  times,  and 
proved  fatal.  The  vein  and  artery  were  both  found  open,  the  opening 
in  the  artery  being  a  minute  puncture,  into  which  a  bristle  could  just  be 
passed.  As  it  is  impossible  to  ascertain  the  existence  of  this  anomaly, 
the  only  security  against  injuring  the  vessels  is  to  make  the  incision  as 
is  consistent  with  the  easy  reduction  of  the  hernia.'  If  the  artery  has 
been  wounded  the  surgeon  may  possibly  succeed  in  securing  it,  either 
by  seizing  its  mouth  and  tying  it,  as  some  operators  have  claimed  to 
have  done,  or  by  thrusting  a  curved  needle  under  the  tissues  in  which 
the  bleeding  vessel  lies  and  passing  a  ligature  around  them,  needle  and 
all,  as  in  one  of  the  forms  of  acupressure,  or  possibly  by  the  method  of 
"uncipression"  recommended  by  Vanzetti  (see  page  125). 

Diagnosis. — Femoral  hernia  is  not  always  easy  of  diagnosis.  Enlarged 
glands  sometimes  lie  in  the  crural  canal  and  exactly  simulate  a  small 
hernial  tumor,  the  impulse  in  which  is  absent  or  obscure.  In  fact,  so 
close  is  the  resemblance  that  exploratory  operations  are  frequently  per- 
formed. And  a  small  hernial  sac  may  be  found  lying  behind  an  enlarged 
gland.  The  diagnosis  is  best  made  b}'  the  greater  mobility  of  the  gland, 
its  being  isolable  from  the  underlying  parts,  its  having  no  impulse  when 
separated  from  the  abdominal  muscles,  and  its  owning  some  cause,  such 
as  a  sore  in  the  lower  limb,  buttock,  anus,  or  parts  of  generation. 

Varix  of  the  saphena  vein  has  been  mistaken  for  hernia,  but  is  distin- 
guishable 1)3'  the  fact  that  after  reduction  of  the  tumor — which  may  be 
accomplished  easil}^  in  the  recumbent  posture — pressure  on  the  ring, 
which  would  keep  the  hernia  back,  will  cause  the  varix  to  reappear. 

Psoas  abscess  has  been  mistaken  for  hernia,  and  has  often  a  ver^'  per- 
ceptible impulse.  But  the  fulness  in  the  iliac  fossa  which  always  can  be 
detected  by  careful  examination  in  psoas  abscess  would  alone  be  sufficient 
for  diagnosis  ;  besides,  a  strict  examination  will  show  that  the  region  of 
the  crural  ring  is  natural,  the  swelling  being  at  a  point  below  this  on  the 
inside  of  the  thigh,  and  being  also  perceptible  on  its  outer  side.  Some 
verj'  rare  cases  of  hernia,  however,  have  been  recorded  in  which  a  hernia 
has  descended  on  the  outside  of  the  femoral  artery. 

A  cyst  has  sometimes  been  found  to  lie  in  the  crural  ring,  which  must 
be  distinguished  from  a  hernia  by  the  same  signs  as  an  enlarged  gland. 

The  tumor  in  femoral  hernia  is  usuall}'  small,  though  cases  are  met 
with  of  very  large  hernise  of  this  kind ;  it  generally  turns  upwards  after 
reaching  the  saphenous  opening,  and  requires  to  be  drawn  somewhat 
downwards  before  the  true  position  of  its  neck  is  seen.  Immediate  at- 
tention should  be  given  to  it,  and  it  should  be  kept  rigidl}'  reduced,  since 
its  strangulation  is  very  often  irremediable  except  by  operation. 

The  operation  is  exactly'  the  same  in  principle  as  that  for  inguinal 
hernia,  only  that  here  the  crural  ring  and  the  edge  of  Gimbernat's  liga- 
ment are  the  points  towards  which  the  surgeon  aims.     An  incision  is 

'  It  is  desirable  on  every  ground  to  make  the  incision  into  the  neck  of  the  sac  as 
small  as  possible,  for,  if  the  neck  of  the  sac  be  too  much  enlarged,  it  is  verj'  difficult 
to  apply  a  truss  satisfactorily. 


650  HERNIA. 

made  over  the  long  axis  of  the  tumor,  somewhat  internal  to  its  middle, 
and  the  parts  are  divided  until  the  sac  is  exposed.  Then  a  director  may 
be  passed  under  Gimbernat's  ligament  (or  an}^  other  constricting  tissue 
that  can  be  felt),  as  recommended  b}'  Mr.  Gay,'  and  the  extraperitoneal 
operation  attempted.     If  this  does  not  succeed  the  sac  is  to  be  opened. 

rmbilical  Hernia^ — The  only  other  form  of  hernia  which  is  of  very 
common  occurrence  is  the  umbilical.  Tliis  occurs  constantly  as  a  con- 
genital affection,  the  bowel  protruding  througli  tlie  unclosed  navel.  And 
there  can  be  no  doubt,  from  the  rarity  of  the  affection  in  the  adult  as 
compared  with  its  extreme  frequency  in  the  infant,  that  this  congenital 
umbilical  hernia  tends  to  spontaneous  cure.  Nevertheless,  it  should  not 
be  neglected,  especially  when  large.  The  bowel  should  be  kept  reduced 
by  means  of  a  well-fitting  pad  which  covers  the  whole  ring,  and  which  is 
kept  accurately  applied  to  the  belly  by  being  let  into  a  laced  belt  with 
india-rubber  sides.  If  this  apparatus  is  too  costl3'  some  extempore  sub- 
stitute can  be  easily  devised.  Careful  attention  for  a  few  months  is 
almost  sure  to  be  followed  by  the  disappearance  of  the  swelling. 

The  acquired  form  of  umbilical  hernia  is  generalh'  caused  by  the  dis- 
tension of  the  abdominal  parietes.  as  a  consequence  of  obesity,  repeated 
pregnancy,  or  both.  The  subjects  of  strangulation  in  this  form  of  hernia 
are  often  fat  elderly  women,  who  have  had  the  disease  for  a  long  time 
and  neglected  it.  The  ring  is  often  of  very  large  size,  the  sac  almost  al- 
ways contains  omentum,  and  frequeutl}'  large  intestine  as  well  as  small. 
The  hernia  is  covered  only  by  the  skin  and  expanded  linea  alba,  and  its 
orifice  is  often  not  the  navel  itself,  but  some  weakened  part  of  the  neigh- 
boring linea  alba.  Often  in  this  hernia  the  symptoms  which  are  described 
as  strangulation  are  rather  those  of  obstruction  ;  and  constipation  with 
vomiting  ma}'  continue  for  several  days,  and  3'et  be  susceptible  of  ultimate 
relief  from  rest,  enemata,  and  the  administration  of  calomel  and  opium. 
Tlie  hernia  is  ver}^  probably  irreducible,  the  sac  being  coated  internally 
with  omentum  (for  in  this  hernia  the  "omental  sac  "  is  very  common), 
and  the  symptoms  are  rather  due  to  the  entanglement  of  distended  bowel 
in  the  folds  of  this  omenium  than  to  strangulation  by  an}-  definite  band. 
The  obstruction  may  subside  on  the  subsidence  of  distension  ;  and  the 
results  of  operations  on  these  irreducible  hernioe  containing  large  quanti- 
ties of  omentum  are  so  unfavorable  that  it  is  prudent  to  avoid  them  if 
possible.  ''J'he  amount  of  pain  and  fever  (in  other  words,  the  acuteness 
of  the  symptoms)  is  the  test  of  the  necessity  for  an  operation.  If  the 
tumor  is  very  tense,  the  pulse  quick  and  irrital>le,  the  tongue  dry,  and 
the  patient  complaining  greatly  of  pain  in  the  tumor  and  the  bellj',  the 
operation  should  not  be  delayed,  especially  if  the  vomit  be  inclining  to 
the  faecal  character. 

The  tumor  is  to  be  freely  laid  open  in  the  vertical  direction,  the  con- 
tained bowel  and  omentum  unravelled,  and  the  finger  passed  beneath  the 
ring  to  feel  for  the  point  of  stricture.  This  being  divided,  tlie  bowel 
should  be  first  reduced,  and  ihe  omentum  then  dealt  with  as  seems 
advisable. 

I  have  seen  a  case  in  which  the  symptoms  wliii-h  were  referred  to  an 
umbilical  hernia  turned  out  after  death  to  have  been  due  to  strangulation 
of  the  bowel  internal  to  the  peritoneum,  and  fairly  within  reach  of  the 
operator.  Kemeral)eiing  this  case,  and  that  under  Mr.  IJryant's  care, 
cited  on  p.  618,  it  would  be  advisable  if  no  strangulation  is  found  in  the 

'  See  Mr.  Gay's  work  on  Femoral  Hernia. 


OBTURATOR    HERNIA. 


651 


hernial  sac  to  pass  the  finger  into  the  peritoneal  cavity,  in  order  to 
ascertain  vvhetlier  there  is  an}'  internal  constriction. 

Ohluralor  Hernia. — Of  the  rarer  forms  of  hernia  the  obturator,  though 
not  the  most  frequent,  is  that  which  presents  most  of  surgical  interest, 
since  it  has  in  late  years  been  made  the  subject  of  successful  diagnosis 
and  treatment.' 

The  accompanying  illustration,  from  a  case  which  occurred  at  St. 
George's   Hospital  before 

the  snccessful  treatment  of  ^^^-  ^'^^■ 

this  disease  was  known, 
will  well  illustrate  its  main 
features.  The  small  sac 
of  the  obturator  hernia  is 
seen  lying  at  the  upper 
and  outer  part  of  the  thy- 
roid foramen,  almost  ver- 
tically below  the  femoral 
ring,  and  there  is  a  small 
empty  hernial  sac  also 
in  the  external  inguinal 
ring.  Mr.  Birkett  has  col- 
lected twenty-five  cases 
of  strangulated  obturator 
hernia,^  from  which  it  ap- 
pears that  this  variet}'  of 
hernia  when  strangulated 
may  be  distinguished  from 
inguinal    hernia    by    find- 


Obturator  hernia  in  a  female,  tet.  sixty-seven,  who  died  in  St. 
George's  Hospital,  in  the  year  1846,  from  the  strangulation  of 
ing  the  inguinal  rings  and    this  hernia.    She  had  also  a  small  inguinal  liernia,  but  the  sac 


canals  empty,  and  from 
femoral  by  tlie  empty  con- 
dition of  the  femoral  ring, 
by  the  fulness  of  the  "  fe- 
moral fossa"  (b}'  which 
term  is  intended  the  flat 


appeared  to  be  empty.  An  exploratory  operation  was  performed, 
and  proved  that  this  was  the  case.  In  the  preparation  the  small 
sac  is  seen  opened  outside  the  external  abdominal  ring,  and  with 
a  bristle  placed  in  it. 

Below  the  femoral  vessels  and  horizontal  ramus  of  the  piibes 

the  sac  of  the  obturator  hernia  is  seen  unopened,  projecting  from 

the  outer  margin  of  the  thyroid  foramen,  and  having  the  nerve 

and  vessels  on  its  outer  sido.     It  contained  a  small  knuckle  of 

surface    of   the    thigh,   just    intestine,  comprising  only  part  of  the  calibre  of  the  bowel,  tightly 

below  Poupart's  ligament,  strangulated. 

.in  r      \  •    \    •     e  J        The  case  occurred  before  the  operation  for  this  form  of  hernia 

the  floor  Ot  which  is  formed    ^^^  ^^^^^  Jntroduced.-St.  George's  Hospital  Museum,  Ser.  ix, 

by  the  pectineus  muscle),  no.  oo. 
by  the  fact  tiiat  the  fe- 
moral vessels  lie  in  front  of  the  tumor  instead  of  outside  it,  by  the 
position  of  the  neck  of  the  sac,  if  perceptible,  below  the  ramus  of  the 
pubes,  and  by  pain  which  is  often  present  in  the  course  of  the  obturator 
nerve.  13ut  the  diagnosis  is  often  very  difficult,  and  in  many  of  the  re- 
corded cases  (as  in  that  figured  above)  other  forms  of  hernia  have  been 
present  and  have  complicated  the  case.  In  some  it  is  said  that  no  tumor 
has  been  present,  and  such  cases  could  not  be  distinguished  from  in- 
stances of  internal  strangulation.  But  whenever  the  symptoms  of  strangu- 
lation are  present  with  no  tumor  in  the  situation  of  the  umbilical,  inguinal, 
or  femoral  hernife  (or  if  such  herniae  though  present  are  completely  re- 
ducible), the  femoral  fossa  on  the  two  sides  should  be  carefully  examined 

1  This  very  satisfactory  advance  in  operative  surgery  was  due,  not  to  a  hospital 
surgeon,  but  to  the  late  Mr.  Obre  of  Paddington. — Med.-Chir.  Trans.,  vol.  xxxiv. 

2  Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p.  781. 


652  HERNIA. 

both  by  palpation  and  sight,  and  if  any  fulness  on  one  side  be  found  as 
compared  with  the  other,  it  will  be  justifiable  to  perform  an  exploratory 
operation,  for  which  there  is  still  more  encouragement,  if  the  characteristic 
pain  in  tlie  course  of  the  nerve  is  present.  The  incision  should  be  made 
as  for  femoral  liernia,  but  should  be  extended  further  downwards,  so  as 
to  have  a  very  free  oi)ening,  lying  to  the  inside  of  and  well  away  from 
the  femoral  vessels.  The  pectineus  muscle  being  exposed  is  to  be  freely 
divided  in  the  course  of  the  skin-wound  and  the  sac  searched  for  and 
opened.  It  may  be  even  necessary  to  separate  or  to  divide  some  of  the 
fibres  of  the  obturator  externus  muscle  before  the  sac  is  reached,  but  the 
suroeon  should  not  desist  from  his  search  until  the  obturator  foramen  is 
clearly  exposed.  The  position  of  the  vessels  and  nerve  with  regard  to 
the  sac  being  variable,  this  search  must  be  conducted  carefully.  If  the 
hernia  be  recognized  while  reducible  (and  Mr.  Kingdon  has  made  the 
diao-nosis  no  less  than  five  times)  tlie  surgeon  must  explain  the  nature  of 
the  case  to  the  trussmaker,  and  must  see  that  the  pressure  acts  in  the 
right  spot,  and  is  directed  backwards  and  somewhat  upwards  below  the 
ramus  of  the  pubes. 

Ventral  Hernia. — Hernia  occurs  also  at  any  part  of  the  belly  which  has 
been  weakened  by  a  cut,  or  by  accidental  rupture  of  a  part  of  the  mus- 
cular fibres,  or  an  abscess,  or  possibly  by  overdistension.  To  such  hernioe 
the  name  of  "  ventral'"  is  given.  The  protrusions  which  follow  on  ovar- 
iotomy' or  ligature  of  the  iliac  arteries  are  familiar  examples.  Such 
hernial  sacs  have  no  neck,  and  are  not  liable  to  strangulation.  When 
the  patient  stands  up  or  coughs  they  form  large  bulging  tumors,  in  which 
the  bowels  can  be  plainly  felt.  Reduction  is  perfectly  easy,  and  the 
wearing  of  an  appropriate  bandage,  so  as  to  keep  the  hernia  completely 
reduced,  is  all  that  is  necessary  as  far  as  I  have  seen. 

Phrenic  or  diaphragmatic  hernia  occurs  as  a  congenital  defect,  a  por- 
tion of  the  diaphragm,  usually  the  left  leaflet,  being  deficient,  whereby 
the  pleural  and  peritoneal  cavities  communicate  quite  freely,  and  the 
stomach,  the  transverse  colon  with  its  omentum,  or  other  viscera,  are 
allowed  to  pass  freely  into  the  thorax.  It  is  surprising  that  this  exten- 
sive malformation  should  produce  no  definite  symptoms.  I  have  more 
than  once  found  it  in  the  bodies  of  adult  persons  who  died  from  other 
causes  and  had  never  been  known  to  make  any  complaint  connected  with 
the  hernia. 

But  in  other  cases  the  diaphragm  has  been  ruptured  in  consequence  of 
severe  contusion,  or  has  been  lacerated  l)y  direct  wound.  When  phrenic 
hernia  occurs  after  injury  it  is  generally  a  consequence  of  the  free  rup- 
ture of  the  muscle  from  contusion,  which,  like  tlie  congenital  defect,  takes 
place  usually  on  the  left  side.  The  stomach  and  transverse  colon  are, 
therefore,  the  viscera  which  usually  protrude  in  this  form  also,  and  the 
accident  may  possibly  be  diagnosed  by  the  greater  fulness  and  unnatural 
resonance  of  that  side  of  the  chest,  the  sickness,  and  the  symptoms  of 
obstruction  which  follow  it.  As  the  accident  is  almost  inevital)ly  fiital, 
either  from  pleurisy  or  from  strangulation,  the  question  of  cutting  freely 
into  the  abdomen  and  endeavoring  to  reduce  the  viscera  from  below  has 
been  mooted  ;  but  no  case  has  as  yet  occurred  in  which  the  diagnosis  has 
been  made  clearly  enough  to  justify  the  surgeon  in  this  hazardous  attempt, 

1  Some  of  these  hernise  when  lying  between  the  curtihiges  of  the  false  ribs  and  the 
navel  are  called  "  epigastric." 


VAGINAL    HERNIA.  653 

and  the  record  which  we  now  possess  of  cases  in  wliich  the  patient  has 
snrvived  for  a  considerable  length  of  time  would  still  further  indispose 
any  prudent  person  from  making  such  an  attempt.  Mr.  Le  Gros  Clark 
has  related  and  figured  a  most  interesting  case,  in  which  the  patient  lived 
more  than  two  years  after  an  accident  in  which  there  seemed  good  reason 
to  believe  that  the  diaphragm  had  been  lacerated,  and  in  whom  after  death 
the  usual  conditions  of  phrenic  hernia  no  doubt  existed.  The  only  am- 
biguity about  this  case  is  the  remote  possibility  that  the  deficiency  of  the 
diaphragm  might  have  been  congenital.' 

Vaginal  Hernia. — The  other  rarer  forms  of  hernia  occur  chiefly  in  the 
vagina  or  female  perineum.  Vaginal  hernia  is  not,  I  think,  on  the  whole 
as  rare  as  is  supposed.  It  occurs  as  a  congenital  defect  or  as  a  conse- 
quence of  stretching  of  the  vaginal  walls  in  parturition.  The  diagnosis 
is  generally  very  easy.  In  a  congenital  case  I  ventured  upon  an  opera- 
tion to  close  the  ring,  which  appeared  successful.^  In  the  adult  I  have 
never  seen  any  inconvenience,  but  it  has  been  observed  that  in  some 
cases  tiie  urinary  bladder  protrudes — an  affection,  however,  which  should 
be  distinguished  from  hernia,  under  the  name  of  vaginal  ctjdocele.  The 
intestinal  hernia  only  requires  support  by  an  appropriate  form  of  pessary. 
The  vaginal  cystocele  may  I'eqnire  to  be  operated  on  by  removing  a 
limited  portion  of  the  vaginal  wall  and  sewing  up  the  edges  after  having 
reduced  the  prolapsed  bladder. 

In  perineal  hernia  the  recto-vaginal  pouch  of  peritoneum  is  thrust  out 
between  the  vagina  and  rectum,  forming  a  hernial  sac  with  small  intestine 
in  it,  and  I  have  seen  the  same  thing  occur  into  the  rectum  itself.  Cases 
rarely  occur  in  which  the  male  perineum  is  similarly  pushed  out.  These 
hernioe  merely  require  reduction  and  proper  support. 

Of  a  similar  nature  are  the  pudendal  hernia?,  in  which  the  neck  of  the 
sac  lies  between  the  ascending  ramus  of  the  ischium  and  the  vagina,  and 
the  sac  itself  protrudes  into  the  posterior  part  of  the  labium  ;  the  ischiatic 
hernia,  where  the  gut  protrudes  beneath  theglutjeus  maximus  muscle  and 
the  neck  of  the  sac  lies  either  above  or  below  the  pyriformis  ;  and  the 
lumbar  hernia,  in  which  the  bowel  makes  its  way  between  the  quadratus 
lumborum  and  external  oblique  muscle. 

In  all  these  forms  of  hernia  the  main  point  is  their  diagnosis,  and  in  all 
such  swellings  around  the  female  parts  of  generation  this  is  a  matter  to 
which  much  care  should  be  given  ;  but  space  fails  me  to  point  out  the 
exact  points  of  distinction  between  such  hernias  and  the  abscesses,  cysts, 
or  other  formations  which  may  be  met  with  in  each  region,  nor  is  it  per- 
haps necessary.  A  surgeon  who  is  well  acquainted  with  the  principles 
of  diagnosis  and  pays  proper  attention  to  his  patient  will  be  in  little 
danger  of  mistaking  a  lumbar  hernia  for  an  abscess  or  a  vaginal  hernia 
for  a  cyst. 

As  to  treatment  I  am  not  aware  that  any  of  these  forms  of  hernia  have 
required  kelotomy ;  but  if  they  do  they  would  present  no  special  diflfi- 
culties,  except,  perhaps,  the  sciatic,  in  which  a  large  incision  would  have 
to  be  made,  and  care  taken  to  ascertain  if  possible  the  position  of  the 
gluteal  or  sciatic  vessels  in  relation  to  the  neck  of  the  sac.  Sir  A.  Cooper 
directs  that  in  such  a  contingency  the  incision  into  the  neck  of  the  sac 
be  made  directly  upwards. 

1  Lectures  on  the  Principles  of  Surgical  Diagnosis,  p.  258. 

2  Holmes's  Surg.  Dis.  of  Children,  2ded.,  p.  560. 


654  DISEASES    OF    THE    RECTUM. 


CHAPTEE   XXXIII. 

DISEASES  OF  THE  RECTUM. 

HAEMORRHOIDS,  or  piles,  are  divided  into  external  and  internal,  and  the 
division  is  a  useful  and  natural  one,  though  there  are  many  examples  of 
piles  in  which  both  the  mucous  membrane  of  the  bowel  and  the  skin  ex- 
ternal to  the  anus  form  a  part  of  the  covering  of  the  tumor,  and  which, 
therefore,  are  partly  external  and  partly  internal.  Both  kinds  of  piles 
are  formed  of  enlarged  vessels  surrounded  by  infiltrated  cellular  tissue. 
External  piles  consist  internally  of  an  enlarged  vein  or  veins,  partl}^  oc- 
cupied by  clot,  and  externally  of  skin  and  connective  tissue  more  or  less 
thickened  and  inflamed.  They  owe  their  origin  to  any  cause  which  deter- 
mines the  blood  to  the  part  or  prevents  its  return.  Pregnancy,  obstruc- 
tion to  the  portal  circulation,  too  luxurious  habits,  and  sedentary  employ- 
ments are  well-known  causes  of  external  piles,  and  they  are  very  com- 
monly increased  by  any  accidental  attack  of  constipation.  These  external 
piles  are  liable  to  inflammation,  when  they  become  distended,  livid,  and 
intensely  painful. 

In  cases  of  external  piles  there  are  generally  also  folds  of  loose  integu- 
ment about  the  anus  in  which  no  enlarged  vessels  can  be  detected,  nor 
does  the  skin  or  cellular  tissue  appear  indurated. 

The  treatment  of  external  piles  consists  in  the  removal  or  palliation  of 
their  cause  and  the  application  of  sedative  and  astringent  lotions  or  oint- 
ments, and  this  is  quite  sufficient  in  the  great  majority  of  cases.  Where 
habitual  constipation  exists  it  must  be  relieved,  and  the  bowels  kept 
rather  loose,  by  some  mild  laxative,  for  purging  is  by  no  means  desirable. 
The  confections  have  obtained  an  extensive  reputation  for  this  purpose, 
especially  the  Conf  Sennse  cum  Sulphure  and  the  Conf.  Piperis  Nigri.  All 
improper  habits,  whether  of  diet,  exercise,  or  anything  else  that  can  pro- 
mote irritation  about  the  pelvic  organs,  should  be  given  up,  and  the  pa- 
tient should  be  encouraged  to  take  gentle  but  regular  exercise. 

When  the  piles  are  inflamed,  if  the  inflammation  is  mild,  leeching  is 
often  serviceable;  if  severe,  the  tumor  should  be  cut  across  with  a  lancet, 
and  the  blood  squeezed  out  of  the  mouth  of  the  vein,  for  an  imperfect 
clot  might  keep  the  mouth  of  the  vessel  open  and  encourage  bleeding. 
Also  when  old  i)iles  have  become  much  indurated  and  are  liable  to  con- 
stant attacks  of  irritation,  it  is  better  to  snip  them  off,  and  along  with 
them  to  remove  any  loose  folds  of  skin.  But  in  doing  this  care  should 
be  taken  not  to  cut  into  the  anus,  so  as  to  implicate  the  mucous  membrane 
in  the  incision.  Negligence  in  this  respect  has  been  followed  by  very 
troublesome  contraction  of  the  orifice  of  the  anus. 

Internal  haemorrhoids  are  produced  by  causes  similar  to  those  of  the 
external  variety,  but  they  constitute  a  far  more  formidable  malady.  They 
produce  bleeding,  which  in  tlie  worst  cases  is  constant,  though  greater 
during  defecation,  and  which  so  exhausts  the  patient  as  to  drain  him  of 
all  strength  and  color  and  leave  him  waxy  in  complexion,  exhausted, 
languid,  and  unable  to  make  any  continuous  clfort.     The  piles  may  also 


OPERATIONS    FOR    PILES.  655 

cause  pain  and  straining  in  defecation  ;  and  if  the  tumors  are  large  they 
may  protrude  even  when  the  bowels  are  not  acting,  and  sometimes  drag 
the  whole  end  of  the  gut  out  of  the  anus — prolapsus.  The}'  are  gener- 
ally situated  close  to  the  anus,  and  often  are  parti}' external  as  well,  i.  e.^ 
part  of  them  is  covered  by  skin,  but  sometimes  they  are  seated  at  a  little 
distance  up  the  bowel,  and  hence  the  necessity  of  having  the  bowel  well 
protruded  in  examinations  for  piles.  This  is  accomplished  either  by  the 
patient's  voluntary  efforts,  which  are  quite  sufficient,  in  cases  where  there 
is  an}'  tendency  to  prolapsus,  with,  perhaps,  a  little  assistance  by  gentle 
traction  on  some  of  the  more  prominent  tumors,  or  by  filling  the  bowel 
with  a  large  quantity  of  warm  water,  so  as  to  make  it  act  forcibly,  when 
the  whole  will  be  protruded,  or  by  sitting  over  warm  water.  The  struc- 
ture of  internal  piles  is  less  uniform  than  that  of  the  external  variety. 
Some  consist  chiefly  of  varicose  veins,  with  more  or  less  condensed  cel- 
lular tissue;  in  some  the  mucous  membrane  is  also  hypertrophied  ;  while 
in  others  the  hypertroi)hy  of  the  mucous  membrane  and  its  capillaries 
seems  to  constitute  the  bulk  if  not  the  whole  of  the  tumor ;  in  others, 
again,  there  are  large  arteries  intermingled  with  the  enlarged  veins  or 
capillaries  and  with  the  hypertrophied  mucous  membrane.  The  form 
also  of  these  tumoi'S  varies  equally.  Some  of  them  are  sessile  and  bright- 
red  like  a  strawberry,  while  others  are  pendulous  and  livid,  the  arterial 
vessels  or  enlarged  capillaries  predominating  in  the  former,  the  venous 
in  the  latter;  while  in  piles  which  have  long  been  irritated  and  inflamed 
the  bulk  of  the  tumor  will  l)e  formed  of  condensed  cellular  tissue,  there 
will  be  little  trace  of  vascularity  in  its  appearance,  and  its  consistence 
will  be  harder. 

The  treatment  of  internal  piles  must  vary  according  to  their  extent, 
appearance,  and  form.  When  only  recent,  and  of  no  great  size,  they 
may  usually  be  relieved,  as  external  piles  may,  by  removing  or  palliating 
their  causes,  and  by  similar  treatment — i.  e.,  gentle  purgatives  or  laxa- 
tives, unloading  the  liver,  and  astringent  applications,  as  the  Ung.  Gallfe 
Co.,  to  the  tumors  when  protruded,  or  astringent  injections  in  small  quan- 
tity after  the  bowels  have  acted.  The  patient  ought  to  be  instructed 
always  to  return  the  piles  when  protruded,  by  gentle  pressure.  The  con- 
striction of  the  sphincter  on  the  protruded  piles  pi'oduces  much  pain  and 
congestion  in  the  tumors.  Sometimes,  it  is  true,  this  proves  curative,  the 
whole  tumor  sloughing  as  if  the  sphincter  acted  as  a  sort  of  natural  lig- 
ature, but  this  is  too  rare  and  too  uncertain  to  be  counted  on.  Far  more 
commonly  the  congestion  increases  the  bleeding  and  causes  painful  inflam- 
mation. 

In  cases  where  the  bleeding  is  considerable  or  the  other  symptoms  are 
urgent  some  steps  must  be  taken  to  remove  the  piles.  The  least  painful 
and  dangerous  is  the  application  of  strong  nitric  acid  to  the  whole  of  the 
surface,  under  which  it  will  shrivel  up,  possibly  the  superficial  part  of 
the  mucous  membrane  will  exfoliate,  and  thus  a  cure  be  procured,  and  no 
doubt  for  those  piles  which  are  of  the  sessile  and  capillary  variety  such 
treatment  is  often  very  efficacious,  at  least  for  the  time.  It  not  unfre- 
quently  happens  that  the  symptoms  recur,  but  in  that  case  the  treatment 
can  be  repeated.  It  causes  usually  but  little  pain,  and  is  attended  with 
no  danger,  at  least  I  have  never  seen  or  heard  of  any  harm  from  it.  But 
it  is  not  likely  to  succeed  in  tumors  of  large  size,  and  in  those  which  are 
pendulous  or  hardened  from  inflammation  it  is  useless.  As  these  three 
classes  form  the  majority  of  piles  wliich  require  operation,  it  follows  that 
the  treatment  by  nitric  acid  is  not  very  frequently  serviceable. 

There  are  two  chief  plans  of  operating  for  piles,  viz.,  with  the  ligature 


656  DISEASES    OF    THE    RECTUM. 

niul  with  the  clamp  and  cautery.  In  the  former  each  pile  is  drawn  out 
in  succession  with  the  forceps,  any  skin  which  is  covering  it  is  turned  off 
the  hiumorrhoidal  tumor  with  a  knife  or  scissors,  its  base  transfixed  with 
a  stout  double  silk  ligature  if  large,  or  encircled  in  a  ligature  if  smaller, 
and  the  ligature  tied  as  tightly  as  possible  and  cut  short.  Some  surgeons 
puncture  the  pile,  or  cut  away  its  superficial  part,  but  this  is  unnecessary. 
Wiien  all  the  piles  have  thus  been  tied  the  mass  is  returned  into  the  bowel. 
In  operating  with  the  cautery  each  pile  is,  as  before,  successively  drawn 
out,  and  then  a  clamp  is  applied  to  its  base.  The  clamp  should  have 
its  lower  surface  coated  with  ivory,  so  that  the  heat  applied  to  its  upper 
part  may  not  burn  the  skin.    If  the  pile  is  only  small  its  whole  tissue  may 

Fig.  309. 


Mr.  H.  Smith's  clamp  for  piles. 

be  seared  down  nearly  to  the  level  of  the  clamp  b}'  the  cautery,  or  this 
may  be  done  without  any  clamp  ;  but  it  is  generally  necessary  to  cut  off 
the  pile  a  short  distance  above  the  clamp,  and  then  sear  the  base  of  it  till 
a  thick  eschar  is  formed.  Mr.  Bryant  saj^s  that  for  this  purpose  tlie  gal- 
vanic is  better  tlian  the  actual  cautery,  as  forming  a  thicker  eschar.  It 
has  the  advantage  that  the  supplj^  of  heat  is  continuous,  and  the  disad- 
vantage that  the  surface  of  the  cautery  is  not  so  large.  A  heat  a  little 
below  white  heat  is  safest,  because  it  chars  the  tissues  more  slowly;  if 
burnt  too  rapidly  the  eschar  ma}' stick  to  the  cautery  and  be  pulled  away, 
causing  bleeding.  When  the  surgeon  thinks  the  parts  sufficiently  seared 
he  cautiously  relaxes  the  screw  of  the  clamp,  and  if  any  point  still  bleeds 
repeats  the  cauterization.  When  all  is  safe  and  every  pile  has  been  treated 
in  this  manner  the  whole  is  returned  into  the  bowel  with  all  possible 
gentleness. 

Chloroform  may  be  given  in  anj^  operation  for  piles,  but  it  makes  the 
proceeding  a  little  more  difficult,  as  the  piles  are  rather  liable  to  slip  up 
wliile  the  patient  is  becoming  unconscious.  However,  filling  the  bowel 
with  water  or  gentle  traction  will  bring  them  down,  and  few  patients  have 
the  resolution  to  submit  to  the  actual  cautery  without  it,  though  in  reality 
the  operation  does  not  seem  very  painful. 

The  operation  by  the  cautery  is  the  more  recent  of  these  two  plans, 
and  is  the  one  now  in  greater  use,  and  it  has  some  incontestable  advan- 
tages over  the  ligature, — the  recovery  is  more  rapid,  there  is  less  need  of 
confinement  to  bed,  and  it  is  less  painful  than  the  ligature.  Against 
these  advantages  is  to  be  set  the  risk  of  secondary  haemorrhage,  which, 
however,  is  not  very  great,  and  the  somewhat  terrifying  nature  of  the 
proceeding,  if  from  any  cause  chloroform  is  not  used.  As  to  danger, 
though  very  confident  opinions  were  expressed  of  the  great  safety  of  the 
canter}',  further  experience  lias  shown  their  incorrectness.     Pyaemia  fol- 


FISTULA.  657 

lows  operations  for  piles,  in  consequence  of  inflammation  of  the  divided 
veins.  This  is  very  rare  in  any  form  of  operation,  but  seems  to  occur 
quite  as  often  after  the  cautery  as  the  ligature.  Tetanus  has  been  known 
to  occur  after  ligature,  but  it  is  a  very  rare  event  indeed. 

ProIapsKf^  Ani. — By  prolapsus  ani  is  meant  tlie  inversion  of  tlie  lower 
part  of  the  bowel,  and  its  protrusion  in  tlie  form  of  a  ring  of  red  tumid 
membrane.  lu  slighter  eases  this  ring  consists  of  the  mucous  membrane 
only,  but  in  the  more  formidable  examples  the  whole  bowel  protrudes, 
and  sometimes  for  several  inches.  Its  causes  are  constitutional  and  local. 
Thus,  in  cachectic  children  with  relaxed  fibre  any  intestinal  irritation,  such 
as  worms,  will  produce  prolapsus,  and  in  the  healthiest  persons,  whether 
children  or  adults,  prolapsus  may  be  caused  by  any  cause  of  straining, 
as  stone,  stricture,  or  enlarged  prostate,  Mr.  H.  Smith  also  says,  with 
indisjjutable  truth,  that  "  the  pernicious  plan  of  frequently  using  copious 
enemata  is  ver}-  constantly  productive  of  the  disordei*."  The  first  thing, 
then,  is  to  ascertain  the  cause,  and  if  this  can  be  removed  the  prolapsus, 
if  moderate,  will  soon  disappear  with  a  little  attention.  When  the  gen- 
eral health  is  at  fault  the  appropriate  treatment  must  be  employed.  In 
childhood  ferruginous  tonics  are  commonly  needed,  and  if  the  complaint 
depends  on  the  irritation  of  worms  this  must  be  remedied.  In  this  way 
most  cases  of  prolapsus  will  be  cured  if  the  protruded  bowel  be  always 
at  once  carefull}'  reduced  (which  is  generally  easily  done  by  pressing  it 
gently  up  with  the  flat  of  the  hand)  and  supported  by  a  T-bandage.  If 
very  large  the  protruded  mucous  membrane  is  to  be  pencilled  over  with 
nitrate  of  silver  in  stick  or  smeared  with  nitric  acid.  P^or  the  cases  which 
resist  such  measures  (which  will  be  very  few,  and  chiefly  inveterate  cases 
in  the  adult)  an  operation  similar  to  that  for  piles  must  be  performed, 
portions  of  the  inverted  gut  being  tied  at  opposite  parts  of  the  circum- 
ference of  the  bowel,  so  that  the  resulting  cicatrization  may  keep  the  gut 
in  ;  or  if  the  anus  be  very  much  stretched  lunated  pieces  of  the  skin  and 
bowel  may  be  removed  with  the  scissors,  and  the  edges  of  the  wound 
stitched  together;  or  similar  portions  of  the  skin  and  bowel  maybe 
clamped,  cut  off,  and  seared,  just  as  in  the  operation  for  piles. 

Fistula  ill  Alio. — A  fistula  in  ano  is  a  channel  or  sinus  leading  by  the 
side  of  the  rectum,  and  having  usually  two  openings  (complete  fistula), 
the  upper  one  in  the  bowel,  and  the  lower  on  the  skin.  The  upper  open- 
ing is  generally  very  near  the  anus,  and  the  lower  is  also  generally  not 
far  from  the  margin  of  the  orifice,  so  that  the  fistula  is  usually  of  no 
great  length.  But  many  exceptions  occur  in  both  respects.  The  sinus 
may  open  a  long  way  up  the  gut,  and  the  external  orifice  may  be  a  very 
long  way  from  the  anus;  and  again,  there  are  fistulre  which  pursue  a 
curved  course,  coasting  round  the  bowel  as  they  pass  upwards,  so  that 
theopening  in  the  gut  is  on  the  opposite  side  from  that  on  the  skin  ("  horse- 
slioe  fistulte  "),  or  a  single  opening  in  the  bowel  ma}'  communicate  with 
two  or  more  orifices  on  the  skin  ('"Y-shaped  fistulre").  Inattention  to 
these  peculiarities  may  cause  a  surgeon  to  overlook  the  internal  orifice  in 
cases  of  complete  fistula.  But  there  is  no  doubt  that  incomplete  fistuhie 
also  exist,  and  that  of  two  kinds, — blind  external  fistula  (Fig.  310),  in 
which  there  is  a  sinus  leading  up  along  the  bowel,  but  no  internal  open- 
ing;  and  blind  internal  fistula,  where  there  is  an  opening  in  the  bowel, 
leading  down  into  the  cellular  tissue,  but  no  orifice  in  the  skin. 

Fistula  originates  in  two  ways,  viz.,  either  as  an  ulcerated  opening  in 

42 


658 


DISEASES    OF    THE    RECTUM. 


the  wall  of  the  bowel,  the  matter  from  which  makes  its  way  down  along 

the  gut  to  open  externally,  or  as 
i''*^'- •"'^-  an  abscess  in  the    cellular  tissue 

which  bursts  at  one  end  into  the 
bowel  and  at  the  other  through  the 
skin.  It  is  obvious  that  either  of 
these  actions  may  be  so  modified 
as  to  give  rise  to  incomplete  fistula. 
Thus,  if  the  matter  from  the  ulcer- 
ated opening  in  the  bowel  does 
not  make  its  way  through  the  skin, 
but  after  gravitating  or  "  pocket- 
ing" down  towards  the  anus  con- 
tinues to  discharge  into  the  bowel, 
we  have  the  incomplete  internal  fis- 
tula. If  the  abscess  outside  the 
bowel  makes  its  way  through  the 
skin,  but  does  not  burst  into  the 
gut,  or  if  in  a  complete  fistula  the 
internal  opening  should  close  (as 
in  Fig.  310),  we  have  the  blind 
external  fistula. 

The  causes  of  the  ulceration  of 
the  bowel  which  leads  to  fistula  are 
not  always  easy  to  trace.  It  is  al- 
ways customary  to  speak  of  foreign 
bodies,  such  as  a  fishbone,  passing 
through  the  whole  intestinal  tract, 
and  then  irritating  or  lacerating 
the  rectum,  being  detained  there  by  the  sphincter,  and  certainly  I  once 
saw  a  case  in  which  a  fishbone  was  found  in  a  fistula,  but  such  cases  are 
mere  curiosities.  It  is  quite  possil)le,  however,  that  either  foreign  bodies 
or  hardened  freces  may  irritate  this  or  an}'  other  part  of  the  mucous 
membrane  and  cause  ulceration,  and  of  course  this  part  would  be  far 
more  exposed  to  such  irritation  than  any  other.  In  many  cases  the  ulcer- 
ation seems  to  be  due  to  the  strumous  cachexia,  and  fistula  is  a  well- 
known  complication  of  phthisis. 

lachio-re.ctal  Abacesa. — The  frequent  connection  between  abscess  near 
the  anus  and  fistula  renders  the  surgeon  always  anxious  to  open  such  ab- 
scesses early  and  very  freely,  in  order  to  avoid  any  denudation  of  the 
wall  of  the  gut  and  consequent  perforation.  The  abscess  is  to  be  punc- 
tured, a  director  passed  into  the  puncture,  and  the  whole  cavity  laid  open 
as  far  as  its  extremity  on  either  side.  If  this  is  early  done  fistula  hardly 
ever  follows. 

In  examining  a  case  of  fistula  the  first  care  of  the  surgeon  is  to  ascer- 
tain the  condition  of  the  patient's  health,  and  more  especially  whether  or 
not  there  are  any  clear  symptoms  of  phthisis.  If  the  patient  be  undoubt- 
edly phthisical  it  is  often  better  not  to  operate,  for  the  operation  is  fre- 
quently unsuccessful,  the  wound  continuing  unhealed  up  to  the  time  of 
the  patient's  death  ;  and  tlu;  divisinn  of  the  fistula  sometimes  appears  to 
aggravate  the  internal  mischief,  possil»ly  by  the  irritation  and  discharge 
which  it  causes.  But  these  objections  apply  chiefly  to  advanced  stages 
of  phthisis.  If  the  disease  in  tlie  lungs  is  in  an  early  stage,  and  the 
patient  is  much  annoyed  by  tlie  consequences  of  the  fistula,  it  is  better  to 
operate. 


Fistula?  in  ano,  witliout  any  internal  opening. 
There  are  two  fistulous  openings,  into  which  bou- 
gies have  been  inserted,  and  which  run  for  some 
distance  in  the  cellular  tissue,  terminating  beneath 
the  wall  of  the  bowel.  At  a  is  an  elliptical  depres- 
sion which  has  every  appearance  of  being  the  orig- 
inal oritice  of  one  (perhaps  of  both)  of  the  fistulie, 
but  is  now  soundly  healed. — Museum  of  St.  George's 
Hospital,  Ser.  i.x.  No.  45. 


FISTULA.  659 

Diagnosis. — It  must  not  be  forgotten  that  every  fistulous  opening  near 
the  anus  is  not  necessarily  a  fistula  in  ano,  i.  e..  a  sinus  originating  in  or 
leading  to  the  rectum.  I  have  seen  a  lal)ial  abscess  from  gonorrhoea, 
contracted  to  a  sinus,  mistaken  for  a  fistula  in  ano,  and  fistulous  chan- 
nels iu  connection  with  disease  of  the  pelvis  not  very  uncommonly  open 
near  the  anus.  Another  very  imi^ortant  caution  as  to  the  diagnosis  of 
fistula  is  not  to  confound  with  simple  listuhie  those  fistulous  openings 
which  form  in  connection  with  stricture  of  the  bowel.  Such  cases  are 
not  rare,  and  they  are  overlooked  sometimes  by  people  who  ought  to 
know  better.  When  the  stricture  is  simple  nothing  is  required  for  the 
cure  of  the  fistula  but  the  dilatation  of  the  stricture,  just  as  in  perineal 
fistula.  When  the  stricture  is  cancerous  no  local  treatment  can  do  any 
good.  In  either  case  the  incision  of  the  fistula  is  a  great  mistake.  Care- 
ful examination  of  the  higher  part  of  the  bowel  is,  therefore,  necessarj'in 
any  case  of  fistula  whose  course  is  obscure,  and  particularly  in  those 
which  are  multiple  and  surrounded  by  a  good  deal  of  indurated  tissue,  as 
the  fistulas  in  connection  with  stricture  usually  are. 

Treatment. — The  operation  for  fistula  is  one  of  the  simplest  possible. 
It  consists  merely  in  passing  a  director  through  the  (istula  and  laying  its 
whole  track  open.  But  it  is  often  very  difficult  to  find  the  internal  open- 
ing, from  the  sinuous  direction  of  the  fistula,  or  from  the  small  size  of  the 
opening  into  the  bowel  comjiared  with  the  extent  of  the  abscess,  for  the 
abscess  often  stretches  to  a  great  distance  up  the  gut,  while  the  internal 
orifice  is  close  above  the  sphincter.  Often  the  surgeon  may  feel  the 
orifice  as  a  small  pimple  on  the  wall  of  the  bowel,  and  if  this  be  on  the 
opposite  side  of  the  gut  from  the  external  opening,  he  will  discover  it  by 
laying  open  the  superficial  part  of  the  sinus  under  chloroform  and  tracing 
it  carefully  step  by  step  around  the  bowel.  But  no  doubt  in  some  cases 
(Fig.  310)  there  is  no  internal  opening,  and  then  the  surgeon  must  make 
one  by  pushing  the  director  through  the  wall  of  the  bowel  where  it  feels 
most  thinned  and  exposed.  Such  oi)erations,  however,  are  unsatisfac- 
tory. If  the  internal  opening  has  been  overlooked  the  fistula  vvill  surely 
reproduce  itself.  If  there  be  no  external  opening  the  internal  orifice  can 
usually  be  seen  or  felt,  and  a  bent  probe  can  be  hooked  in  it,  so  that  its 
point  projects  under  the  skin.  This  is  then  cut  down  upon,  and  so  the 
fistula  is  rendered  complete  and  at  once  laid  open. 

There  is  no  necessity  for  any  elaborate  dressing  after  the  operation.  It 
is  well,  I  think,  to  put  a  piece  of  oiled  lint  into  the  wound,  and  keep  it 
there  twenty-four  or  forty-eight  hours,  so  as  to  avoid  the  agglutination 
of  the  superficial  part  of  the  wound  ;  and  afterwards  to  pass  a  probe  or 
director  down  to  the  bottom  of  it,  to  insure  its  filling  up  regularly;  and 
it  is  a  comfort  for  the  patient  if  he  can  be  spared  any  action  of  the  bowels 
for  a  lew  days. 

The  other  methods  which  have  been  used  for  the  cure  of  fistula  are  the 
elastic  ligature,  the  electric  cautery,  and  the  ecraseur.  Tliey  are  much 
inferioi'  to  the  cutting  operation,  but  one  or  other  may  be  used  on  jjatieuts 
who  will  not  submit  to  the  latter,  and  I  should  think  the  best  would  be 
the  elastic  ligature,  but  I  have  no  experience  of  it.^ 


'  I  would  refer  tins  reader  to  a  disoussi(/n  at  the  Clinical  Society,  reported  in  the 
Lancet,  June  5,  1875,  on  an  interesting  case  under  Mr.  Maunder's  care  of  double 
fistula  in  the  same  patient.  One  was  trf^ated  by  incision,  the  other  with  the  elastic 
ligature.  The  result  showed  the  great  superiority  of  the  cutting  operation,  for  the 
wound  made  with  the  knife  united  kindly  and  with  little  pain,  while  that  jiroduccd 
by  the  elastic  ligature  was  left  with  callous  in-ominent  edges,  and  did  not  unite  till 
five  weeks  after  the  other  was  healed.     Ail  the  surgeons  who  took  j)artin  the  debate 


660 


DISEASES    OF    THE    RECTUM. 


Fig.  311. 


The  cause  of  the  persistence  of  fistula,  is  doubtless  the  action  of  the 
sphincter  ani,  which  constantl}'  presses  upon  the  walls  of  the  abscess 

and  disturbs  any  attempt  at 
union.  Yet  spontaneous  cure, 
in  long  periods  of  time,  is  not 
unknown.  Mr.  Prescott  Hewett 
mentioned  a  short  time  ago  at 
St.  George's  Hospital  two  as 
occurring  under  his  own  obser- 
vation ;  but  the  event  is  too 
rare  and  the  length  of  time  re- 
quired too  long  to  afford  anj'- 
valid  argument  against  the  ad- 
visability of  operating  whenever 
the  general  health  will  bear  it. 

Fistula  in  ano.     The  puckered  part  represents  the  -tlSSlire,    Or,    aS    it    IS    perhaps 

amis.    A  bougie  has  been  passed  through  the  fistula,  better    Called,  ulcer  of  the  anuS, 

and  the  mucous  membrane  has  been  removed,  in  order  Jg  a  VCrV  paiuful  and  distressino" 

to  show  the  fibres  of  the  external  sphincter,  outside  „^,„„i„:,,i       ,„k;^U       l>^.„„,r^..       i^ 

„,.,.,      ,        I    <•  »i    c  .  1       /  J     T,  ,      „     complaint,    wiiicn,    liowever,    is 

wliicli  the  channel  of  the  fistula  extends.    Below  the  '-              '                    '         ^     v.    v^i,     i^ 

letter  a  is  seen  an  external  pile,  which  has  been  cut  USUally  relieved  immediately  by 

across.    The  preparation  well  illustrates  both  the  cause  very  simple  treatment.      It  foriUS 

of  the  persistence  of  fistula  and  the  manner  in  which  ^  ^^^^-^^  ^j.^^^].  ^^^  ^j^^  g^|„^  ^f  ^j^g 

the  operation  removes  that  cause.    The  director  being  ,            i      i        ^i        •         i-         • 

passed  in  the  track  of  the  bougie  above  figured,  the  "OWei,     hardly    implicating     the 

sphincter  is  cut  completely  across,  and    is   then   pre-  wholc  tllickueSS  of  the   skiu,  CX- 

ventcd  from  reuniting  till  the  track  of  the  sinus  below  tending,  perhaps,  a  Certain  dis- 

has  been  obliterated  by  cicatrization. — St. George's  Hos-    .  ii  ^  i     lo 

pitai  Museum,  ser.  ix.  No.  42.  t^nce  up  the  gut— Say  half  an 

inch — and  situated  in  the  great 
majority  of  instances  towards  the  coccyx.  It  is  the  seat  of  great  pain, 
especially  when  the  bowels  act,  and  this  pain  frequently  lasts  for  a  long 
while  after  defecation,  and  is  often  so  severe  that  the  dread  of  it  causes 
the  patient  to  avoid  emptying  the  gut  as  long  as  possible,  so  that  some- 
times a  very  deleterious  habit  of  enforced  constipation  is  set  up,  which 
greatly  impairs  the  digestive  functions.  The  obstacle  to  the  healing  of 
this  ulcer  lies  obviously  in  the  connection  of  the  ulcerated  skin  with  the 
sphincter  ani.  Its  cause  is  not  always  apparent.  It  is  more  common  in 
women  than  men,  and  may  be  produced  by  the  irritation  of  discharges. 
Cracks  form  on  the  anus  from  gonorrlujeal  and  syphilitic  discharges,  but 
are  generally  more  superficial  and  more  easily  cured  than  the  proper 
"fissure  of  the  anus." 

Some  of  the  milder  cases  of  fissure  are  amenable  to  treatment  by  clean- 
liness, attention  to  the  state  of  the  bowels,  so  that  the  fasces  are  never 
hard  nor  the  action  costive,  and  some  stimulating  application,  of  which 
the  stick-caustic  is  the  best.  But  the  operation  which  cures  the  disease 
is  so  sim))le  and  alfords  so  much  immediate  relief  that  it  is  seldom  w^orth 
while  to  spend  time  on  any  other  local  treatment.  It  consists  simply  in 
exposing  the  whole  extent  of  the  nicer  with  a  speculum,  and  then  making 
an  incision  tlii-ougli  its  whole  length  and  depth  with  a  stout  straight  probe- 
pointed  })istoury.  This  incision  should  be  made  carefuU}',  so  as  to  reach 
the  healthy  tissue  throughout  its  whole  extent.     This  is  usually'  quite 

appoarod  to  be  unanimou.'i  in  cimclcmniiiij;  flu;  trcatmont  by  the  elastic  ligature  as  a 
method  for  general  use,  while  admitting  that  it  might  be  indicated  under  exceptional 
circumstiinccs,  chiefly  when  the  ()j)ening  is  very  high  and  the  surgeon  has  rea.^on  to 
fear  the  effect  which  the  necessary  division  of  somewhat  large  vessels  may  have  on 
hi.>  patient. 


POLYPUS  OF  THE  RECTUM.  661 

sufficient.     If  it  fails,  the  division  of  the  entire  sphincter  (including,  of 
course,  the  ulcer  in  the  cut)  may  be  necessary. 

Pruritus  ani  is  often  a  troublesome  aftection,  and  in  some  cases  is  so 
distressing  and  uncontrollable  that,  as  is  the  case  with  pruritus  vuIvjb,  it 
almost  ol)liges  the  sufferer  to  renounce  society.  Usually,  however,  it  is 
symptomatic  of  some  disorder  of  the  digestive  organs,  and  if  taken  in 
time  is  perfectly  manageable.  Careful  attention  to  the  state  of  the  bowels, 
the  expulsion  of  worms,  and  the  careful  regulation  of  the  diet,  are  the 
first  requisites.  It  seems  to  me  often  to  depend  on  the  too  free  use  of 
stimulants.  The  local  treatment  consists  of  astringent  and  sedative 
lotions,  with  scrupulous  cleanliness,  and  perhaps  a  narcotic,  at  bedtime, 
when  tlie  itching  is  apt  to  be  severe.  Careful  examination,  however,  is 
necessary  to  ascertain  the  absence  of  fissure  of  the  anus  or  condylomata, 
of  which  pruritus  is  sometimes  only  a  symptom.  The  disease  is  often 
attended  with  small  excoriations,  hardly  deserving  the  name  of  fissures, 
around  the  anus,  and  the  itching  will  disappear  when  these  are  brought 
to  heal,  which  is  usually  effected  by  touching  them  with  nitrate  of  silver 
and  applying  nitrate  of  silver  in  solution. 

Mr.  H.  Smith  recommends  in  these  cases  glycerin  ointment — a  drachm 
of  glycerin  to  an  ounce  of  lard — or  an  ointment  composed  of  calomel  of 
the  same  strength  (3j  :  Sj).  The  black  or  yellow  wash  is  also  sometimes 
useful,  and  the  daily  passage  of  a  bougie  will  sometimes  render  the  anus 
less  irritable. 

Polypus  of  the  rectum  is  a  disease  which,  though  not  confined  to  child- 
hood, is  most  common  at  that  period  of  life.  Two  forms  of  it  are  de- 
scribed— the  vascular  and  the  fibrous — but  the  difference  is  one  rather  of 
degree  of  vascularity  than  of  kind,  both  being  formed  of  fibrous  tissue 
with  vessels  intermixed.'  The  earlier  the  age  is  the  more  vascular  as  a 
rule  will  be  the  polypus.  These  polypi  are  often  attached  by  long  stalks 
to  the  bowel,  so  that  when  they  float  up  into  the  gut  they  are  impercep- 
tible and  cause  no  symptoms,  but  when  they  are  carried  down  they  are 
grasped  by  the  sphincter,  and  this  causes  pain  and  bleeding.  If  a  child 
suffers  from  occasional  bleeding  from  the  bowel  it  is  usually  from  this 
cause.  Piles  are  very  rare  in  childhood.  The  polypus,  however,  may 
easily  escape  detection,  especially  if  the  bowels  have  not  acted  recently. 
The  surest  way  to  detect  it  is  to  make  the  bowels  act  by  an  enema,  when 
it  will  probably  present  as  a  small  red  projection  at  the  anus,  or  can  be 
felt  and  drawn  down  by  sweeping  the  finger  round  the  bowel.  Sometimes 
the  surgeon,  in  so  doing,  breaks  it  off  and  cures  the  disease,  otherwise  it 
is  necessary  to  remove  it.  There  is  little  or  no  danger  in  the  less  vascu- 
lar specimens  in  twisting  it  off  with  a  pair  of  forceps  ;  but  it  is,  of  course, 
safer  to  tie  the  base  and  cut  it  off  close  to  the  ligature  ;  and  as  this  gives 
little  if  any  pain,  it  is  the  course  generally  adopted. 

Villous  disease  of  the  rectum  is  a  rare  form  of  tumor,  of  which,  how- 
ever, I  once  saw  a  very  striking  instance,''  in  wliich  the  tumor  used  to 
grow  to  such  an  extent  as  to  produce  some  obstruction,  from  which  the 
patient  was  relieved  by  tearing  away  portions  of  the  mass.     This  was 

1  In  some  of  these  polypi  adenoid  tissue  may  be  detected;  others  consist  entirely 
of  epithelium — are,  in  fact,  gic;antic  warts.  A  case  of  this  sort  is  figured  in  Mr.  H. 
Smith's  essay,  Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p   8(50. 

2  Path.  Trans  ,  vol.  xii,  p.  120.  The  jireparation  is  preserved  in  St.  George's  Hos- 
pital Museum,  and  is  figured  in  Mr.  H.  Smith's  essay. 


662 


DISEASES    OF    THE    RECTUM. 


Fig.  312. 


done  thirty-three  times,  and  always  with  temporary  relief.  The  patient 
survived  tive  years,  and  died  at  the  age  of  seventy.  The  whole  course 
of  the  disease  in  tliis  case,  as  well  as  tlie  microscopic  examination,  showed 
that  the  tumor  was  of  a  non-malignant  nature,  though  probably  in  the 
rectum,  as  in  the  bladder,  cancerous  tumors  may  be  covered  with  a  layer 
of  villous  i)rocesses.  The  diagnosis  of  such  tumors  when  within  the  reach 
of  the  finger  or  hand  will  rest  on  their  comparatively  slow  growth,  the 
villous  character  of  their  surface,  the  absence  of  hardness  at  their  base, 
and  of  an}'  symptoms  not  explicable  by  their  mechanical  pressure. 

Mucous  Tubercles  and  Condylomata. — I  ought  to  mention  here,  though 
chietly  for  the  sake  of  diagnosis,  the  syphilitic  atfections  so  frequently 
found  ne?a"  the  anus,  vnz.,  mucous  tubercles  and  condylomata.  Mucous 
tubercles  are  often  confounded,  even  at  the  present  day,  with  external 
jjiles.     Yet  the  diagnosis  is  as  easy   as    possible.     Piles   are  rounded, 

somewhat  pendulous  tumors,  covered  with 
healthy  skin,  and  only  occasionall}'  con- 
nected with  any  symptoms  of  syphilis, 
which  on  careful  examination  will  be  found 
to  have  nothing  but  an  accidental  refer- 
ence to  the  disease.  Mucous  tubercles,  on 
the  contrary,  form  small,  perfectly  flat, 
sessile  elevations  covered  with  a  velvet}' 
or  warty  and  moist  epidermis,  and  are 
always  developed  in  the  course  of  a  reg- 
ular outbreak  of  secondary  or  (what  is 
the  same  thing)  congenital  syphilis.  I 
have  spoken  above  (page  402  )  of  the 
proliably  contagious  nature  of  their  moist 
secretion  and  the  great  etRcacy  of  the 
local  and  general  administration  of  mer- 
cury in  their  treatment. 

Condylomata  are  generally  syphilitic, 
though  they  may  proceed  from  the  irrita- 
tion of  gonorrhoeal  and  possibly  other  dis- 
charges. They  form  large  pedunculated 
masses,  in  which  all  the  textures  of  the 
skin  can  be  detected,  covered  with  a  foul 
warty  surface  and  exhaling  a  fetid  mois- 
ture, frequently  very  vascular,  and  bleed- 
ing to  an  alarming  extent  sometimes  when 
removed.  The  elastic  ligature,  thougli  infe- 
rior in  most  situations  to  the  knife  for  tlie 
removal  of  tumors,  seems  to  me  very  appro- 
l)riate  for  the  treatment  of  condylomata. 

Sii  i|  1     ^ti  1   till        I   I     tui  1    Tt  a  iKiinl 

about  .111  inch  irom  the  iiiuv   The  sur-        Stvicture  of  the  rectum  is  either  simple 

lace  of  the  mucous  membrane  is  much    ^..  „ „„.,„.,„       "n^i-K  ,.,:n     ^e  «^.,..^^     \^^  «« 

,      ,  ,      ,  ,,        „   ,r,u.  1,,.,  1 ;.,   or  cancerous.    J3oth  will,  ot  course,  be  ac- 

ulcerateu,  and  tlio  walls  of  the  bowel  lu  "  " 

this  situation  (wiiich  was  continuous  to   compauicd  by  tlic  Same  symptoms  of  me- 

Ihe  uterus)  are  much  thickened  and  indu-  cliauical  obstrUCtioU  in   proportion   tO  their 

rated.  On  microscopical  examination  g^tent,  i.  fi.,  COnstil)ation,  foUowcd  by  diar- 
tlii.s  tbickeninL'  was  found  to  be  due  en-       ,  ;,.',.  t    ,  •  i.,i        i     n 

tirely  to  thedevelopmentofafirm  fibrous  ^'l^^^,  UUllgestlOn,  dlStCnSlOU  of  tllC  bclly, 

material  in  the  submucous  areohir  tissue,  losS    of  appetite,  health,    and    COmplcxioU. 

and  in    the   cellular   tissue    outside    the  ThcSC  symptouiS  are  UOt,  llOWCVCr,  whollj 

bowel.  N^u.ecuiiare,.ii..oniiati.,nscouid   n.ecliau ical,    though     they     pcrhaps    are 

be  detected  in  this  material. — Museum  of        ,      ,,  i   i  i  i         .       i      i     ^ 

St.  George's  Hospital,  ser.ix,  No.  a?.         whoUy  caused  by  the  mechanical  obstruc- 


STRICTURE.  663 

tion.  There  can  be  no  clonbt  that  the  diarrhoea  and  the  acrid  discharge 
present  cA'en  in  non-cancerous  stricture  are  caused  in  part  at  least  by  re- 
tention of  the  faeces  setting  up  inflammation  of  the  mucous  lining  of  the 
bowel  and  catarrhal  discharge.  In  some  cases  (rarer,  however,  than 
might  perhaps  be  inferred  from  their  constant  mention  in  surgical  books) 
foreign  bodies  become  impacted  in  the  strictured  intestine  and  thus  com- 
plete the  obstruction  w])ich  otherwise  would  be  imperfect. 

Simple  stricture  depends  on  tlie  deposit  of  fibroid  material  in  the  wall 
of  the  bowel  or  external  to  it,  probably  from  chronic  inflammation,  or  on 
the  healing  of  ulcers,  and  these  are  either  strumous,  syphilitic,  dysen- 
teric, or  accidental.  Strumous  ulcers  are  believed  to  be  very  common. 
When  they  perforate  the  bowel  they  lead  to  fistula,  and  are  then  usuall3' 
of  small  size.  Larger  strumous  ulcers  may  produce  firm  bands  of  cica- 
trix considerably  narrowing  the  calibre  of  the  intestine. 

So  also  with  venereal  disease.  Sir  J.  Paget  has  shown  how  common 
it  is  in  women  who  sufl^er  from  constitutional  sy|)hilis  to  find  the  rectum 
occupied  by  ulcerations  of  a  horseshoe  shape,  which  in  their  healing  pro- 
duce cicatricial  bands  stretching  across  the  cavit}^ 

The  main  feature  in  the  diagnosis  between  these  simple  forms  of  stric- 
ture and  the  obstruction  of  cancer  lies  in  the  fact  that  in  cancer  the  mor- 
bid deposit  is  infiltrated  for  a  considerable  distance  into  the  walls  of  the 
bowel  and  the  neighboring  tissues,  producing  a  hard  irregular  nodular 
mass  which  extends  for  some  distance  from  the  seat  of  obstruction  (Fig. 
313),  while  in  simple  stricture  there  is  often  merely  a  constriction  as  if 
a  string  had  been  tied  round  the  bowel,  the  coats  of  which  feel  quite 
healthy  up  to  the  stricture;  and  if  the  finger  can  be  passed  through  it, 
the  mucous  membrane  on  the  other  side  feels  healthy,  and  there  is  no 
deposit  around  the  bowel. 

It  must  be  admitted,  however,  that  the  diagnosis  is  often  by  no  means 
easy  in  cases  such  as  that  shown  in  Fig.  314,  where  the  ulcerated  and 
contracted  surface  is  very  extensive,  and  the  patient  exhausted  by  suf- 
fering. 

After  either  kind  of  stricture  fistulous  passages  will  form,  precisely  as 
after  stricture  of  the  urethra,  the  wall  of  the  bowel  giving  way  from 
ulceration  above  or  in  the  tissue  of  the  stricture,  a  little  of  the  contents 
being  infiltrated  into  the  textures  around,  and  suppuration  extending 
gradually  from  this  point  to  the  skin.  Such  fistulous  passages,  however, 
form  much  more  readily  in  cancerous  strictures,  for  obvious  reasons, 
since  the  substance  of  these  cancerous  deposits  very  readily  breaks  down 
and  ulcerates  ;  and  for  this  reason  also,  as  well  as  from  their  greater  ex- 
tent, the  passage  of  fffices  through  the  stricture  is  much  more  painful  in 
cancerous  than  in  simple  stricture,  and  is  often  the  chief  source  of  the 
patient's  misery. 

The  treatment  of  stricture  of  the  rectum  is  in  some  cases  decisive  and 
very  successful.  When  the  obstruction  is  formed  merely  by  an  ulcer 
which  has  cicatrized,  and  the  constitutional  condition  on  which  it  may 
have  depended  has  passed  away,  the  health  may  be  as  completely  and 
rapidly  restored  by  dilating  the  stricture  as  in  the  parallel  case  of  stric- 
ture of  the  urethra  ;  and,  as  in  the  urethra,  this  dilatation  may  be  ac- 
complished either  gradually  by  means  of  bougies  or  rapidly  by  incision. 
The  latter  method  is  by  no  means  free  from  danger.  I  have  seen  peri- 
tonitis and  death  follow  Ihe  incision  of  a  stricture  of  the  rectum  even 
when  the  incision  was  quite  away  from  the  peritoneal  cavit}'  and  strictly 
limited  to  the  posterior  wall  of  the  bowel.  It  should  be  reserved  for 
dense  cicatricial  strictures  in  wdiich  the  method  of  gradual  dilatation  fails 


664 


DISEASES    OF    THE    RECTUM. 


or  is  too  painful.  It  is  accomplished  by  passing  a  director  through  the 
stricture  (which  is  suppose  to  be  too  tight  to  admit  the  finger)  and  guid- 
ing a  hernia  knife  upon  it,  with  which  the  tissue  of  the  stricture  is  to  be 
slightly  notched  backwards  or  towards  the  sacrum  in  one  or  two  places 
to  an  extent  suflicient  to  admit  the  passage  of  the  little  finger,  and  there- 
fore of  a  small  bougie.     Perhaps  the  bistouri-cache  is  a  safer  instrument. 


Fig.  313. 


Fig.  314. 


Fig.  313.— Scirrhous  deposit  and  ulceration  of  tte  rectum.— Museum  of  St.  George's  Hospital,  Ser.  i.v, 
No.  64. 

Fig.  314.— E.xtensive  ulceration  and  contraction  of  the  bowel,  with  distension  above  the  contracted 
part,  due  probably  to  strumous  ulceration. — St.  George's  Hospital  Museum,  Ser.  ix.  No.  149  a. 


This  operation,  however,  is  only  intended  as  a  preliminary  to  the  use  of 
the  bougie.  Although,  as  I  have  said  before,  it  is  not  free  from  grave 
risk,  in  appropriate  cases  (r.  e.,  cases  of  tough  cicatrix)  its  beneficial 
effects  are  almost  magical. 

For  slighter  cases  of  non-cancerous  stricture  the  rectum  bougie  is  all 
that  is  required.  It  should  be  passed  at  first  l)y  the  surgeon  or  by  a 
skilled  attendant  until  the  stricture  will  freely  admit  an  instrument  the 


MALFORMATIONS. 


665 


Fig.  315. 


size  of  the  middle  finger,  and  all  trouble  from  obstruction  is  over,  when 

the  patient  may  be  instructed  to  pass  it,  and 

should   at  first    be   watched  to  see  that  he 

really  does    pass    it   through  the   stricture. 

As  in  the   urethra   it   will  be   necessary  to 

keep  the  stricture  dilated  for  a  time,  which 

is  practically  unlimited. 

Malignant  stricture,  on  the  contrary,  can 
only  be  aggravated  by  any  form  of  mechan- 
ical treatment.  Gentle  laxatives,  to  keep 
the  motions  soft  and  avoid  the  irritation 
produced  in  the  upper  bowel  by  the  deten- 
tion of  hardened  faeces ;  opium  or  morphia, 
to  relieve  pain  and  procure  sleep;  and  nour- 
ishing food  in  small  bulk,  constitute  all  that 
can  be  done  in  an  early  stage.  Later  on 
the  question  of  affording  relief,  though  only 
for  a  time,  by  opening  the  bo\vel  above  the 
seat  of  stricture  becomes  an  urgent  one. 

Gololomy. — The  operation  of  colotomy  is 
one  which  has  become  a  very  common  one 
of  late,  and  about  which,  therefore,  much 
more  is  known  than  was  the  case  formerly. 
We  know  that  after  successful  colotomy,  or 
indeed  after  the  formation  of  an  artificial 
anus  in  any  part  of  the  intestine,  the  pa- 
tient's life  is  not  by  any  means  so  miserable 
as  was  thought  formerly  to  be  the  case  ;  and 
we  also  know  that  the  cancer  which  affects 
the  lower  bowel  is  frequently  of  the  less 
malignant  and  rapidly  growing  forms,'  and 
consequently  that  if  the  effects  of  mechan- 
ical obstruction  and  consequent  irritation 
can  be  obviated  the  patient  may  survive  a 
long  time.  Then,  again,  the  sufferings  which 
cancer  occasions  when  the  surface  over  which 
the  fseces  pass  is  extensively  ulcerated  are 
often  very  acute,  and  it  is  worth  his  while  to  submit  to  the  risk  of  the 
operation  even  for  that  cause  onl}',  irrespective  of  any  obstruction. 

The  operation,  however,  is  much  more  urgently  indicated  and  much 
more  certain  to  afford  immediate  relief  when  it  is  performed  with  a  view 
of  relieving  the  symptoms  of  total  obstruction,  besides  being  more  easy 
of  execution. 

For  a  description  of  the  operation  see  the  section  on  Internal  Stra'ngu- 
lation  (page  614). 


Bistouri-cache.  The  instrument  is 
passed  through  the  orifice  to  be  in- 
cised, with  the  knife  concealed  in  the 
stem.  By  pressure  on  the  handle  the 
blade  is  projected  to  an  extent  which 
is  regulated  by  the  screw. 


Malformations  of  the  lower  bowel  are  usually  described  as  either 
(1)  imperforate  anus,  or  (2)  imperforate  rectum.  1.  In  the  former  case 
there  is  no  anal  opening ;  in  the  latter  there  is,  but  it  does  not  lead  into 
the  bowel.  When  a  child  is  born  with  no  anal  aperture  the  circumstance 
may  escape  notice  for  a  time,  and  then  the  symptoms  are  usually  com- 
plicated by  the  useless  administration  of  purgatives.     Yery  commonly, 

^  Cancer  of  the  rectum  is  either  of  the  epithelial  or  scirrhous  form.  It  often  re- 
mains for  a  long  time  without  spreading  to  the  neighboring  viscera,  and  without 
much  growth  or  ulceration,  if  not  irritated  by  the  constant  passage  of  fjBces. 


666 


DISEASES    OF    THE     RECTUM. 


bowever,  the  malformation  is  detected  soon  after  birth.  If  relief  is  not 
afforded  the  usual  symptoms  of  obstruction  set  in  ;  after  a  day  or  two  of 
constipation  the  belly  becomes  distended,  vomiting  commences  (the 
period  being  dependent  in  a  great  measure  on  the  amount  of  fluid  put 
into  the  stomach),  the  food  only  being  rejected  at  first,  and  then  the 
meconium,  and  the  child  dies  in  a  few  days,  either  from  exhaustion  or 
peritonitis.  Many  of  these  cases  are,  however,  perfectly  curable,  and  b}' 
so  simple  a  proceeding  that  it  should  hardly  be  dignified  with  the  name 
of  an  operation.  The  bowel  comes  close  to  the  skin,  and  if  the  surgeon 
will  make  a  moderately  free  incision  in  the  position  of  the  anus,  draw 
the  bowel  down  to  the  level  of  the  skin,  and  attach  the  mucous  mem- 
brane to  the  skin  around  the  whole  of  the  circumference,  nothing  more 
need  be  done.  The  patient's  life  Avill  be  preserved  for  the  moment,  and 
it  ma}'  be  confidenth'  anticipated  that  the  power  of  retaining  the  faeces 
will  ])e  perfect.^ 

These  are  the  simplest  cases,  and  they  maybe  recognized  conjecturally 
b}'  the  perfect  development  of  the  pelvic  bones,  so  that  the  coccyx  is  at 
the  normal  distance  from  the  scrotum  or  vagina,  and  by  the  bulging  in 
the  perineum  when  the  child  cries.  A  surgeon  who  would  not  operate 
in  a  case  of  this  kind  would,  I  think,  neglect  one  of  the  plainest  duties 
of  his  profession.  Yet  man}'  such  cases  are  sacrificed  to  the  prejudice 
that  children  with  imperforate  anus  had  better  be  left  to  die. 

With  Faecal  Fialula. — There  are  other  cases  in  which  imperforate  a'nus 
is  complicated  with  fistuloe  opening  into  the  vagina,  into  the  bladder 
or  the  male  urethra,  or  into  the  scrotum. 

When  the  rectum  communicates  with  the  vagina,  there  are  cases  in 
which  the  deformity  has  produced  so  little  inconvenience  that  the  patient 


Imperforate  rf!ctuin  with  scrotal  fistula.    An  incision  has  been  made  into  the  rectum  from  the  natural 
situation  of  the  anus,  and  a  probe  passed  through  this  incision  from  the  scrotal  fistula. 


has  reached  maturity,  and  even  had  children,  without  being  sensible  of 
it.''     In  such  cases  some  sphincter  action  must  be  exercised  by  the  fibres 

^  The  .sphincter  exists  in  some  of  these  cases,  tlioucjii  the  anus  is  imperforate.  See 
a  dissection  by  Mr.  Partridge,  described  in  the  Path.  Trans.,  vol.  v,  p.  176.  But 
oven  if  there  were  no  external  spliincter,  tiie  circuhir  fibres  of  the  internal  sphincter 
would  prevent  any  incontinence  oC  fieces. 

^  A  striking  case  recorded  by  Mr.  Loon  Lcfort,  will  be  found  in  my  work  on  the 
Treatment  of  Children's  Diseases. 


IMPERFORATE    ANUS. 


667 


of  the  vagina  as  the  gut  passes  obliquely  through  them.  But  generally 
the  patient  suffers  the  most  terrible  misery  from  tlie  deformity,  and  then 
an  attempt  must  be  made  to  draw  the  bowel  down,  as  is  done  in  simple 
imperforation,  and  at  tiie  same  time  to  detach  it  from  the  vagina,  and 
this  is  sometimes  successful.^ 

When  the  opening  is  into  the  male  bladder  or  urethra  the  only  thing 
that  can  be  done  to  preserve  life — which  will  otherwise  be  gradually  but 
surely  destroyed  b}'  the  accumulation  of  semi-solid  fneces  in  the  urinary 
passages,  causing  symptoms  analogous  to  stone,  or  absolutely  forming 
the  nucleus  for  a  stone — is  to  open  the  bowel  higher  up,  either  in  the 
loin  or  groin. 

In  cases  where  external  fistula  exists  the  bowel  is,  I  think,  never  or 
very  rarely  far  from  the  integument,  and  the  free  re-establishment  of  the 
natural  passage  will  cure  the  unnatural  one. 

WifJi  Deficiency  of  the  Bowel. — But  there  are  more  formidable  cases 
of  imperforate  anus,  in  which  the  bowel  is  entirely  deficient,  and  may 
terminate  at  an}^  level,  though  usually  it  ends  at  the  sigmoid  flexure  of 
the  colon,  which  then  sometimes  bends  over  to  the  right  side  instead  of 
ending  on  the  left.  These  eases  of  deficient  rectum  may  be  suspected 
b}'  the  ill-developed  condition  of  the  pelvic  bones,  the  tuberosities  of  the 
ischia  being  close  together,  and  the  coccyx  near  to  the  parts  of  genera- 
tion, and  by  the  absence  of  all 

bulging  in  the  perineum  when  fig.  317. 

the  child  cries.  The  surgeon  is, 
however,  justified  in  making 
an  exploratory  incision — keep- 
ing very  close  to  the  coccyx  as 
he  gets  deeper — and  if  he  does 
not  find  any  bowel  it  is  a  mat- 
ter for  his  own  judgment  whe- 
ther to  open  a  higher  part  of 
the  gut,  and  if  so  which  part. 
I  cannot  doubt  that  in  healthy 
infants  such  an  attempt  to  pre- 
serve life  should  be  made,  and 
that  the  groin  is  the  best  place 
to  make  the  opening.  Persons 
in  whom  this  operation  (Lit- 
tre's)  has  been  performed  in 
infancy  have  been  known  to 
live  till  middle  life  or  be3'ond 
it  in  perfect  health  and  com- 
fort, marrying  and  taking  their 
part  in  all  the  business  and 
pleasures  of  their  station;'^ 
and  though  such  cases  are  un- 
doubtedly very  exceptional,'' 
still  I  think  we  are  bound  to 
give  the  patient  the  chance. 

M.  Hug-uier  has  recommend- 


Dissection  of  the  parts  from  the  above  case.  Tlie  bowel 
is  seen  with  the  Madder  lying  in  front  of  it.  The  bowel 
terminates  in  a  eul-de-sac,  close  to  the  skin,  from  which  a 
small  canal  runs  forward.  This  opens  on  the  skin  at  B, 
and  from  thence  an  almost  imperceptlTjle  tube  can  be 
traced  forwards  as  far  as  c,  where  it  opens  into  the 
urethra,  a  marks  the  situation  of  the  anus,  while  the 
incision  is  shown  in  the  previous  figure. — From  Larcher. 
Translation  of  Holmes's  Surg.  Dis.  of  Childhood. 


1  Sigr.  Rizzoli  has  lately  published  several  cases  in  which  this  deformity  has  been 
treated  with  much  success. 

2  See  Rochard,  Mem.  de  I'Acad.  Imp.  de  Mi«d.,  1859. 

3  Holmes,  Surg.  Dis.  of  Children,  2d  ed.,  p.  173. 


668 


DISEASES    OF    THE    RECTUM. 


Fig.  318. 


ed  that  in  these  cases  the  opening  should  be  made  in  the  right  groin  instead 
of  in  tlie  left,  as  would  seem  more  natural.     His  reason  is  the  occasional 

deviation  of  tlie  sigmoid  flex- 
ure to  the  right  side  in  cases 
of  deficiency  of  the  rectum. 
But  tliis  deviation  is  after  all 
only  occasional.  I  think  it 
better  to  make  the  opening  in 
the  left  groin  ;  and  if  the  end 
of  the  bowel  is  not  found  there 
a  slight  extension  of  the  wound 
upwards  will  probably  enable 
the  surgeon  to  open  it  as  it 
bends  over  to  the  right  side. 

Imperforate  Rectum.  —  In 
imperforate  rectum  (in  the 
proper  sense)  the  anus  and 
the  portion  of  bowel  contigu- 
ous to  it,  which  are  developed, 
as  the  skin  is,  from  the  ex- 
ternal embryonic  layer,  are 
natural,  and  this  almost  al- 
ways causes  the  deformity  to 
be  overlooked  at  first.  But 
as  the  child  can  pass  no  mo- 
tions the  same  symptoms  come 
on  as  in  imperforate  anus,  and 
then  on  examination  with  the 
finger  the  anus  is  found  to  lead 
into  a  depression,  or  cul-de-sac, 
like  a  thimble.  The  bowel  ter- 
minates at  a  variable  height 
above.  Usually,  as  in  the  figure, 
the  lower  end  of  the  gut  is  at 
no  great  distance;  but  the  condition  of  parts  may  be  just  the  same  as  in 
imperforate  anus,  i.e.,  the  gut  may  end  at  the  sigmoid  flexure  or  at  any 
higlier  level. 

The  first  thing  to  be  done  is  to  make  a  free  incision,  through  the  skin 
and  soft  parts,  including  the  cul-de-sac,  from  the  coccyx  as  far  forwards 
as  the  parts  of  generation  permit,  having  a  staff  in  the  urethra  or  vagina, 
according  to  the  sex,  so  that  the  bladder,  uterus,  and  peritoneal  reflexions 
may  be  avoided.  The  incision  should  be  extended  as  deep  as  possible  by 
very  gradual  dissection,  the  surgeon  feeling  constantly  for  the  bulging- 
bowel,  and  when  tliis  is  reached  he  endeavors  to  draw  it  down  and  at- 
tach it  to  the  external  wound  before  opening  it.  When  tliis  cannot  be 
done  it  must  be  opened  in  situ,  and  the  patency  of  the  opening  main- 
tained either  by  tents  or,  what  I  tliink  is  better,  by  passing  the  little 
finger  gently  through  into  the  gut  twice  a  day.  But  as  these  fistulous 
channels  are  very  liable  to  close,  it  is  far  better,  if  possible,  to  draw  the 
gut  down. 

The  old  plan  used  to  be  to  explore  the  parts  with  a  trocar,  but  it  is 
an  undeniably  l)ad  one.  The  gut  may  be  missed  altogether,  and  the  pe- 
ritoneum or  some  otlier  part  opened  (as  shown  in  Fig.  319);  or  if  the 
upper  cul-de-sac  is  readied  and  punctured,  the  escajje  of  air  from  it 
renders  it  more  difficult  to  dissect  down  on  it  afterwards,  and  no  punc- 


Iiuperforate  rectum.  The  bowel  terminates  at  the  mid- 
dle of  the  sacrum.  There  is  an  anal  cul-de-sac,  separated 
by  a  small  cellulo-fibrous  interspace  from  the  bowel. — 
After  Giraldfes. 


DISEASES    OF    THE     LARYNX. 


669 


tare  with  a  trocar,  however  enlarged  by  subsequent  passage  of  instru- 
ments, gives  that  free 

exit   for  the    motions  fig.  319. 

which  is  necessary  in 
after  life. 

In  many  cases  the 
obstruction  of  the 
bowel  is  forined  by  a 
mere  membrane,  and 
all  that  is  necessary  is 
to  make  a  free  crucial 
opening  and  keep  it 
distended  by  the  daily 
passage  of  the  finger 
for  a  month,  with  oc- 
casional exploration  Parts  removed  from  a  case  where  Littre's  operation  was  performed 
from  time  to  time  after-  ^y  ^^^-  -^^  Johnstone,  in  a  ease  of  imperforate  rectum,  after  an  unsuc- 
_  1  cessful   exploratory   puncture,   which  passed   into  the    recto-uterine 

WaiClS.  ^  pouch  of  peritoneum,    a,  the  uterus  ;  6,  a  bristle  passed  in  the  course 

The  cases  of  imper-    of  the  trocar  tlirough  the  anaJ.  cul-de-sac  into  the  peritoneal  cavity,  c, 

forate  rectum  in  which    the  termination  of  the  rectal  cul-de-sac  partly  invested  with  perito- 

r.  t    oon    ho    fnnurl     neum,  and  lying  close  to  the  track  of  the  trocar  ;  d,  the  artificial  anus 

no    gUl    can    Oe    lOUna     j^  ti,e  left  groin— From  a  preparation  in  the  Museum  of  the  Hospital 

on     exploration     must    for  sick  children.— Holmes's  Surg.  Treatment  of  Children's  Diseases, 

be  treated  on   similar   p.  172. 

principles  to  those  of 

imperforate  anus  with  the  same  malformation.     In  fact,  the  presence  or 

absence  of  a  small  anal  cul-de-sac  is  quite  immaterial. 


CHAPTER    XXXIV, 

DISEASES  OF  THE  LAKYNX. 


Lori/ngoscopy. — The  diseases  of  the  larynx  have  been  brought  within 
the  fieid  of  actual  observation,  and  their  treatment  has  been  rendered 
certain  and  successful,  by  the  happy  invention  of  the  laryngoscope,  an 
instrument  which  is  usually  regarded  as  the  invention  of  Signor  Garcia, 
an  eminent  musician,  though  tlie  late  Dr.  Babington,  of  Gruy's  Hospital, 
is  believed  to  have  a  prior  claim  to  the  distinction.  The  late  Dr.  Czer- 
mak  was  perhaps  the  one  who  did  more  than  any  other  laryngoscopist 
to  perfect  the  details  of  the  method  and  to  extend  and  popularize  its 
use.  Laryngoscopy  has  now  become  so  universal  that  a  certain  amount 
of  familiarity  with  it  may  fairly  be  expected  of  every  practitioner. 

The  details  of  instruments  \ary  considerably,  and  it  would  be  impossi- 
ble here  to  speak  of  their  various  advantages.  All  I  shall  attempt  is  to 
descrilie  the  essentials  of  the  method.  The  laryngoscope  consists,  then, 
essentially  of  two  mirrors,  one  the  reflector,  which  is  usually  fixed  to  the 
forehead  of  the  surgeon,  who  sits  in  front  of  the  patient;  and  the  other. 


670  DISEASES    OF    THE    LARYNX. 

the  laryngeal  mivrov  or  speculnm,  mounted  on  a  stem,  small  enough  to 
vest  between  the  tonsils  on  the  lower  surface  of  the  uvula  and  soft  palate, 
and  inclined  at  an  angle  of  45°  to  the  stem.  A  po\verful  lamp  is  })laced 
behind  the  patient,  unless  the  direct  rays  of  the  sun  are  available  (which 
is  but  rarely  the  case).  The  speculum  is  warmed  by  holding  its  reflecting 
or  glass  surface  over  the  lamp  flame  till  its  back  is  just  warm  enough  to 
be  comfortably  borne  on  the  cheek.  If  it  is  hotter  the  patient's  palate 
will  not  bear  it,  if  colder  his  breath  will  dim  it.  He  is  then  directed  to 
open  his  mouth  widely,  holding  the  tongue  down,  if  he  can,  and  breath- 
ing easily.  A  person  who  can  show  the  fauces  well,  and  who  is  not  pecu- 
liarly sensitive,  requires  no  preparation  ;  and  if  the  surgeon  is  dexterous 
at  the  examination  he  can  lay  the  speculum  on  the  uvula  and  direct  the 
light  on  to  it  so  as  to  show  the  image  of  the  larynx  on  it  at  once.  This 
imase  will  be  reversed,  so  that  the  epiglottis  and  the  convergence  of  the 
vocal  cords  appear  to  be  behind  and  their  divergent  extremities  with  the 
arytttnoid  cartilages  in  front,  and  the  right  vocal  cord  is  on  the  left  side 
ofthe  image.  Most  patients  wdio  are  examined  for  the  lirst  time  require 
a  little  preliminary  exercise,  especially  if  in  the  hands  of  an  inexperienced 
examiner,  for  practice  gives  a  precision  and  a  gentleness  in  manipulating 
tiie  mirror  which  are  invaluable  as  aids  to  successful  laryngoscopy.  And 
there  are  many  patients  whose  fauces  are  so  narrow  or  so  irritable  that 
they  can  hardly  tolerate  the  lightest  touch  of  even  the  smallest  mirror. 
Still,  with  patience  on  the  part  of  the  surgeon  and  perseverance  on  that 
ofthe  patient,  almost  all  adults  can  ultimately  be  successfully  examined. 
In  children  it  is  sometimes  actually  impossible  to  obtain  a  satisfactory 
view  of  the  parts.  The  management  of  the  tongue  is  often  very  trouble- 
some. After  a  little  practice  most  patients  can  keep  it  out  of  the  way.  If 
not,  the  patient  may  hold  the  tip  of  it  out  of  the  mouth  with  his  hand- 
kerchief or  a  cloth,  or  the  surgeon  may  depress  it  with  a  spatula.  The 
shape  of  the  mirror  seems  to  me  of  little  importance,  though  I  prefer  a 
round  one;  but  it  is  of  unquestionable  advantage  to  use  as  large  a  one 
as  the  fauces  can  tolerate. 

With  the  laryngoscope  all  the  back  of  the  mouth  and  the  fauces  can 
be  thoroughly  examined,  and  in  the  mirror  the  epiglottis,  arytoeno-epi- 
glottidean" folds,  the  apices  of  the  arytenoid  cartilages  surmounted  by 
the  cornicula,  the  openings  of  the  ventricles,  the  true  vocal  cords,  and  a 
part  of  the  wall  of  the  trachea  (while  the  glottis  is  open)  can  be  fully 
seen.  In  some  cases  where  the  cords  are  widely  apart  an  experienced  ex- 
aminer can  direct  the  light  so  as  to  catch  the  bifurcation  of  the  trachea.' 
When  the  parts  are  fully  in  view  the  patient  is  directed  to  pronounce  the 
vowel  '■'Ah  "  in  tones  varying  from  the  lowest  to  the  higiiest  pitch  of  his 
voice,  so  as  to  throw  the  vocal  cords  into  free  vibration,  and  show  whether 
they  are  as  mova])le  and  as  elastic  as  they  should  be ;  their  outline  is 
carefully  examined  for  the  marks  of  ulceration  or  other  injury;  vegeta- 
tions on  the  cords  or  tumors  of  any  other  kind  in  any  part  ofthe  larynx, 
or  foreign  Ijodies^can  hardly  escape  observation;  and  any  deviation  from 
the  natural  color  of  the  various  parts  will  be  readily  appreciated  by  one 
who  has  accustomed  liimself  to  the  examination  of  the  paits  in  health. 
This  is,  indeed,  indisjicnsable.  No  description  or  Ijook  of  plates  will  en- 
able a  surgeon  to  recognize  morltid  ai)pearances,  unless  he  has  habituated 
himself  to  the  aspect  of  the  parts  in  health,  which  is  perhaps  best  done 
by  auto-laryngoscopy  at  first,  though  it  is  also  very  necessary  to  examine 

1  I  think  Prof.  Czermiik  was  tho  first  to  show  this  on  his  own  person,  but  many 
dt-monstrators  of  iuilo-laryngoscopy  have  been  able  to  follow  his  example. 


RHINOSCOPY LARYNGITIS.  671 

a  variety  of  individuals,  in  order  to  learn  the  wa.y  of  overcoming  the 
difficulties  caused  by  varying  idios^'ncrasies,  which  can  only  be  done  by 
various  little  changes  in  manipulation.  Success  in  l^l•^•ngoscopy  can 
only  be  obtained  by  constant  practice,  and  this  is  still  more  necessary  in 
order  to  succeed  in  the  delicate  manipulations  by  which  some  afl'ections 
of  the  larynx  must  be  treated. 

Rhinosco])}/. — The  posterior  nares  and  npi)er  part  of  the  pharynx  can 
also  be  illuminated  more  or  less  completely  b}-  means  of  the  laryngeal 
speculum,  but  the  view  obtained  is  far  less  satisfactorj- ;  still,  enough 
can  in  many  cases  be  seen  to  enable  the  surgeon  to  diagnose  with  confi- 
dence aftections  which  would  otherwise  be  only  matters  of  inference. 

The  instruments  are  the  same,  with  the  addition  of  a  long,  narrow 
spatula  turned  up  at  the  end,  or  a  blunt  flat  hook,  by  whicli  the  uvula 
and  soft  palate  are  to  be  gently  raised  and  drawn  forwards  with  the  left 
hand  while  the  mirror,  which  is  somewhat  smaller  and  longer  in  the  stalk 
than  the  common  laryngoscopic  speculum,  and  has  the  stem  a  little  bent 
downvvards  near  its  junction  with  the  handle,  is  passed  to  the  back  part 
of  the  pharynx.  By  slight  variations  of  its  position  and  of  that  of  the 
reflector  the  surgeon  tries  to  bring  successively  into  view  the  various 
parts  of  the  naso-pharyngeal  region.  Mr.  Durham  sa3's :  "Under  the 
most  favorable  circumstances  the  two  superior  meatuses  may  be  inspected 
more  or  less  completely,  and  considerable  portions  of  the  mucous  mem- 
brane covering  all  three  turbinated  bones  may  be  seen  ;  the  septum  may 
be  examined  throughout  a  great  part  of  its  extent,  but  the  view  obtained 
is  necessarily  very  oblique.  Some  portions  of  the  posterior  surface  of 
the  velum  palati  may  also  be  seen.  Lastly,  if  the  mirror  is  turned  to- 
wards one  side,  the  lateral  wall  of  the  nasopharyngeal  cavity  and  the 
orifice  of  the  Eustachian  tube  may  be  brought  into  view.  But  the  dififi- 
culties  of  posterior  rhinoscopy  are  great,  and  it  is  rarely  that  the  cavities 
ma}^  be  inspected  to  the  extent  indicated,  although  this  is  theoretically 
possilile  in  most  eases,  and  has  been  actually  accomplished  in  man3^"^ 

When  the  laryngoscopical  appearances  in  health  and  those  in  disease 
to  a  certain  extent  have  become  familiar,  the  surgeon  proceeds  to  learn 
the  use  of  the  laryngeal  brush  and  the  stem  by  which  solutions  or  solid 
substances  are  conveyed  to  any  accessible  point  of  the  larynx  which  may 
be  desired  ;  and  that  of  the  forceps,  laryngeal  scissors,  or  guillotine,  by 
which  new  growths  may  be  removed. 

Laryngitis  occurs  either  in  the  acute  or  chronic  form.  In  the  former 
it  is  a  most  formidable  aflTection,  very  dangerous  to  life,  and  often  prov- 
ing fatal  in  spite  of  the  most  vigorous  and  judicious  treatment.  Its 
causes  are  exposure  to  cold  (acute  catarrhal  laryngitis),  the  poison  of 
the  contagious  fevers,  small-pox  and  scarlet  fever  especially,  doubtless 
from  the  extension  to  the  mucous  membrane  of  the  characteristic  affec- 
tion of  the  skin  (exanthematous  laryngitis),  the  extension  inwards  of 
cutaneous  or  phlegmonous  erysipelas  (erysipelatous  and  diffuse  cellular 
laryngitis),  and  injury  (traumatic  laryngitis).  Chronic  laryngitis  may 
also  be  catarrhal,  or  phthisical  (strumous),  or  syphilitic,  or  it  may  result 
from  overuse  of  the  voice  (clergymen's  sore  throat,  chronic  glandular  or 
follicular  disease  of  the  larynx). 

Besides  these  affections,  which  are  found  at  any  time  of  life  and  local- 
ized in  the  lar3'nx,  there  must  be  added  to  the  list  of  acute  affections  the 
peculiar  spasmodic  inflammatory  affection  in  children  called  croup,  and 


Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p.  259. 


672  DISEASES    OF    THE    LARYNX. 

the  diphtheritic  affections  of  the  throat  which  spread  downward  into  the 
air-passages. 

It  would  be  out  of  place  here  to  attempt  a  complete  view  of  the  affec- 
tions of  the  larynx.  I  must  content  myself  with  a  general  summary  of 
the  more  important  practical  points  connected  with  its  acute  and  chronic 
diseases,  referring  the  reader  for  more  extensive  details  to  Mr.  Durham's 
excellent  essay  in  the  System  of  Surgery,  or  to  some  of  the  special  treat- 
ises on  the  subject. 

Acute  laryyigitis  is  characterized  by  the  sudden  accession  of  formidable 
obstruction,  very  liable  to  be  complicated  by  attacks  of  spasmodic  d3'sp- 
ncea  (spasm  of  the  glottis),  in  which  life  may  easily  terminate.  The  ra- 
pidity with  which  the  disease  proves  fatal  in  some  cases  is  well  known. 
I  have  known  a  man,  tolerably  well  in  the  early  afternoon,  who  died  four 
hours  afterwards ;  nor  are  such  cases  very  rare.  The  complaint  begins 
with  ordinary  sore  throat  (and  probably'  the  catarrhal  form  usually  com- 
mences in  the  pharynx),  then  feverishness  and  distress  supervene,  inspi- 
ration becomes  difficult  and  painful,  with  some  cough  ;  dysphagia  in- 
creases, the  patient  begins  to  hawk  up  small  hard  masses,  which  are 
supposed  to  come  from  the  ventricles  of  the  larynx  ;  then  the  d3'spnoea 
rapidly  increases,  expiration  as  well  as  inspiration  is  obstructed,  the  face 
becomes  livid,  the  features  bathed  in  sweat,  the  pulse  small  and  inter- 
mittent, and  death  follows  either  from  spasm  of  the  glottis,  from  sudden 
suffocation  without  spasm,  or  from  more  gradual  obstruction  preceded 
by  unconsciousness. 

The  treatment  of  this  formidable  disease  must  necessarily  be  vigorous 
and  decisive  if  the  patient  is  to  have  any  chance.  In  the  first  stage, 
when  dysphagia  and  dyspnoea,  for  which  there  is  no  other  cause  present, 
point  to  the  spread  of  pharyngitis  over  the  epiglottis  to  the  larynx,  a 
careful  inspection  of  the  fauces  (with  the  larjnigoscope,  if  the  patient 
can  tolerate  it,  if  not  with  as  good  a  light  and  as  free  an  opening  of  the 
mouth  as  can  be  procured)  is  essential;  and  if,  as  will  probably  be  the 
case,  the  parts  about  the  arytffino-epiglottidean  fold  are  found  congested 
and  thickened  they  should  be  very  freely  scarified.  At  the  same  time 
antimony  and  aconite  should  be  given  in  small  but  frequent  doses. ^  If 
the  inflammatory  appearances  are  less  decided,  the  patient  should  be  in- 
closed in  a  warm,  moist  atmosphere,  and  the  throat  should  be  constantly 
steamed  with  simple  steam,  or  the  same  mixed  with  henbane  or  hops;  or 
the  inflamed  membrane  may  be  carefully  pencilled  with  a  very  strong 
solution  of  nitrate  of  silver  (3j  to  ^j). 

But  if,  as  too  often  happens,  the  symptoms  advance,  tracheotomy,  or 
laryngotomy,  must  not  be  long  delayed.  Unfortunately  it  seldom  saves 
the  patient's  life,  but  it  is  his  on!}'  chance,  and  the  earlier  it  is  performed 
the  better  for  him.  There  is  no  necessity  for  opening  any  part  of  the 
tube  lower  than  the  cricothyroid  interval  in  these  cases.  Mr.  llewett  has 
shown  that  the  (cdema  never  extends  below  the  A'ocal  cords,  so  that  the 
ordinary  operation  of  laryngotomy  will  give  the  patient  the  means  of 
breathing,  but  in  most  of  the  cases  I  have  seen  he  has  sunk  nevertheless. 
In  many  of  these  instances,  especially  when  occurring  in  later  life,  the 
kidneys  will  be  found  diseased  ;  otherwise  I  do  not  know  how  to  account 
for  the  fatality  of  the  affection.  After  the  opening  is  established  I  do 
not  tliink  any  further  employment  of  depressing  remedies  is  indicated. 


'  Mr.  Durham  prescribos  two  or  throe  minims  of  the  Vin.  Ant.  with  one  or  two 
drops  of  Tinct.  Aconit.  (B.  P.)  imd  half  a  druclnn  of  Liq.  Amnion.  Acet.  in  some 
vehicle  every  quarter  or  half  hour  till  some  obvious  effect  has  been  produced  on  the 
pulse,  and  then  the  same  less  frequently. 


ACUTE    LARYNGITIS CROUP.  673 

The  pulse  and  temperature  should  be  watched,  and  the  patient  supplied 
with  stimulants  and  nourishment  in  accordance  with  his  condition. 

The  above  refers  to  the  catarrhal  form  of  acute  laryngitis.  In  the 
exanthematous  forms  no  scarification  and  no  depression  should  be 
thought  of.  The  onl}'  question  is,  whetlier  tracheotomy  will  give  the 
patient  any  further  chance  of  survival. 

When  erysipelas  in  either  form  extends  inwards  to  the  larj'nx  the 
complaint  is  usually  fatal.  Still,  instances  of  successful  tracheotomy  are 
not  wanting,  and  the  operation  should  not  be  long  delayed. 

In  traumatic  cases,  as  I  have  stated  above  (page  208),  the  operation 
should  always  be  performed  early,  when  tiiere  are  loose  portions  of  car- 
tilage lianging  into  the  lar3'nx,  or  the  mucous  membrane  has  been  pene- 
trated by  the  edge  of  a  fracture.  For  the  treatment  of  the  laryngitis 
which  follows  burn  or  scald  I  would  refer  to  page  214. 

Croup. — The  acute  laryngitis  of  croup  is  not  preceded  by  pharyngitis, 
as  the  common  catarrhal  laryngitis  is,  nor  is  there  any  diphtheritic  or 
croupous  memljrane  in  the  phar3nx  or  mouth,  as  there  is  in  diphtlieria. 
Still,  the  resemblance  or  relationship  between  croup  and  ordinary  laryn- 
gitis on  the  one  hand  and  diphtheria  on  the  other  is  very  close,  so  that 
many  authorities  regard  croup  and  diphtheria  as  essentially^  the  same 
disease,  an  opinion  which  is  strengthened  by  observing  that  in  epidemics 
of  croup  there  are  cases  in  which  the  false  membrane  does  extend  into 
the  fauces,  and  which  are  called  "diphtheritic  croup."  Croup  sets  in 
with  feverish  symptoms  and  a  hard,  dry,  ringing  cough,  without  dys- 
phagia, but  soon  running  on  to  considerable  dyspna?a,  aggravated  into 
formidable  paroxysms,  and  accompanied  by  cough  and  expectoration,  in 
which  very  commonly  shreds  of  false  membrane  may  be  observed.  In- 
flammation rapidly'  extends  down  tlie  trachea  to  the  bronchi,  the  breath- 
ing becomes  more  oppressed,  so  that  the  sides  of  the  neck  are  seen  to 
be  drawn  in  during  inspiration,  the  face  becomes  livid,  consciousness 
oppressed,  and  the  child  dies  asphyxiated. 

In  this  formidable  disease  there  are  two  stages  to  be  considered  in  the 
treatment — the  first,  that  which  occurs  before  the  dyspnoea  has  become 
very  dangerous,  when  there  is  suHicient  evidence  of  acute  laryngeal 
inflammation  spreading  down  the  trachea,  but  the  breath  still  comes 
pretty  freelj'.  In  such  cases  anatomical  examination  would  show  the 
larynx  inflamed  and  more  or  less  coated  with  a  fibrinous  or  leathery  exu- 
dation, whicli  extends  some  distance  down  the  trachea,  but  does  not  line 
the  whole  of  it  nor  reach  the  lungs.  During  this  stage  emetics,  leeches 
to  the  chest,  and  the  free  use  of  antimony  are  the  measures  indicated. 
Some  practitioners  rely  much  on  mercury,  on  account  of  its  solvent 
action  on  fibrinous  exudations  ;  but,  as  Dr.  Barclay  has  pointed  out, 
that  action  is  too  slow  to  lie  available  in  croup.  At  the  same  time 
mercury  may  be  combined  with  the  antimony,  on  which  latter  drug,  no 
doubt,  the  chief  reliance  is  to  be  placed.  Warm  fomentation,  with  opiate 
liniment  to  the  throat,  and  the  creation  of  a  warm,  moist  atmosphere 
round  the  bed,  are  decidedly  useful.  Most  cases  of  croup  are  thus 
brought  to  a  favorable  issue.  But  in  the  second  stage,  when  the  respira- 
tion is  very  labored,  and  the  subclavicular  spaces  are  seen  to  be  de- 
pressed in  every  eft'ort  at  breathing,  when  the  child  is  becoming  livid 
and  oppressed,  yet  the  lungs  are  not  much  loaded,  tracheotomy  becomes 
urgently  necessary.  At  this  period  it  will  be  found  that  the  glottis  is 
extensively  trenched  upon  by  the  exudation  which  now  nearly  fills  the 
larynx,  and  which  is  beginning  to  extend  beyond  the  bifurcation  of  the 

4S 


674  DISEASES    OF    THE    LARYNX. 

traclica.     If  the  operation  is  delayed  till  the  lungs  also  become  much 
loaded  it  is  useless  to  perform  it. 

Opinions  differ  as  to  the  place  which  should  be  selected  for  the  opera- 
tion. My  own  is  in  favor  of  operating  above  the  th^yroid  isthmus;  for 
though,  if  we  could  make  sure  of  getting  below  the  lower  end  of  the  in- 
flammatory membrane,  it  would  no  doubt  be  worth  some  risk  and  trouble 
to  attain  tliis  object,  yet  the  extra  half  or  three-quarters  of  an  inch  which 
is  the  distance  between  the  incisions  in  the  two  operations  is  quite  use- 
less for  this  purpose,  while  the  operation  below  the  thyroid  isthmus  is  in 
a  fat  child  a  very  dangerous  one. 

The  more  the  disease  approaches  to  pure  diphtheria  the  less  is  the 
prospect  of  relief  from  tracheotom}-,  though  the  chance  of  relief  should 
not  be  refused,  as  numerous  examples  of  recovery  have  been  recorded, 
even  when  the  patient's  condition  had  been  regarded  as  desperate. 

Larynginmuii  Stn'duIuH. —  Clearly  distinguished  from  croup  or  diph- 
theria is  laryngismus  stridulus,  or  "■  child-crowing,"  a  spasmodic  affection 
allied  to  convulsions,  often  very  alarming,  but  accompanied  by  no  general 
fever  and  by  no  exudation,  therefore  having  .intervals  of  perfect  remis- 
sion, and  to  be  treated,  not  by  the  administration  of  depressing  rem- 
edies, still  less  by  tracheotomy,  but  by  bringing  the  child  slightly  under 
the  influence  of  chloroform  when  the  spasm  comes  on  ;  or,  if  the  spasm 
is  not  very  powerlul,  by  the  use  of  the  warm  bath. 

The  success  of  traclieotomy  in  croup  will  depend  a  good  deal  on  the 
period  at  which  it  is  employed.  If  the  surgeon  resorts  to  the  operation 
early,  and  is  dexterous  in  its  performance,  a  large  proportion  of  his  pa- 
tients will  recover ;  but  then  a  good  man}'  of  these  would  certainly  have 
recovered  without.  Nothing  seems  to  me  to  show  the  fallacy  of  statis- 
tical reasoning  in  matters  of  practice  more  than  the  conclusions  hastily 
drawn  from  the  great  apparent  success  which  attends  the  operation  of 
tracheotomy  for  croup  in  the  hands  of  the  surgeons  who  perform  that 
operation  very  frequently.  Without  denying  that  an  early  resort  to 
tracheotomy  may  be  better  practice  than  waiting  till  the  child  is  nearly 
in  extremis,  I  would  point  out  that  this  conclusion  rests  on  observation, 
and  cannot  be  proved  by  quoting  numbers. 

Chronic  Laryngitis — Phthisical. — The  constitutional  forms  of  chronic 
laryngitis  are  all  marked  by  the  prominent  symptom  of  aphonia  rather 
than  by  any  danger  to  life,  though  any  of  them  may  become  dangerous 
to  life  when  complicated  with  ulceration,  since  that  ulceration  may  irri- 
tate the  vocal  cords  and  produce  spasm  of  the  glottis,  or  may  extend  to 
the  cartilages,  and  portions  of  the  necrosed  cartilage  may  become  dis- 
placed or  entirely  loose  and  act  as  a  foreign  body.^  In  "phthisis  laryn- 
gea"  the  disease  consists,  as  it  seems,  in  tlie  development  of  tubercle 
beneatli  the  mucous  membrane  of  the  epiglottis  and  larynx,  which  runs 
on  witi)  more  or  less  rai)idity  to  ulceration,  leading  to  loss  of  voice, 
destruction  of  tlie  epiglottis,  dysphagia,  cougii,  expectoration,  necrosis  of 
the  cartilages,  and  death.  Asa  general  rule  the  disease  in  the  larynx  is 
only  a  part  of  tlie  general  affection,  and  tlie  patient's  death  is  due  to  the 
disease  in  the  lungs;  but  in  othei-  cases  the  complaint  commences  in  the 
larynx,  and  may,  iiideed,  be  confined  to  it.  The  treatment  of  the  disease 
must,  of  course,  be  regulated  by  the  general  condition.    When  the  lungs 

'  There  is  even  a  case  on  record  in  whieli  a  diseased  gland  made  its  way  by  uleera- 
tion  into  the  trachea,  and  a  |iortioii  of  it  dropped  into  tlie  tube,  producing  the  usual 
syni[)tonib  of  foreign  body. 


FOLLICULAR    LARYNGITIS.  675 

are  profoundly  affected  notliing  can  be  done  beyond  soothing  the  patient's 
sufferings  by  steaming  the  lar^'nx  from  time  to  time  with  hot  water  mixed 
with  henbane  or  sti'amonium,  touching  any  ulcers  which  may  he  visible 
on  laryngoscopic  examination  with  a  wire  coated  witli  nitrate  of  silver  or 
with  a  solution  of  nitrate  of  silver  on  the  laryngeal  brush,  and  enjoining 
rest  to  the  laryngeal  organs  as  much  as  possible.  Even  in  these  hopeless 
cases,  however,  Mr.  Durham  urges  the  occasional  justifiability  of  trache- 
otomy as  a  palliative,  if  the  patient  is  greatly  troubled  l)y  pain  or  diffi- 
culty of  breathing  ;  while  there  are  doubtless  cases  in  which  the  laryngeal 
disease  is  the  essence  if  not  the  whole  of  the  complaint,  and  in  which 
tracheotomy  is  urgently  indicated. 

S[/pJiilitic  larijngitix  is  either  secondary  or  tertiary,  and  the  affections 
of  the  larynx  apjiear  to  bear  a  general  resemblance  to  tlie  secondary  and 
tertiary  |)lienomena  of  syphilis  in  other  parts  of  the  body.  Thus  the 
seconciary  laryngitis  seems  to  depend  usually  on  the  spread  of  roseola  or 
psoriasis  from  the  throat,  or  to  the  development  of  similar  affections,  or 
of  mucous  tubercles  on  the  laryngeal  mucous  membrane.  Secondary 
ulceration  may  also  spread  from  the  fauces  down  to  the  larynx,  and  may 
either  destroy  the  vocal  cords  partially  or  completelj',  or  maj'  so  displace 
and  bind  them  down  as  to  prevent  their  proper  action,  and  so  lead  to  per- 
manent aphonia. 

Secondary  laryngitis  as  a  rule  involves  no  worse  consequence  than  loss 
of  voice,  which  is  usually  only  partial  and  temi)orary,  though  when  ulcer- 
ation or  inflammation  occurs  in  the  neigliborhood  of  the  cords  the  patient 
is,  of  course,  never  free  from  the  danger  of  spasm. 

The  tertiary  affections  of  the  larynx  are  more  deep  and  more  dangerous. 
Some  of  them  seem  to  consist  in  warty  growths  in  tlie  larynx,  not  unlike 
the  syphilitic  vegetations  or  condylomata  found  elsewhere  ;  but  the  chief 
tertiary  affection  of  the  larynx  is  ulceration,  which  rapidly  extends  to  the 
cartilages  and  vocal  cords,  destroying  the  larynx  as  an  instrument  of 
voice  and  producing  the  most  serious  danger  to  life. 

Syphilitic  affections  of  the  larynx  can  usually  be  diagnosed  from  other 
diseases  by  the  concomitant  symptoms;  but  in  any  case  of  doubt  the 
effect  of  anti-syphilitic  remedies  will  assist  the  diagnosis.  The  exhibition 
of  mercury  in  the  form  of  calomel  vapor,  inhaled  through  a  moutlipiece 
attached  to  the  common  mercurial  lamp,  or  the  repeated  application  of 
the  Liq.  Hyd.  Perchlor.,  pure  or  diluted  with  an  equal  bulk  of  water,  are 
the  most  useful  applications  in  sypliilitic  sore  throat.  In  secondary 
affections  the  i)atient  should  undoubtedly  be  brought  fully,  though  grad- 
ually, under  the  intiuence  of  mercury.  In  the  tertiary  stage  of  the  disease 
iodide  of  potassium  with  tonics  may  be  given  internally  while  the  local 
mercurial  treatment  is  being  carried  on.  In  these,  as  in  all  other  ulcera- 
tive diseases  of  the  larynx,  the  surgeon  must  be  prepared  for  the  necessity 
of  tracheotomj',  and  must  not  let  his  patient  die  or  run  an}'  serious  danger 
of  dying  for  want  of  an  opening  tlirough  the  cricothyroid  membrane. 

Follicular  Laryngitiii. — The  follicular  disease,  or  dysphonia  clericorum, 
has  its  seat  in  the  glandules  or  follicles  of  the  mucous  membrane,  and  is 
often  accompanied  by  a  similar  affection  of  the  mucous  membrane  around. 
"The  membrane  covering  the  aryta?noid  cartilages  and  immediately 
adjoining  parts  is  more  rich  in  glandular  structures  than  any  other  por- 
tion of  the  laryngeal  mucous  membrane.  Now,  this  part  is  constantly 
subject  to  a  very  great  extent  of  motion,  and  also  perhajis  to  considera- 
ble strain,  during  forced  vocalization." — (Durham).  Thus  is  explained 
the  prevalence  of  this  complaint  in  those  whose  occupation  leads  to  con- 
stant exertion  of  the  voice,  though  it  occurs  in  others  also ;  in  photogra- 
phers, according  to  Gibb,  who  are  exposed  to  acrid  chemical  fumes ;  and 


676  DISEASES    OF    THE    LARYNX. 

in  persons  laboring  under  the  herpetic  diathesis,  according  to  Trousseau 
and  others. 

''  The  symptoms  are  :  alteration  of  the  voice  and  sense  of  effort  in  sus- 
taining it — these  are  by  far  the  most  prominent  and  constant  symptoms  ; 
more  or  less  discomfort  about  the  larynx,  never  amounting  to  pain,  but 
occasionally  troublesome  ;  dryness  and  sometimes  a  sense  of  heat  about 
the  throat;  and  constant  desire  to  clear  the  throat  by  'hemming'  and 
'  liawking.'  There  is  little  or  no  regular  cough  ;  and  the  expectoration 
which  sometimes  occurs  is  slight,  scanty,  and  mixed  with  saliva.  There 
is  neither  difficulty  in  swallowing  nor  tenderness  upon  pi-essure  over  the 
larynx.  There  are  no  definite  constitutional  symptoms,  but  the  general 
health  and  spirits  of  the'patient  are  otlcn  observed  to  be  more  or  less 
depressed." ' 

The  voice  is  much  affected  in  these  cases,  and  especially  in  distinct  or 
loud  speaking  or  reading.  The  mucous  membrane  of  the  fauces  and 
throat  as  well  as  that  of  the  larynx  is  seen  in  the  early  stage  of  the  com- 
plaint studded  vvith  enlarged  glands,  surrounded  by  an  area  of  redness, 
and  at  a  later  period  these  may  have  formed  small  points  of  ulceration  ; 
but  it  does  not  seem  that  the  deeper  structures  are  liable  to  disease  or  that 
the  larynx  is  ever  incurably  disorganized. 

The  local  treatment  consists  in  the  persevering  application  of  astrin- 
gents, nitrate  of  silver,  tincture  of  iodine,  sulphate  of  zinc  or  copper,  in 
such  strength  as  is  found  to  be  suitable,  toucliing  the  ulcerated  parts 
with  the  solid  nitrate  of  silver,  and  the  inhalation  of  pulverized  solutions 
of  "common  salt,  chloride  of  ammonium,  iodide  of  potassium,  and  in 
some  cases  alum  or  weak  solution  of  perchloride  of  iron."  Mr.  Durham 
says  also  that  benefit  may  be  derived  from  sucking  medicated  lozenges 
(ciiloride  of  ammonium,  with  or  without  cayenne  and  the  "red  gum 
lozenges  ")  and  from  wearing  the  beard.  The  general  health  must  be  care- 
fully attended  to,  and  the  patient  may  be  comforted  with  the  assurance  that 
though  the  treatment  may  be  tedious  tliere  is  every  reason  to  hope  for 
complete  success.. 

Tumors  of  the  Larynx. — The  diagnosis  of  tumors  of  the  larynx  is  due 
exclusively  to  the  laryngoscope.  Formerly,  though  tiie  existence  of  such 
a  tumor  miglit  be  guessed  at,  it  could  never  be  affirmed.  Now  they  can 
be  seen,  and^  what  is  of  far  more  importance,  tliey  can  often  be  removed 
without  any  incision  or  any  inconvenience  whatever,  and  the  patient  in 
some  instances  restored  to  tlie  full  use  of  the  voice,  and  in  all  rescued 
from  the  imminent  danger  of  suffocation  which  is  incident  to  the  presence 
and  growth  of  a  tumor  in  the  neighborhood  of  tlie  glottis. 

Most  of  the  tumors  which  affect  the  larynx  are  common  warts  or  papil- 
lomatous growtlis,'^  which  spring  up  from  any  part  of  the  mucous  mem- 
brane, sometimes  in  considerable  number,  and  often  grow  to  a  very  large 
size.  They  are  sometimes  congenital.  They  are  said  to  spring  more 
commonly  from  the  front  of  the  larynx,  near  the  convergence  of  the  vocal 
cords,  tliough  they  may  grow  in  any  part  of  the  cavity.  Fibrous  and 
fibrocellular  tumors  are  next  in  number,  some  of  which  are  sarcomatous 
and  grow  rai)idly  ;  otiiers  are  pedunculated,  like  the  l)olypi  of  otlier  parts. 
Adenoid  growtlis  are  rare,  and  grow  from  the  base  of  tlie  epiglottis,  the 
arytaeno-epiglottidean  folds,  or  the  membrane  covering  the  epiglottis. 


1  Syst.  of  Siirg.,  2d  ed.,  vol.  iv,  p.  548. 

2  Out  of  244  case.*  of  hiryngoiil  tumor  collected  by  Mr.  Duriinni  110  were  of  tliis 
nature — 19  only  were  cancerous. 


TUMORS    OF    THE    LARYNX.  677 

A  few  instances  of  cystic,  cartilaginous,  and  osseous  tumors  are  also 
recorded.  These  are  tlie  innocent  forms  of  tumor — the  cancerous  growths 
are  mostly  epitheliomatous,  though  instances  of  soft  cancer  are  not  want- 
ing. Epithelioma  is  generally  an  extension  from  the  pliar>'nx  ;  but  it 
sometimes  begins,  as  Mr.  Durham  describes  it,  on  the  mucous  membrane 
lining  the  back  of  the  cricoid  cartilage,  and  doulttless  in  other  parts  of  the 
larynx  also,  in  the  form  of  small  irregular  nodules,  which  gradually  in- 
crease in  size  and  soon  ulcerate.  In  any  case  the  tumor  will  soon  present 
an  ulcerated  surface,  and  can  then  be  recognized  from  the  other  forms  of 
ulceration  by  its  elevated  edge,  by  its  dirty  gray  color,  by  the  amount  of 
new  deposit,  causing  irregular  thickening  in  the  parts  around,  and  in 
some  cases  by  the  presence  of  enlarged  glands. 

The  symptoms  caused  by  a  tumor  of  the  larynx  are  the  same  as  those 
accompanying  an}'  other  chronic  affection,  viz.,  aphonia,  more  or  less  com- 
plete ;  hoarseness,  cough,  occasional  dyspnoea,  sometimes  aggravated  into 
fits  of  si)asm,  and  in  some  cases  (chiefl_v  those  of  cancer),  more  or  less 
dN'sphagia.  The  more  movable  and  pedunculated  the  growths  are,  the 
more  liable  are  tliey  to  cause  spasm  of  the  glottis,  while  the  degree  of 
permanent  obstruction  of  course  will  depend  mainly  on  the  size  of  the 
growth. 

The  diagnosis  can  only  be  arrived  at  by  laryngoscopy,  unless  in  the 
rare  instances  (chiefly  in  childhood)  in  which  the  growths  can  be  felt  by 
passing  the  finger  round  the  epiglottis. 

The  treatment  of  a  tumor  of  the  lar^'nx  is  directed  to  fulfil  two  different 
indications,  viz.,  either  to  remove  the  growth  altogether  or  to  protect  the 
patient  from  the  danger  of  suffocation  liy  tracheotomy.  Of  the  perform- 
ance of  laryngotomy  or  tracheotomy,  in  order  to  avert  suffocation  by  a 
tumor,  I  need  say  nothing  further;  the  indications  are  the  same  as  in 
spasm  of  the  glottis,  or  alarming  dyspnoea  from  any  other  cause.  There 
are  various  ways  of  removing  laryngeal  tumors.  There  may  be  small 
warty  elevations  hardly  deserving  the  name  of  tumors,  yet  quite  suffi- 
cient, if  seated  on  the  cords,  to  produce  aphonia,  and  which  ma}'  be 
repressed  by  touching  them  with  the  nitrate  of  silver,  fused  and  ai)plied 
to  the  end  of  a  bent  wire,  or  by  means  of  a  wire  carefully  conveyed  down 
to  them  and  connected  with  a  galvanic  battery  ;  but  this  last  manoeuvre 
is  a  very  delicate  one,  and  the  surgeon  must  first  well  exercise  himself 
and  his  patient  to  see  that  he  can  always  bring  the  wire  into  unfailing 
contact  with  the  little  growth. 

Removal  from  the  Moulh. — More  commonly,  however,  the  growths 
which  are  large  enough  to  produce  symptoms,  are  also  large  enough  to 
be  seized  and  removed  by  delicate  forceps  of  appropriate  shape  and  con- 
struction, or  by  a  snare  or  ecraseur,  constructed  on  the  same  principles 
as  Hilton's  snare  for  nasal  polypi,  figured  on  p.  600,  with  the  necessary 
modifications  in  size  and  shape  ;  or  by  a  knife,  scissors,  or  guillotine,  i.  e., 
an  instrument  which  is  slipped  over  the  tumor,  and  pressure  on  a  handle 
then  projects  a  blade  which  cuts  it  off.  Laryngeal  grovvths  have  also 
been  removed  b}^  the  galvanic  cautery,  though  the  method  seems  unnec- 
essarily dangerous,  and  those  which  are  cystic  have  disappeared  after 
simple  puncture. 

In  all  cases  where  it  is  possible  the  method  of  removal  from  the  mouth 
ouglit  to  be  adopted.  But  sometimes,  from  the  age  of  the  patient,  from 
his  intolerance  of  the  necessary  manipulation,  or  from  the  size  and  attach- 
ments of  the  tumor,  it  may  become  necessary  to  remove  it  by  external 
incision. 

Thyr-otomy,  as  the  operation  is  called,  is  an  extension  of  laryngotom}' , 


678  DISEASES    OF    THE    LARYNX. 

the  incision  into  the  larynx  being  continued  upwards  between  the  alae  of 
the  th3^roid  cartilage.  It  is  best  done,  I  think,  at  two  different  sittings. 
The  usual  oi^ening  having  been  made  through  the  cricothyroid  membrane, 
the  patient  is  relieved  from  all  danger  of  suffocation,  and  the  common 
tube  is  introduced.  Then,  at  a  subsequent  da}',  a  tube  can  be  substituted 
which  has  a  notch  in  its  upper  or  convex  wall.  Into  this  notch  the  knife 
is  inserted  (the  patient  being,  of  course,  fully  narcotized,  which  is  readily 
effected  by  administering  the  ansestbetic  through  the  tube),  and  the  in- 
cision is  slowly  and  cautiously  carried  along  the  middle  line  of  the  pomum 
Adarai,  so  as  to  wound  neither  vocal  coi'd,  till  the  thyrohyoid  membrane 
is  reached.  A  couple  of  blunt  hooks  will  now  drag  the  two  halves  of  the 
larynx  apart.  If  there  is  much  bleeding  (as  there  often  is)  a  piece  of 
sponge  must  be  firmly  pressed  into  the  larynx  till  it  has  subsided.  The 
patient  is  all  this  time  breathing  quietly  through  the  original  tube.  On 
the  subsidence  of  the  bleeding  the  whole  interior  of  the  larynx,  with  the 
mouths  of  its  ventricles,  will  be  exposed,  and  the  tumors  can  be  cut 
away,  their  bases  cauterized,  and  any  other  manipulation  carried  out 
most  satisfactorily.  The  same  proceeding  is  sometimes  required  for  the 
removal  of  foreign  bodies  impacted  in  the  ventricle  (see  p.  211). 

E-xtirpation  of  the  Larynx. — Latterl}^  in  Germany,  still  more  extensive 
operations  have  been  practiced  for  malignant  disease  of  the  larynx,  all 
the  parts  affected  having  been  removed,  so  as  to  extirpate  the  whole 
larynx  and  lay  the  pliarynx  freely  open.  I  have  no  experience  of  this 
formidable  operation,  and  should  be  disposed  to  believe  that  it  will  not 
ultimatel}'  Itecome  received  into  general  surgery;  but  I  think  it  right  to 
direct  the  reader's  attention  to  the  possibility  of  its  performance,  and 
will  quote  the  following  account  of  a  case  recently  operated  on  by  Pro- 
fessor von  Langenbeck.  The  patient  had  had  tracheotomy  performed 
previously^  chloroform  being  administered  through  the  tube: 

"  A  transverse  incision  was  made  above  the  hyoid  bone,  and  a  perpen- 
dicular one  carried  down  from  it;  and  the  two  flaps  of  skin  having  been 
turned  aside,  the  diseased  parts  were  removed.  The  specimen  was  shown 
b}'  Dr.  von  Langenbeck,  at  a  meeting  of  the  Berlin  Medical  Society.  The 
anterior  wall  of  the  oesophagus  and  pharynx  was  divided,  the  larj'nx  cut 
away,  and  the  hyoid  bone  sawn  through  in  the  middle.  The  disease, 
which  was  cancerous,  had  involved  the  upper  part  of  the  larynx,  the 
epiglottis,  and  the  hyoid  bone  to  such  an  extent  that  it  was  difficult  to 
distinguish  the  several  parts.  The  inner  surface  of  the  cricoid  and  thy- 
roid cartilages  as  far  as  the  laryngeal  pouches  and  the  inferior  vocal  cords 
were  free.  The  disease  commenced  close  above  the  ventricles  of  the 
larynx,  in  the  form  of  nodular  masses  which  completely  filled  the  upper 
part  of  the  organ.  The  arytenoid  cartilages  and  the  arj'tfeno-epiglottic 
ligaments,  the  hyoid  bone,  and  the  base  of  the  tongue,  were  all  involved 
in  the  disease,  and  were  removed.  A  week  after  the  operation  the  patient 
was  free  from  fever,  and  his  general  condition  was  satisfactory."^ 

Aphonia^  Nervous  and  Hii^terical. — Aphonia,  besides  being  a  symptom 
of  all  chronic  laryngeal  diseases,  occurs  also  from  causes  unconnected 
with  any  disease  in  the  larynx.  The  nervous  or  hysterical  aphonia,  which 
is  often  seen  in  young  women — though  sometimes  in  men — is  an  affection 
not  very  well  understood,  and  sometimes  devoid  of  any  other  symptom 
of  iiysteria  or  nervous  disease,  tliough  agreeing  with  such  disorders  in 
the  fact  that  there  is  no  visible  degeneration  of  tissue  in  the  parts  af- 


'   Brit.  Med.  Jour.,  Aug.  21,  1875. 


SPASM    OF    THE    GLOTTIS.  679 

fected,  and  that  the  function  may  often  be  completely  and  immediately 
restored  without  any  visible  cause  for  the  change. 

In  a  case  of  this  kind  laryngoscopic  examination  will  show  all  the  parts 
of  their  natural  appearance,  but  the  motion  of  the  cords  is  variously  af- 
fected. The  voice  sometimes  appears  and  disappears  quite  suddenly,  and 
in  all  cases  there  is  the  same  want  of  proportion  between  any  recog- 
nizable cause  and  the  presumed  effect  which  is  noticeable  in  other  "■  ner- 
vous mimicries."  There  may  have  been  some  little  cold  or  some  extra 
exertion  of  the  voice  alleged  as  the  cause,  but  this  is  wholly  insufficient 
to  account  for  a  total  inability  to  speak. 

These  cases  often  get  well  of  themselves,  or  any  method  of  treatment 
may  cure  them — the  mere  introduction  of  the  laryngoscope  has  produced 
a  return  of  the  voice.'  The  approved  methods  of  treatment  seem  to  act 
by  giving  the  patient  a  shock — a  "shake-up,"  as  Mr.  Durham  terms  it. 
Such  are  the  pinching  or  squeezing  of  the  larynx,  the  application  of  gal- 
vanism either  to  the  cords  themselves  or  to  the  parts  near  them,  the  ap- 
plication of  strong  or  irritating  lotions  to  the  interior  of  the  cavity,  such 
as  solutions  of  nitrate  of  silver  or  sulphate  of  copper,  and  the  applica- 
tion of  irritating  fumes,  as  those  of  solutions  of  ammonia  or  chlorine. 

Aphonia  is  said  also  to  result  from  idiopathic  atrophy  of  the  muscles 
of  the  larynx,  but  on  this  head  little,,  I  believe,  is  known. 

Aphoina  from  Paralysis. — Usually,  when  a  patient  has  lost  his  voice 
and  ori  lar3aigoscopic  examination  one  of  the  vocal  cords  is  seen  to  be 
motionless,  the  cause  is  to  be  sought  in  pressure  on  the  recurrent  nerve, 
and  the  commonest  cause  of  that  pressure  is  either  an  aneurismal  tumor, 
especially  aneurism  of  the  aorta  pressing  on  the  left  recurrent,  or  an  en- 
larged gland,  or  a  malignant  tumor  in  the  thorax  or  neck.  It  is  not  very 
uncommon  for  a  person  to  be  unaware  of  the  existence  of  aortic  aneurism 
until  the  attention  of  his  physician  is  called  to  the  part  by  either  paraly- 
sis or  spasm  of  the  glottis.  And  there  seems  good  reason  to  believe  that 
the  pressure  of  a  tumor  on  any  part  of  the  windpipe  may  set  up  irrita- 
tion in  its  substance  which  may  lie  so  reflected  down  the  nerves  of  the 
part  as  to  produce  either  paralysis  or  spasm  of  the  cords  without  any 
direct  interference  with  the  nerve-trunks. 

Spasm  of  the  glottis  is  one  of  the  most  painful  and  most  fatal  of  all 
surgical  accidents.  It  comes  on  from  the  most  various  causes,  and  may 
terminate  life  in  a  few  minutes,  if  prompt  help  be  not  given.  That  help 
lies  in  the  immediate  opening  of  the  windpipe  below  the  glottis;  and 
when,  as  sometimes  happens,  a  patient  is  found  in  obvious  and  imminent 
danger  of  death  from  spasmodic  dyspnoea,  of  the  cause  of  which  the  by- 
standers can  give  no  account,  the  surgeon's  duty  is  to  make  an  opening 
at  once  through  the  cricothyroid  membrane,  and  if  necessary  perform 
artificial  respiration  through  the  opening.  But  what  has  been  said  above 
is  sufficient  to  show  that  in  many  cases  of  spasm  of  the  glottis  the  im- 
mediate opening  of  the  windpipe  is  unnecessary,  and  fortunately  it  is 
only  in  rare  emergencies  that  we  have  not  the  opportunity  for  more  de- 
liberation in  the  treatment. 

The  chief  causes  of  spasm  of  the  glottis  have  been  pointed  out  in  the 
foregoing  pages.  They  are :  Foi'eign  bodies  fixed  in  the  larynx  or  loose 
in  the  lower  part  of  the  windpipe  when  they  impinge  on  the  cords,  burns 
and  scalds  of  the  larynx,  inflammation  and  ulceration  (whether  acute  or 
chronic)  trenching  on  the  neighborhood  of  the  cords,  tumors  when  they 

1  See  Durham,  in  Syst.  of  Surg.,  2d  ed.,  vol.  iv,  p.  592. 


680  DISEASES    OF    THE    LARYNX. 

move  so  as  to  get  between  the  cords,  aneurisms,  tumors,  and  enlarged 
glands  irritating  the  recurrent  nerves  or  pressing  on  the  windpipe,  and 
central  irritation,  such  as  is  often  seen  in  tetanus  and  less  frequently  in 
cerebral  affections.  The  treatment  of  all  these  conditions  has  been  dis- 
cussed, as  far  as  the}'  fall  within  the  surgeon's  province,  and  the  neces- 
sity of  tracheotomy  under  certain  circumstances  pointed  out.  I  would 
merel}'  add  that  the  patient's  safety  is  best  consulted  in  circumstances 
of  doubt  b\'  resort  to  operation,  rather  than  by  hesitation,  which  may  at 
any  time  involve  fatal  consequences. 

Bronchotomy. — The  windpipe  may  be  opened  in  three  different  posi- 
tions, viz.,  between  the  cricoid  and  thA'roid  cartilages,  above  the  thyroid 
isthmus  and  below  it.  All  three  operations  are  often  comprised  under 
the  comnion  name  Tracheotomy,  which  is  thus  used  as  synonymous  with 
Bronchotomy,  meaning  any  operation  by  which  an  artificial  opening  for 
respiration  is  made:  otherwise  the  word  Bronchotomy  is  used  for  all  the 
operations  on  the  air-passages,  while  the  term  Tracheotomj'  is  restricted 
to  the  operation  below  the  thyroid  isthmus,  that  above  it  being  called 
Laryngo-tracheotomy,  and  the  operation  through  the  cricoth3'roid  inter- 
val Laryngotomy. 

Laryngotomy  is  the  easiest  of  the  three.  Nothing  is  necessary  except 
to  keep  in  the  middle  line,  to  divide  the  skin  pretty  freely  from  the  th3'- 
roid  to  the  cricoid  cartilage,  and  to  cut  through  the  cricothyroid  mem- 
brane entirely  from  the  lower  border  of  the  thyroid  to  the  top  of  the 
cricoid  cartilage,  and  then  insert  the  tube.  In  urgent  cases  there  is  no 
need  to  make  any  preliminary  incision.  The  knife  can  be  plunged  direct 
into  the  windpipe,  and  the  tube  may  follow  it  at  once.  No  vessel  of  im- 
portance can  be  injured.  The  little  anastomotic  arch  formed  by  the 
cricothyroid  arteries  never,  as  far  as  I  know,  furnishes  more  than  slight 
haemorrhage,  whicli  is  stopped  at  once  by  the  pressure  of  the  tube. 

Laryngotomy  is  often  required  under  circumstances  of  urgency  when 
no  tube  is  at  hand.  A  pair  of  forceps,  or  in  the  last  resort  the  blades  of 
a  pair  of  scissors,  or  a  couple  of  hairpins  or  pieces  of  bent  wire,  will  suf- 
fice to  keep  the  wound  open,  and  if  necessary  the  operation  can  be  done 
with  a  common  penknife. 

This  operation  is  suflficient  in  all  cases  which  involve  only  the  vocal 
cords  or  the  tissues  above  them.  It  is,  therefore,  practiced  in  spasm  of 
the  glottis  from  all  causes,  including  burn  and  scald,  in  erysipelatous 
affections  spreading  down  the  throat,  and  in  cases  of  foreign  body  lodged 
in  or  above  the  glottis.  Opinions  differ  as  to  the  operation  which  is  to 
be  employed  in  cases  of  laryngitis  and  croup,  as  to  which  I  have  already 
expressed  my  own. 

Lary I) go-tracheotomy  consists  in  making  a  freer  incision  than  in  laryn- 
gotom3'  from  the  lower  border  of  the  pomum  Adami  to  about  three- 
quarters  of  an  inch  below  the  cricoid  cartilage,  dissecting  the  parts  till 
the  trachea  and  the  isthmus  of  the  thyroid  body  are  plainly  seen,  and 
plunging  the  knife  into  the  windpipe  with  its  back  to  the  thyroid  isthmus 
and  cutting  upwards  through  the  two  upper  rings  of  the  trachea  and  the 
cricoid  cartilage. 

This  operation  is  chiefly  used  in  childhood,  when  the  small  size  of  the 
larynx  seems  to  forbid  lai-yngotomy  and  the  depth  and  shortness  of  the 
neck  renders  tracheotom3'  dangerous. 

Tracheotomy  Proper. — Tracheotomy  below  the  thyroid  isthmus  re- 
quires a  freer  opening  and  a  deeper  dissection.  The  extent  of  the  in- 
cision will,  of  course,  be  proportioned  to  the  thickness  of  the  neck.     In  a 


TRACHEOTOMY. 


681 


short,  deep  neck  there  is  no  objection  to  extending  the  incision  from  tlie 
cricoid  cartilage  to  the  episternal  notch,  bnt  this  is  rarely  requisite.  An 
average  incision  would  be  from  an  inch  and  a  half  to  two  inches  down- 
wards from  the  cricoid  cartilage.  Having  divided  the  skin  and  deep 
fascia,  the  sternothyroid  muscles  may  be  seen  touching  each  othei-  in 
the  middle  line,  and  these  parts  should  be  drawn  asunder  with  hooks. 
Any  vessels  (arteries  or  veins)  which  bleed  freely  had  better  be  tied  ;  the 
lower  border  of  the  thyroid  isthmus  will  be  recognized,  and  may  be  drawn 
lip  vvith  a  hook  if  it  is  unusually  broad.  The  trachea  should  be  dissected 
clean  till  three  rings  are  seen  fairly  exposed,  and  should  then  be  opened 
in  the  whole  extent  whicli  is  denuded,  with  the  edge  of  the  knife  turned 
upwards.  Then  the  tube  is  to  be  inserted.  If  the  thyroid  isthmus  comes 
down  unusually  far  it  is  safer  to  divide  it  in  the  middle  line  than  to  risk 
a  deep  dissection  close  to  or  under  the  sternum.  In  following  the  other 
course  I  once  lost  a  patient  from  wound  of  a  branch  close  to  the  innomi- 
nate vein. 

There  are  a  few  precautions  which  are  essential  to  success  in  all  these 
operations.  The  first  is  to  keep  in  the  middle  line,  and  this  is  not  always 
easy  in  cases  which  are  operated  on  late  at  night  under  urgent  circum- 
stances. The  head  ought  to  be  extended,  as  much  as  is  possible  without 
increasing  the  dyspnoea,  by  putting  a  pillow  under  the  neck  and  shoulders  ; 
and  the  surgeon,  if  he  has  no  trained  assistant,  must  see  that  the  head  is 
held  firmly  and  the  body  kept  straight.  Next  it  is  desirable  to  stop 
bleeding  before  the  trachea  is  opened  ;  but  if  the  bleeding  is  merely 
venous  or  capillary,  and  from  a  number  of  imperceptible  vessels,  the  best 
plan  is  to  make  the  opening  at  once.  If  a  gush  of  blood  passes  into  the 
windpipe  the  patient  must  be  instantly  turned  on  his  face,  and  it  will  run 
out  again.  The  free  admission  of  air  into  the  lungs  will  relieve  the  venous 
congestion  and  the  haemorrhage  will  cease.  It  is  most  important  to  make 
a  free  opening  at  first,  so  that  the  tube  has  ample  space.  I  have  seen 
the  patient  die  while  the  operator  was  vainly  endeavoring  to  force  a  tube 
through  an  opening  too  small  for  it,  and  thereby  of  course  increasing  the 
dyspna^a.  There  is  no  objection  in  most  cases  to  the  administration  of 
chloroform,  nor  is  there  usually  an}'  reason  for  hurry  in  the  dissection. 
A  quiet  and  methodical  dissection  may  take  a  minute  or  two  longer  than 
one  where  haste  is  the  only  thing  thought 
of;  but  it   really  often   saves  time,  as  it  fig  320. 

enables  the  operator  to  insert  the  tube  at 
once,  instead  of  boggling  about  it.  As 
to  the  insertion  of  the  tube  there  is  not 
generally  any  difficulty  if  the  windpipe 
has  been  opened  with  the  requisite  free- 
dom. The  old  solid  canula  is  now  rarely  UJ 
used.     Fuller's  bivalve  canula  is  the  one 

most  commonly  met  with  ;  but  Durham's  Fuller's  bivalve  tracheotomy  canula. 
lobster-tail  director    finds    its  way  in  ver}'    The   canula  is  introduced  with  its  blades 

easily,  and  enables  the  surgeon  to  glide  in   «'°^«','^-   Then,  by  depressing  the  handles 

,       /^  \  ...  Txri  5  /.to    the  position    marked    by   the   dotted 

the  tube  very  readdy.  Whatever  form  of  ,i„es_  the  blades  are  opened,  and  a  tubular 
tulje  is  used  it  must    be  double,  for  it  will    canula  is  introduced  between  them. 

soon  become  obstructed  with  mucus,  and 

the  inner  tube  must  often  be  withdrawn  for  the  purpose  of  cleansing  it. 

For  the  same  reason  the  inner  tube  must  project  beyond  the  outer  one, 

otherwise  the  withdrawal  of  the  inner  tube  might  leave  the  outer  one 

obstructed. 

When  the  double  canula  is  securely  lodged  in  the  trachea  it  must  be 


682 


DISEASES    OF    THE    LARYNX. 


tied  in  with  a  piece  of  tape  round  the  neck  ;  and  if  there  is  any  super- 
tlnons  incision  it  may  be  united  with  one  or  two  stitches.  Several  dan- 
gerous complications  may  occur  after  the  operation.  The  secretion 
(especially  in  the  diphtheritic  affections)  will  collect  in  the  tube  and  must 


Fig.  321. 


Durham's  canula,  with  "  lobster-tail"  director. 

be  assiduously  removed  by  passing  the  feather  of  a  pen  down  the  inner 
tube,  and  when  this  no  longer  serves,  by  removing  the  inner  tube  and 
clearing  it.  It  may  even  become  necessar}'  to  remove  the  outer  tube  also 
and  draw  up  the  croupous  membrane  out  of  the  trachea.  I  haA^e  seen  a 
complete  cast  of  the  trachea  and  bronchi  thus  removed  with  immense  re- 
lief to  the  dyspno?a. 

Again,  the  pressure  of  the  end  of  the  tube  against  the  windpipe  some- 
times produces  ulceration  of  the  trachea,  which  has  even  been  known  to 
extend  into  the  innominate  artery,  and  still  more  frequently  induces 
tracheitis  and  bronchitis.  To  obviate  this  Mr.  Bryant  has  devised  a 
canula  in  which  the  shield  lying  on  the  skin  is  jointed  to  the  stem  which 
rests  in  tlie  trachea,  in  order  that  the  tube  may  follow  the  motions  of  the 
windpipe.  But  the  presence  of  the  foreign  bod}^  must  always  cause  some 
irritation,  and  this  seems  often  to  be  the  starting-point  of  general  tra- 
cheitis and  bronchitis. 

Another  frequent  complication  is  that  the  fluids  run  down  from  the 
mouth  into  the  larynx,  and  so  are  expelled  from  the  wound.     I  have 

Fig.  322. 


Bryant's  cauula.    The  shield  is  movable  on  the  neck-plate  by  means  of  a  joint,  and  can  be 
shortened  if  required. 


already  spoken  of  tlie  same  distressing  complication  after  cut  throat. 
After  tracheotomy  it  seems  to  depend  on  the  obstacle  which  the  presence 
of  the  foreign  body  causes  to  the  elevation  of  the  larynx  under  cover  of 
the  epiglottis,  and  possibly  to  effusion  into  the  arytoeno-epiglottidcan 
folds  from  inflammation. 

It  is  very  desirable  to  restore  the  natural  respiration  as  early  as  possi- 
ble after  traciieotomy,  and  dispense  with  the  canula.  Not  only  is  the 
foreign  Ijody  a  constant  source  ol"  irritation,  but  the  vocal  cords  ma_y  get 
more  or  less  consolidated  together,  and  even  in  some  cases  the  upper 


DISEASES    OF    THE    EYE.  G83 

part  of  the  larynx  nearly  obliterated.  A  canula  should  be  inserted 
having  an  opening  in  its  eonvexity  looking  towards  the  glottis,  through 
whicli  the  air  can  pass  in  expiration,  and  a  valve  ap[)lied  to  its  moutli,  so 
that  the  air  can  be  drawn  inwards  in  insi)iration,  l)ut  the  valve  then  shuts. 
If  it  is  found  that  this  cannot  be  borne  and  tliat  the  glottis  seems  ob- 
structed, the  patient  should  be  narcotized  and  a  bougie  passed  tlirongh 
the  glottis,  to  break  down  the  adhesions. 


CHAPTER   XXXV. 

DISEASES  AND  INJURIES  OF  THE  EYE. 
By  R.  B.  Carter,  Ophthalmic  Surgeon  to  St.  George's  Hospital. 

The  great  importance  of  the  eyes  as  the  instruments  of  the  visual 
function,  their  accessibility  to  many  kinds  of  examination,  and  tlie  trans- 
parency of  many  of  the  structures  of  which  tliey  are  composed,  have 
combined  to  invest  their  diseases  with  much  attractiveness,  and  to  render 
them  objects  of  speciall3^  careful  and  painstaking  research.  Tiie  benefits 
hence  arising  are  attended  by  the  disadvantage  that  it  is  scarcely  possi- 
ble, in  the  space  which  can  be  devoted  to  tlie  subject  in  this  work,  to  pre- 
sent anything  more  than  a  sketcli  in  the  liarest  outline  of  the  present  state 
of  Ophtlialmic  Surgery  ;  and  by  tlie  still  greater  disadvantage  tliat  surgical 
students  are  apt  to  look  upon  tlie  subject  as  one  which  is  especially  re- 
condite or  difficult,  and  hence,  doubting  whether  they  will  have  time  to 
master  it,  to  turn  from  it  without  even  tliat  moderate  degree  of  attention 
which  is  necessary  in  order  to  enable  -them  to  deal  skilfully  with  the  com- 
mon forms  of  eye  disease  which  constantly  present  themselves  in  practice. 
Than  this  there  can  be  no  greater  error,  for  these  common  forms  are  as 
a  rule  extremely  easy  of  recognition,  and  are  highly  amenable  to  well- 
directed  treatment. 

AccesKibility  of  the  Organ. — Perhaps  the  first  consideration  which 
should  be  impressed  upon  the  mind  of  the  student  is  the  importance  of 
utilizing  to  the  utmost  extent  the  accessibility  and  the  transparency  of 
the  eye,  in  such  a  manner  that  he  may  become  acquainted  with  all  the 
facts  of  every  case  which  is  brought  under  his  notice.  Errors  of  diag- 
nosis in  the  ordinary  forms  of  eye  disease  are  scarcely  possible  to  any  one 
who  habitually  practices  careful  scrutiny  of  the  affected  tissues ;  and  in 
this,  even  more  than  in  any  other  branch  of  surgery,  haste  and  careless- 
ness are  the  most  frequent  sources  of  mistake.  A  general  observance  of 
the  cardinal  rule  never  to  prescribe  for  an  inflamed  eye  without  making 
sure  that  no  foreign  body  is  either  imbedded  in  the  cornea  or  lodged 
beneath  the  lids,  without  looking  to  see  whether  either  the  cornea  or  the 
iris  is  implicated  in  the  inflammation,  and  without  determining  the  pres- 
ence or  absence  of  heightened  tension  of  the  globe,  would  do  much  to 
withdraw  ophthalmic  diseases  from  the  domain  of  specialists,  and  to  re- 
store ophthalmic  surgery  to  the  general  body  of  the  art. 

Sujyerfieial  Examination. — Tlie  first  glance  at  a  patient  will  often  suf- 
fice to  show  to  an  ordinarily  careful  observer  in  what  direction  disease 
of  the  eves  is  to  be  looked  for.     Sometimes  there  will  be  manifest  coarse 


684  DISEASES    OF    THE    EYE. 

external  changes,  such  as  swelling  and  redness  of  the  lids,  with  or  witli- 
ont  exudation  at  their  margins;  sometimes  there  will  be  manifest  con- 
gestion of  the  ocular  surfiice,  witli  or  without  discharge,  and  with  or 
without  loss  of  tlie  natural  polish  and  brightness  of  the  cornea;  some- 
times thei'e  will  be  evidence  of  failing  vision  in  the  gait,  the  aspect,  and 
the  manner  of  approacli ;  sometimes,  in  the  absence  of  all  the  foregoing 
conditions,  there  will  lie  complaint  of  speedy  fatigue  or  dimness  of  sight 
wiien  the  eyes  are  employed  upon  near  objects.  Any  clue  which  may 
be  thus  afforded  must,  of  course,  be  taken  as  a  guide  to  further  inquiry, 
but  must  not  be  accepted,  without  complete  examination,  as  containing 
or  expressing  the  whole  truth  of  the  case.  For  instance,  it  is  not  very 
uncommon  in  hospital  practice  to  see  patients  who  have  been  energeti- 
call_y  treated  for  an  inflamed  eye  by  leeches  and  local  applications,  but  in 
whom  the  presence  of  a  foreign  body  under  the  lid,  or  even  imbedded 
in  the  cornea,  has  been  overlooked  by  some  one  who  was  more  ready  to 
prescribe  than  to  practice  careful  scrutiny. 

The  EijeliiU. — It  is  most  convenient  to  consider  the  diseases  of  the 
eye  in  an  anatomical  order;  and  the  eyelids  first  present  tliemselves  for 
examination.  Being  covered  externally  b}'  the  common  integument,  the}^ 
are  exposed  to  all  the  morbid  changes  to  wliich  it  is  prone,  and  may  be 
the  seats  of  inflammation,  of  ulcer,  of  eruptions,  of  ntevi  and  other 
growths,  all  of  which  conditions  pass  into  the  domain  of  general  surgery. 
Regarded  only  as  appendages  of  the  eye,  they  are  liable  to  tumors  caused 
by  obstruction  of  the  ducts  of  the  Meibomian  glands,  to  distortions  of 
shape  caused  by  the  shrinking  of  inflammatory  effusions,  to  alterations 
of  position  caused  by  excessive  or  perverted  muscular  action,  and  to 
chronic  inflammation  of  the  follicles  of  the  hairs  which  fringe  their  mar- 
gins. They  are  also  liable  to  marginal  boils,  which  do  not  differ  in  any 
essential  resi)ect  from  boils  elsevvhei'e,  but  whicli  are  called  "styes,"  and 
require  especial  consideration,  on  account  of  their  tendency  to  destroy 
the  eyelashes. 

Tamal  Tumoi's. — When  the  duct  of  a  Meibomian  gland  is  obstructed 
at  its  orifice  tlie  duct  itself  becomes  visible  through  the  inner  portion  of 
the  tarsal  cartilage  as  a  white  line,  which  is  sometimes  sutiiciently  promi- 
nent to  produce  mechanical  irritation  of  the  eye.  This  condition  is  most 
common  in  gouty  people,  in  whom  the  retained  secretion  is  often  rendered 
still  more  irritating  l)y  becoming  the  seat  of  chalky  deposit.  In  such  cases 
the  margins  of  the  lids  may  be  soaked  with  a  warm  alkaline  lotion,  con- 
taining perhaps  ten  grains  of  bicarbonate  of  soda  to  an  ounce  of  water, 
in  the  hope  of  dissolving  the  accumulated  secretion  at  the  orifice,  so  that 
tiie  rest  may  I)e  forced  out  by  pressure  along  the  inner  surface  of  the  lid. 
If  this  method  does  not  succeed,  tiie  white  line  may  be  split  with  the  point 
of  a  sharp  lancet,  and  the  little  cylinder  of  fatty  or  clialky  matter  turned 
out  of  its  bed  and  removed.  Wlien  the  obstruction  is  in  tlie  channel  of 
a  duct,  above  its  orifice,  the  ordinary'  result  is  the  formation  of  a  small 
hemispherical  tumor,  fixed  in  the  tarsal  cartilage,  and  projecting  exter- 
nally. The  skin  is  freely  movable  over  such  a  tumor,  and  is  unchanged 
in  appearance;  but  when  the  lid  is  everted  the  base  of  the  tumor  appears 
as  a  thinned  and  discolored  spot  on  the  cartilage.  If  left  alone  the  tumor 
will  eventually  suppurate,  and  will  in  most  cases  discharge  itself  through 
the  cartilage  and  conjunctiva  rather  than  through  tiie  skin,  in  the  former 
case  leaving  a  l)utton  of  granulation  projecting  from  the  orifice  by  which 
tiie  pus  lias  escajjcd.  This  button  may  for  a  time  be  a  source  of  irrita- 
tion, but  it  will  eventually  disappear.     The  tumors  are  harmless,  but  in- 


BLEPHARITIS.  685 

convenient  and  nnsiglitly,  and  they  ma}'  be  got  rid  of  hv  a  simple  incision 
through  the  tliinned  cartilage.  If  this  gives  exit  to  pus  nothing  more 
need  be  done;  but  if  suppuration  has  not  taken  i)lace  the  tumor  will  con- 
tain semi-transparent  gelatinous  matter,  and  is  then  lined  by  a  secreting 
membrane.  In  such  case  the  contents  must  be  emptied  out  by  a  scoop 
or  by  pressure,  and  the  lining  membrane  must  be  lacerated  in  all  direc- 
tions by  the  point  of  a  knife  or  cataract  needle,  in  order  to  excite  sufficient 
inflammation  to  destroy  its  secreting  pro|)erty.  When  this  is  done  the 
cavity  will  fill  with  blood,  and  then,  in  the  course  of  a  few  weeks,  the 
swelling  will  dwindle  and  disappear.  Should  it  fail  to  do  so  it  may  be 
punctured  again,  and  its  lining  membrane  scarified  moi'e  effectually  than 
before.  A  patient  who  has  once  had  such  a  tumor  will  l)e  liable  to  others, 
because,  as  in  the  case  of  sebaceous  cysts,  there  seems  to  be  a  special 
proclivity  on  the  part  of  some  persons  to  obstruction  of  the  ducts  or 
orifices  of  glands. 

Blepharitis. — The  inflammation  of  the  hair-bearing  margins  of  the 
e3elids,  which  has  been  called  ophthalmia  tarsi,  tinea  tarsi,  l)lei)liaritis,  and 
l)y  other  names,  is  almost  confined  to  the  children  of  the  poor,  and  seems 
to  be  due  either  to  the  direct  influence  of  dirt  and  atmosi)heric  irritants,  or 
to  contagion.  The  seat  of  the  disease  is  in  the  follicles  of  the  eyelashes, 
and  it  is  essentially  an  ulcerative  inflammation,  atfecting  the  lining  of 
these  follicles.  It  usually  commences  in  the  upper  lid,  near  its  middle 
portion,  and  first  shows  itself  by  the  formation  of  a  scab  or  crust,  which 
cements  together  the  bases  of  three  or  four  of  the  cilia.  The  maroin  of 
the  lid,  at  the  point  corresponding  to  the  scab,  is  somewhat  swollen,  and 
the  swelling  extends  a  line  or  a  line  and  a  half  upwards.  The  skin  cover- 
ing the  swelling  is  seldom  reddened,  but  is  usually  smooth  and  glossy 
from  tension.  The  size  of  the  swelling  is  about  equal  to  that  of  the  scab, 
and  the  whole  matter  looks  very  unimportant.  If  the  scab  is  softened 
and  removed,  it  may  be  seen  with  a  magnifying  glass  that  the  orifices  of 
the  hair-follicles  are  patulous,  and  that  they  yield  a  small  quantity  of  thin 
discharge.  This,  mingling  with  the  secretions  of  the  adjacent  Meibomian 
and  sebaceous  glands,  dries  into  the  crust  which  is  characteristic  of  the 
malad}-.  The  inflammation  appears  to  commence  near  the  orfice  of  each 
follicle,  and  gradually  to  spread  to  its  deeper  parts,  killing  and  loosening 
the  eyelashes  as  it  proceeds.  The  secretion  is  either  contagious  or  is  at 
least  actively  irritating,  so  that  the  disease  spreads  along  the  margin  of 
the  lid  from  its  original  centre,  and  appears  liefore  long  in  the  lower  lid 
also.  After  a  time  the  swelling  of  the  lid-margin  removes  the  lower 
lachrymal  punctuni  from  contact  with  the  eyeball,  so  that  the  tears  are  no 
longer  carried  into  the  nose,  but  lodge  and  overflow  and  become  additional 
sources  of  irritation,  often  giving  rise  to  inflammation  of  the  conjunctiva, 
and  to  the  development  of  bloodvessels  beneath  the  corneal  epithelium. 
The  effusion  which  forms  the  marginal  swelling  of  the  lids  undergoes 
gradual  contraction,  which  curves  and  everts  the  tarsal  cartilages,  while 
the  persistent  follicular  inflammation  destroys  the  eyelashes,  or  leaves 
them  weak,  scanty,  distorted,  and  useless.  The  edges  of  the  lids  become 
bare,  red,  everted,  and  unsightly,  the  tears  overflow  the  cheeks,  the  con- 
junctiva is  highly  vascular,  and  the  cornea  is  clouded  by  active  inflam- 
mation or  residual  opacity.    Such  are  the  results  of  neglected  blepharitis. 

Treatment. — In  its  early  stages  the  malady  yields  readily  to  treatment. 
It  is  then  onl}'  necessary  to  remove  the  crusts  by  soaking  them  with  a 
warm  alkaline  lotion,  and  to  apply  an  astringent  to  the  inflamed  surface 
beneath.  A  good  lotion  is  made  by  dissolving  five  grains  of  bicarbonate 
of  soda  in  an  ounce  of  hot  water;  and  the  best  astringent  for  home  use 


686  DISEASES    OF    THE    EYE. 

is  an  ointment  of  tlie  precipitated  yellow  oxide  of  mercniy,  which  may 
be. thrown  down  by  any  alkali  from  a  solution  of  the  perchloride.  This 
ointment  is  commonly  known  as  Pagenstecher's,  and  has  many  uses  in 
oplithalmic  surgery.  For  blepharitis  it  should  contain  about  twenty 
grains  of  the  oxide  to  an  ounce  of  simple  ointment.  It  is  necessary  to 
remove  the  crusts  and  apply  the  ointment  once  a  day,  and  to  persevere 
with  this  plan  for  some  little  time  after  recovery  is  apparently  complete. 
If  the  application  is  too  soon  abandoned  the  disease  will  again  creep  out 
of  t  he  follicles,  and  speedy  relapse  will  occur.  In  cases  which  resist  treat- 
ment the  surgeon  should  himself  remove  the  crusts,  and  should  pencil  the 
exposed  surface  with  a  fine  point  of  nitrate  of  silver,  diluted  b}'  having 
been  fused  with  an  equal  weight  of  nitrate  of  potash,  and  then  run  into 
a  mould  for  use.  In  the  chronic  cases,  in  which  structural  mischief  has 
already  taken  place,  in  which  the  eyelashes  are  destroyed  and  the  lids 
everted,  little  more  can  be  done  than  to  slit  up  the  lower  lachrymal  cana- 
liculus as  far  as  the  caruncle,  so  as  to  permit  the  escape  of  tears,  and 
thus  to  diminish  the  discomfort  of  the  patient. 

Sii/es. — The  little  marginal  boils  whicli  are  called  styes  do  not  differ  in 
any  essential  resjiect  from  boils  in  other  parts  of  the  bod3%  and,  like 
tliem,  tliey  generally  indicate  some  derangement  of  health,  to  which  at- 
tention should  be  paid.  They  run  an  ordinar}'  course  in  a  brief  period 
of  time,  and  woulcl  be  of  little  importance  were  it  not  for  their  tendency 
to  destroy  the  hair-follicles,  and  thus  to  occasion  unsightly  gaps  in  the 
row  of  eyelashes.  On  this  account,  while  an  endeavor  is  made  to  prevent 
their  recurrence  b^'  constitutional  treatment,  it  is  desirable  to  check  the 
development  of  each  individual  boil,  which  may  be  done,  if  it  is  seen 
sufficiently  early,  by  pulling  out  an  eyelash  from  the  centre  of  the  little 
pimple,  and  then  touching  it  with  a  fine  point  of  nitrate  of  silver.  If 
supi)uration  cannot  be  pre\'ented  a  poultice  and  an  earl}^  incision  will  be 
desirable  ;  and,  if  there  is  no  special  indication  for  constitutional  treat- 
ment, the  administration  of  the  tincture  of  perchloride  of  iron  will  often 
prove  advantageous. 

Malposition  of  Eyelashes. — Perverted  growth  or  direction  of  the  eye- 
lashes, by  which  the}-  are  brought  into  contact  with  the  eyeball,  and  l)e- 
come  sources  of  irritation  and  even  of  ulceration,  is  met  with  under  three 
different  conditions:  first,  as  a  result  of  hypertrophy  or  redundancy  of 
growth  ;  secondly,  as  a  result  of  incurvation  of  the  tarsal  cartilage  by  tiie 
contraction  of  inflammatory  products  in  the  conjunctiva;  thirdly,  as  a 
result  of  disi)lacement  of  tlie  cartilage  by  muscular  spasm.  Tlie  first 
variety  is  most  commonly  a  remote  consequence  of  a  slight  degree  of 
Idepharitis;  the  second  is  a  remote  consequence  of  the  more  severe  forms 
of  conjunctivitis;  the  third  occurs  chiefly  in  elderly  persons,  is  confined 
to  the  lower  lid.  and  occasionally  follows  operations  upon  tlie  eye. 

Redirndancij  of  Eyi'lashes. — Redundancy  of  growth  of  cilia  is  usually 
met  with  only  on  some  small  portion  of  the  margin  of  the  upper  lid,  and 
generally  near  the  outer  cantluis.  The  superfluous  hairs  may  be  i)lucked 
out  from  time  to  time  with  forceps  ;  and  if  this  is  done  frequently,  the 
follicles  from  which  they  spring  will  sometimes  undergo  atrophy.  In 
other  cases  epilation  will  rather  tend  to  the  production  of  a  more  active 
growth;  and  then  the  portion  of  cartilage  containing  the  follicles  may  be 
excised  without  sacrifice  of  skin,  or  the  follicles  may  be  destroyed  bj'  in- 
cluding tlicm  in  a  thread  of  silk,  inserted  after  the  manner  of  a  seton, 
and  left  until  it  produces  suppuration.  When  the  cartilage  is  incurved 
the  beist  method  of  treatment  is  U)  split  it  into  an  anterior  and  a  posterior 
layer,  b}'  the  careful  use  of  a  thin  and  keen  scalpel.     The  middle  portion 


AFFECTIONS    OF    THE    LIDS.  687 

of  the  anterior  la^yer  may  then  be  excised  in  a  horizontal  direction,  in- 
cluding skin  and  orbicularis  muscle,  and  the  lower  strip,  carrying  the 
eyelashes,  may  be  transplanted  upwards  and  secured  by  sutures,  leaving 
the  lower  margin  of  the  posterior  layer  exposed.  No  dressing  but  the 
dried  blood  is  required,  and  the  disfigurement  of  the  lid  which  is  at  first 
produced  will  be  recovered  from  in  the  course  of  a  few  weeks,  leaving 
the  lashes  permanently  removed  from  the  eye.  The  inversion  of  the 
lower  lid  by  muscular  action  may  sometimes  be  overcome  by  the  applica- 
tion of  sticking-plaster  or  of  contractile  collodion,  but  will  more  fre(piently 
require  the  excision  of  a  strip  of  skin  and  muscle,  which  should  l)e  \evy 
narrow,  and  should  be  taken  from  immediately  below  the  tarsal  margin. 
When  inversion  follows  an  operation  upon  the  eye,  excision  of  skin 
should,  in  most  cases,  be  performed  without  delay,  as  otherwise  the  me- 
chanical irritation  of  the  displaced  lashes  may  produce  disastrous  conse- 
quences. The  good  result  of  the  operation  depends  chiefly  on  the  re- 
moval of  the  marginal  portion  of  the  orbicularis;  and,  if  too  much  skin 
is  taken,  absolute  eversion  of  the  lid  may  be  the  result. 

Ectropium. — Eversion  of  the  lid  (commonly  called  ectropium)  may  be 
produced  in  the  way  already  mentioned,  by^  the  contraction  of  inflamma- 
tory exudations  external  to  the  cartilage,  by  the  contraction  of  cica- 
trices on  the  face,  l)y  redundancy  or  hypertrophy  of  the  conjunctiva,  by 
the  mere  weight  of  the  lid  in  cases  of  paralysis  of  the  portio  dura,  and 
also,  sometimes,  in  aged  people  in  whom  there  is  no  paralysis,  but  in 
whom  the  orbicularis  is  very  feeble  and  tlie  skin  loose  and  relaxed.  In 
the  treatment  of  wounds  about  the  face  the  probable  action  of  cicatrices 
on  the  lids  must  be  considered,  and  contractions  must  as  far  as  possible 
be  prevented  by  skin-grafting,  and  by  carefid  attention  during  the  heal- 
ing process.  When  tlie  cicatrix  has  assumed  its  permanent  condition 
any  ectropium  which  has  l)een  produced  may  often  be  remedied  by  a 
well-planned  plastic  operation.  The  treatment  of  paral\tic  ectropium 
resolves  itself  into  that  of  the  paralysis,  which  ma,y  sometimes  be  amena- 
ble to  the  judicious  application  of  a  continuous  or  an  induced  galvanic 
current;  and  the  form  which  is  due  to  conjunctival  hypertrophy,  or  to 
mere  senile  relaxation  of  parts,  may  often  be  cured  by  the  contracjtion  of 
a  conjunctival  eschar,  made  by  the  free  application  of  solid  nitrate  of 
silver.  Ectropium  should  always  be  remedied  if  possible,  for  it  is  not 
only  a  conspicuous  and  unsightly  deformity,  which  entails  much  incon- 
venience by  interfering  with  the  natural  course  of  the  tears,  but  it  also 
exposes  the  eye  to  injury  from  tlie  altsence  of  its  natural  protectors. 

Wounch  of  Eyelidfi.—  W oundn  or  injuries  of  the  eyelids,  of  whatever 
nature,  should  be  treated  on  the  principle  of  jireserving  every  fragment 
of  skin,  and  of  endeavoring  to  avoid  distortion  of  shape.  Cuts  or  lacer- 
ations should  be  carefully  cleansed  from  dirt  and  coagula,  their  edges 
accurately  united  by  a  sufficient  number  of  fine  sutures,  and  tlien  covered 
by  a  crust  of  styptic  colloid,  or  of  dried  blood  and  tincture  of  benzoin, 
beneath  which  primary  union  will  often  take  place  under  the  most  un- 
promising circumstances,  thanks  to  the  vitality  and  vascularity  of  the 
parts  concei'ned.  The  best  material  for  eyelid  sutures,  especially  for 
complicated  or  irregularly  lacerated  wounds,  for  which  many  are  required, 
is  the  finest  platinum  wire,  as  fine  as  human  hair;  and  it  may  be  con- 
veniently inserted  b}'  the  needles  which  are  made  for  threading  the 
smallest  beads.  When  wire  is  not  at  liand  human  hair  makes  a  good 
substitute,  except  that  its  elasticity  exposes  it  to  slip  when  it  is  being 
tied. 

Fto.sis. — The  condition  known  as  ptosis,  in  which  the  upper  lid  is  par- 


688  DISEASES    OF    THE    EYE. 

tially  or  entirely  closed,  may  be  a  result  of  injury,  or  of  paralysis  of  the 
levator  palpebral  muscle.  I  have  seen  one  instance  in  which  complete 
ptosis  was  [)roduced  by  accident.  Tlie  i)atieiit,  a  lad  of  ten  years  old, 
fell  down  in  sucli  a  manner  that  a  small  batswing  gas-burner  caught  be- 
neath his  ui)per  lid,  and  the  weiglit  of  his  l)ody  tore  the  tarsal  cartilage 
from  its  attachment  to  the  tendon.  Some  months  after  the  injury  I  made 
an  incision  along  the  upper  lid,  sought  for  and  recovered  the  muscle,  and 
reunited  it  to  the  cartilage  by  three  catgut  sutures.  The  result  was  en- 
tirely successful,  only  very  slight  drooping  of  the  lid  remaining.  When 
ptosis  is  caused  liy  paralysis  it  is  often  recovered  from  under  the  influ- 
ence of  treatment  addressed  to  the  nervous  affection  on  which  the  paraly- 
sis depends  ;  but,  failing  this,  an  operation  may  be  required  in  order  to 
reopen  the  eye,  and  to  enable  it  to  take  part  in  vision.  The  most  suc- 
cessful plan  is  to  make  a  single  horizontal  incision  along  the  middle  of 
the  fallen  lid,  to  detach  the  skin  upwards  and  downwards,  to  excise  a 
broad  strip  of  the  orbicularis  muscle,  and  to  unite  the  edges  of  the  muscu- 
lar gap  by  catgut  sutures  without  any  sacrifice  of  skin.  In  this  wa3'  the  lid 
may  be  effectually  lifted,  without  producing  the  appearance  of  dragging  or 
straining  which  follows  the  removal  of  skin,  and  also,  if  the  operation  is 
nicely  m^anaged,  without  tilting  forward  the  lower  margin  of  the  cartilage. 

Diseases  of  the  Conjunctiva. — Next  in  order  to  the  diseases  of  the  eye- 
lids come  those  of  the  conjunctiva,  which,  after  lining  the  lids,  is  reflected 
to  cover  the  surface  of  the  eyeball,  and  is  continued  over  the  cornea  by 
its  epithelial  layer,  although  its  other  elements  are  firmly  united  to  the 
sclerotic  at  the  corneal  margin.  The  conjunctiva,  as  a  mucous  mem- 
brane, is  liable  to  inflammation  attended  by  increased  secretion,  which 
may  assume  a  purulent  character,  and  may  become  actively  contagious. 
It  is  also,  as  the  external  covering  of  the  eye,  exposed  to  irritation  by 
atmospheric  dirt  or  noxious  vapors,  or  by  the  lodgment  of  foreign  bodies 
upon  its  surface. 

In  fammatio7i  of  the  covjnndiva  is  commonly  divided  into  the  simple 
or  catarrhal  and  the  purulent ;  and,  although  these  two  forms  pass  into 
one  another  by  imperceptiV)le  gradations,  the  distinction  is  not  without 
practical  convenience.  In  simple  conjunctivitis  the  membrane  is  con- 
gested and  somewhat  tumid,  and  its  secretion,  which  is  of  a  mucous 
character,  readily  dries  into  crusts  upon  the  eyelashes  and  the  margins 
of  the  lids.  The  caruncle  and  plica  semilunaris  are  somewhat  swollen, 
there  is  a  certain  amount  of  itching  or  smarting,  and  the  lids  become 
adherent  during  sleep  from  the  drying  of  the  viscid  secretion.  There  is 
also  some  increase  in  the  flow  of  tears,  but  there  is  no  tensive  or  deep- 
seated  pain,  no  impairment  of  vision,  no  turbidity  of  the  cornea  or  dimin- 
ution of  the  lustre  of  the  iris,  no  irregularity  or  sluggishness  of  the  pupil, 
and  the  congestion  is  limited  to  the  conjunctiva,  and  neither  extends  to 
the  cornea  nor  to  the  fine  zone  of  sclerotic  vessels  which  surrounds  the 
corneal  margin.  The  latter  point  may  readily  be  determined  by  finger- 
pressure,  through  the  medium  of  the  lower  lid,  which  should  be  first 
pushed  up  so  as  partially  to  cover  the  cornea,  and  then  made  to  glide 
downwards  over  the  ocular  surface.  The  pressure  w^ill  empty  the  con- 
junctival vessels  for  a  moment,  and  will  leave  a  pure  white  track  right  up 
to  the  corneal  margin.  This  track  will  be  instantly  effaced  by  the  return- 
ing blood  ;  but  its  perfect  whiteness  in  tiie  neighborhood  of  the  cornea  is 
the  point  to  i)e  observed,  and  shows  the  absence  of  any  tendency  to  iritis. 
In  order  tf>  see  that  there  is  no  encroachment  of  vessels  upon  the  cornea, 
it  isVjest  to  examine  the  margin  with  a  magnil'ying  lens. 


INFANTILE    PURULENT    OPHTHALMIA.  689 

Simple  conjunctivitis,  such  as  lias  been  described,  is  a  trivial  affection, 
which  can  be  cured  in  a  short  time  by  the  local  employment  of  any 
metallic  astringent,  and  which  yields  most  readily  to  the  frecinent  use  of 
a  comparatively  mild  application.  A  solution  of  nitrate  of  silver,  of 
about  two  grains  to  the  ounce  of  distilled  water,  is  perhaps  the  most  effi- 
cacious ;  but  its  tendency  to  stain  handlvcrchiefs  is  an  objection  to  its 
use,  and  a  solution  of  sulphate  or  chloride  of  zinc,  or  of  sulphate  of  cop- 
per, will  usually  fulfil  every  indication,  Tlie  lower  lid  should  be  drawn 
down,  and  a  little  of  the  lotion  should  be  applied  to  its  inner  surface,  by 
means  of  a  goosequill  scoop.  A  solution  of  acetate  of  lead  would  be 
equally  beneficial,  but  the  application  of  a  salt  of  lead  to  the  eye  is 
attended  by  the  objection  that,  if  there  should  be  any  loss  of  corneal 
epithelium,  an  opaque  white  deposit  of  carbonate  of  lead  may  be  left 
upon  the  abraded  surface.  The  lotion  wliich  has  been  beneficial  in  one 
case  is  sometimes  preserved  by  a  patient,  to  be  used  again  under  very 
different  circumstances  ;  and  hence  an  application  containing  lead  should 
only  be  ordered  with  great  circumspection. 

When  conjunctivitis  passes  beyond  this  simple  form,  and  produces 
purulent  discharge  and  swelling  of  the  conjunctiva  and  eyelids,  it  often 
becomes  a  very  formidable  afl!"ection,  which  not  unfrequently  leads  to 
blindness  by  interfering  with  the  nutrition  of  the  cornea  and  producing 
sloughing  or  necrosis  of  that  membrane.  The  chief  forms  of  purulent 
conjunctivitis  are  three  in  number,  the  infantile,  the  gonorrlioeal,  and  the 
epidemic. 

Infantile  Purulent  Ophthalmia. — The  first  of  these,  infantile  purulent 
ophthalmia,  commences  about  the  third  day  after  birth,  and  is,  in  most 
cases,  clearly  due  to  inoculation  with  the  vaginal  secretions  of  the  mother. 
The  inflammation  rapidly  gains  in  intensity,  the  conjunctiva  lining  the 
eyelids  becomes  greatly  swollen,  the  lids  are  puffy  and  red  externally, 
and  a  profuse  discharge  of  thick  pus  is  poured  out.  The  conjunctiva 
covering  the  globe  is  always  much  congested  ;  and  in  the  worst  cases  it 
is  elevated  by  swelling,  and  overlaps  the  corneal  margin,  producing  the 
condition  called  chemosis.  When  this  occurs  the  cornea,  which  derives 
much  of  its  nourishment  from  the  conjunctival  vessels,  is  placed  in  great 
danger.  It  soon  becomes  turbid,  and  the  turbidity  may  soon  pass  into 
necrosis.  In  neglected  cases  the  pus  dries  upon  tlie  palpebral  margins 
and  cements  them  together,  so  as  to  retain  the  fresli  secretion  in  the 
conjunctival  sac,  where  it  distends  the  lids  and  presses  injuriously  upon 
the  eye.  The  severity  of  the  affection  varies  much  in  different  cases,  and 
may  be  measured  by  the  swelling  of  the  lids,  and  by  the  viscidity  of  the 
discharge.  It  probably  depends  in  some  measure  upon  the  character  of 
the  vaginal  secretion,  and  also  upon  the  strength  and  vital  resistance 
of  the  infant;  and  on  both  grounds  the  worst  cases  are  met  with  in  the 
subjects  of  inherited  syphilis.  When  the  inflammation  is  violent,  or  the 
infant  diseased  or  weakly,  sloughing  of  the  cornea  may  take  place  very 
rapidly  ;  but  when  the  inflammation  is  moderate,  the  infant  vigorous, 
and  the  discharge  thin  and  as  if  muco-purulent,  the  disease  may  even 
wear  itself  out  harmlessly.  Under  almost  all  circumstances,  if  the  cornea 
is  bright  and  clear  when  first  seen  by  the  surgeon,  a  favorable  prognosis 
may  be  confidently  given.  If  the  cornea  is  turbid  the  prognosis  must  be 
very  guarded  ;  and,  if  it  is  concealed  by  the  swelling  of  the  lids,  no  opin- 
ion must  be  hazarded  until  it  can  be  seen. 

Treatment. — As  long  as  the  cornea  retains  its  integrity  the  treatment 
required  is  cleanliness,  and  the  regular  application  of  an  astringent ;  and 
if  properly  carried  out  it  is  not  too  much  to  say  that  this  treatment  will 

44 


690  DISEASES    OF    THE    EYE. 

be  invariably  successful.  The  lids  being  separated  by  the  fingers,  a  small 
stream  of  warm  water  may  be  allovved  to  trickle  gently  between  them 
from  a  sponge,  being  received  at  tlie  side  of  the  face  in  a  basin,  until  all 
diseiiarge  is  washed  awa3\  The  lids  must  be  gently  pressed  with  a  soft 
absorbent  handkerchief,  to  remove  water  from  the  conjunctival  sac,  and 
then  a  few  drops  of  a  solution  of  nitrate  of  silver,  of  the  strength  of  two 
grains  to  the  ounce  of  distilled  water,  must  be  suffered  to  fall  between 
them.  Ijastl_v,  the  margin  of  the  lids  must  be  effectually  anointed  wath 
spermaceti  ointment  or  with  almond  oil,  to  prevent  their  adhesion  from 
the  drying  of  the  discharge;  and  the  whole  proceeding  must  be  repeated 
every  four  hours.  In  a  very  short  time  manifest  improvement  will  take 
place  ;  and  the  applications  may  be  made  less  frequently,  but  they  must 
not  be  entirely  discontinued  until  the  cure  is  complete. 

Merrurial  Inunction. — If  the  infant  is  the  subject  of  inherited  syphilis 
mercurial  inunction  should  lie  practiced.  For  this  the  best  method  is  to 
spread  half  a  drachm  of  blue  ointment  on  a  strip  of  flannel,  and  to  but- 
ton it  round  the  abdomen,  renewing  the  ointment,  on  the  same  piece  of 
flannel,  every  day.  If  the  infant  is  feeble  it  may  take  half  a  drachm  of 
cod-liver  oil,  with  a  drop  of  liquor  cinchouiTe,  twice  a  da,y ;  and  if  the 
mother's  milk  is  deficient  in  quantity  or  quality,  a  wet-nurse  should  be 
procured,  or  careful  hand-feeding  should  be  had  recourse  to.  It  is  sel- 
dom enough  for  the  surgeon  to  be  content  with  verbal  instructions,  but 
he  must  show  the  nurse  how  the  nitrate  of  silver  lotion'is  to  be  applied, 
and  must  carefully  supervise  the  arrangements  for  the  feeding. 

Implication  of  Cornea. — When  the  cornea  is  already  turbid  the  same 
kind  of  treatment  must  be  pursued,  and  if  sloughing  does  not  occur  the 
turbidity  will  in  most  cases  clear  away  in  the  course  of  time,  if  not  en- 
tirely, yet  sutficientl}'  to  leave  useful  vision.  If  only  a  small  portion  of  the 
cornea  should  perish,  recovery  may  still  take  place,  leaving  the  curvature 
of  the  membrane  altered  and  flattened,  the  iris  adherent  to  the  cicatrix, 
and  the  pupil  more  or  less  closed  or  displaced.  When  the  corneal  slough 
is  extensive  the  result  is  the  condition  called  complete  staph3'loma,  in 
which  the  iris  becomes  blended  with  the  cicatrix,  and  projects  as  a  bluish- 
wdiite  prominence  in  the  situation  of  the  cornea.  In  such  cases  percep- 
tion of  light  is  often  preserved,  but  never  vision  of  objects  ;  and  the 
subjects  of  this  misfortune  form  a  very  large  proportion  of  the  inmates 
of  our  blind  asylums  and  similar  institutions.  It  should  never  be  for- 
gotten, esi)ecially  by  those  who  are  engaged  in  obstetric  practice,  that 
no  case  of  corneal  staphyloma  would  ever  occur,  as  a  result  of  infantile 
purulent  ophthalmia,  if  that  malady  were  alwaA  s  promptly  and  properly 
treated.  Tiie  medical  attendant  of  a  lying-in  woman  should  alwa3's  leave 
orders  that  he  must  be  summoned  without  delay,  if  any  inflammation  of 
the  child's  eyes  should  be  perceived. 

GonorrhfroJ  ophfhahnia.i  in  its  s^ymptoms,  course,  and  termination, 
greatly  resembles  the  infantile  variety.  As  its  name  implies,  it  occurs 
only  in  adults,  or  at  least  only  in  those  who  have  been  in  contact  vvith 
the  secretion  of  gonorrhoea.  It  is  generally  believed  to  be  the  result  of 
direct  inoculation  with  the  urethral  discharge,  and  is  doubtless  often 
produced  in  this  way.  It  is  thought  by  some  to  be  occasionally  part  of 
the  original  disease  independently  of  inoculation,  and  I  have  seen  a  few 
cases  which  rather  tend  to  this  conclusion,  although  inoculation  would 
be  very  difficult  to  disprove.  In  the  treatment  of  gonorrluea,  more 
especially  of  a  first  attack,  it  is  always  desirable  to  caution  the  patient 
about  his  eyes,  so  that  he  may  neither  rub  them  vvith  fingers  soiled  with 
urethral  discharge  nor  thi'ow  a  drop  of  discharge  directly  into  one  of 
them  (a  thing  which  I  have  known  happen)  by  shaking  the  penis.     It 


GONORRHCEAL.    OPHTHALMIA.  691 

is  an-  important  difference  between  infantile  and  gonorrhneal  ophthalmia 
that  the  latter,  either  from  the  essential  natnre  of  the  affection,  or  from 
the  different  character  of  the  mncons  membrane  in  the  adult,  is  mnch 
less  amenable  to  treatment  than  the  former,  so  that  a  very  guarded 
prognosis  should  be  given  in  every  case.  In  old  times  the  treatment  of 
gonorrhoeal  ophthalmia  was  of  the  most  heroic  description,  including 
bleeding  from  the  arm,  the  application  of  many  leeches  to  the  temples, 
the  administration  of  purgatives  and  mercury,  and  the  enforcement  of 
an  antiphlogistic  regimen.  Under  this  method  the  cornea  usually 
sloughed;  and  the  credit  of  introduciug  a  more  rational  system  is  due 
to  Mr.  Dixon,  who  perceived  that  slonghing  was  the  danger  chiefly  to  be 
guarded  against,  and  that  the  best  way  of  guarding  against  it  was  by 
stimulants  and  a  generous  diet.  Von  Graefe  carefully  studied  the  ques- 
tion of  local  medication,  and  laid  down  rnles  for  the  application  of  nitrate 
of  silver,  which,  if  they  are  carefully  observed,  will  conduct  most  cases 
to  a  successful  termination.  The  first  principle  of  treatment,  when  only 
one  eye  is  affected,  is  to  protect  the  other  from  accidental  inoculation. 
For  this  purpose  the  sound  eye  should  be  covered  with  a  piece  of  water- 
proof tissue,  gummed  down  to  the  skin  by  collodion,  and  over  this  a 
compress  and  bandage  should  be  applied.  A  still  better  protection  has 
lately  been  introduced  at  the  Moorfields  Eye  Hospital,  and  consists  of  a 
watch-glass  inserted  into  a  piece  of  waterproof  tissue,  which  is  spread 
with  adhesive  plaster.  The  sound  eye  being  covered,  the  surgeon  takes  a 
solution  of  nitrate  of  silver,  of  about  a  scruple  to  the  ounce,  or,  still  lietter, 
a  solid  stick  of  a  compound  made  by  fusing  together  one  part  of  nitrate 
of  silver  and  three  parts  of  nitrate  of  potash.  The  eyelids  being  everted 
and  cleansed  from  discharge,  their  inner  surfaces  are  carefully  painted 
over  with  the  solution, or  touched  in  every  part  with  the  stick;  and  then, 
after  a  few  moments,  befoi'e  they  are  released,  the  superfluous  nitrate  of 
silver  is  decomposed  by  a  brushiul  of  a  solution  of  common  salt,  which,  in 
its  turn,  is  washed  away  with  water.  The  nitrate  of  silver  should  be  so 
applied  as  to  produce  only  a  superficial  eschar,  extending  no  deeper  than 
the  epithelium,  and  sparing  the  basement  membrane,  and  it  should  not 
be  suffered  to  come  into  contact  with  the  cornea.  The  application  should 
be  renewed  as  often  as  the  superficial  eschar  is  cast  off,  which  will  gener- 
ally be  about  every  eight  hours.  It  will  occasion  acute  pain,  and  hence, 
more  especially  in  bad  cases,  in  which  the  lids  are  brawny,  much  swollen, 
difficult  to  evert,  and  slippery  from  discharge  when  they  are  everted,  it 
is  often  desirable  to  administer  an  an;iesthetic,  and  to  hold  the  margin  of 
the  upper  lid  with  toothed  forceps.  In  the  intervals  between  successive 
cauterizations,  unless  the  patient  is  sleeping,  the  conjunctival  sac  should 
be  frequently  and  gently  syringed  out — perhaps  every  hour — with  a 
weak  solution  of  chloride  of  zinc,  of  one  or  two  grains  to  the  ounce; 
and,  as  the  local  symptoms  abate,  the  nitrate  of  silver  may  be  laid  aside 
and  the  strength  of  the  zinc  lotion  increased. 

General  Treatment. — While  such  is  the  local  treatment  as  far  as  the 
eye  is  concerned,  the  constitutional  state  and  the  urethritis  should  also 
receive  attention.  For  the  latter  it  is  the  best  to  use  very  weak  astringent 
injections,  and  to  abandon  any  internal  remedies,  such  as  copaiba,  which 
might  interfere  with  appetite  "or  digestion.  The  diet  should  be  nourish- 
ing but  nnstimulating,  and  means  should  be  taken  to  allay  pain  and  to 
procure  sleep.  As  already  stated,  the  chief  risk  attendant  upon  the 
ophthalmia  is  that  of  sloughing  of  the  cornea,  which  is  produced  partly 
by  the  mechanical  arrest  of  its'blood-supply,  and  partly  also,  in  all  prob- 
aisility,  by  the  depressed  state  of  the  general  bodily  nutrition,  or  even. 


692 


DISEASES    OF    THE    EYE. 


Fig.  323. 


in  some  cases,  by  the  septic  influence  of  the  gonorrhooa  itself.  In  order 
to  obviate  the  etfects  of  these  conditions,  the  administration  of  quinine, 
in  doses  of  two  or  three  grains  tliree  times  a  day,  will  generally  be  de- 
sirable. 

Scarijication. — When  tlie  swelling  of  the  ocular  part  of  the  conjunc- 
tiva is  very  thick  and  firm,  tlie  cornea  will  be  exposed  to  additional 
danger,  and  in  sucli  cases  it  is  desirable  to  divide  the  swollen  tissues 
freel,v,  by  three  or  four  incisions  radiating  from  the  corneal  margin,  and 
carried  well  down  to  tlie  sclerotic.  Such  incisions  may  be  conveniently 
made  witli  scissors,  which  do  not  expose  the  sclerotic  itself  to  an}'  danger 
of  being  divided. 

Sloughing  of  Cornea. — When  sloughing  of  the  cornea  takes  place  it 
will  sometimes  be  universal,  destroying  the  whole  of  the  membrane,  and 
leading  to  collapse  and  wasting  of  the  globe,  or  to  the  forma- 
tion of  a  complete  staphyloma,  in  either  case  with  total  loss 
of  sight.  More  frequently  it  is  only  partial  as  regards  its 
superficial  extent,  but  it  usually  goes  on  to  perforation,  after 
which  improvement  commences,  and  the  resulting  ulcer  heals, 
leaving  an  opaque  cicatrix,  to  which  some  portion  of  the  iris, 
and  more  or  less  of  the  pupillary  margin,  are  firmly  and  in- 
separably adherent.  When  this  happens  vision  will  be  more 
or  less  impaired,  according  to  the  position  of  the  cicatrix, 
to  the  degree  of  flattening  of  the  cornea  which  has  been  pro- 
duced by  its  contraction,  and  to  the  extent  of  the  incarcera- 
tion of  the  pupil ;  and  the  flattening  of  the  cornea  often 
seriously  limits  the  improvement  of  sight  which  may  be 
gained  by  placing  an  artificial  pupil  behind  some  still  trans- 
parent part.  It  is,  therefore,  highly  important  to  prevent 
perforation  of  the  cornea,  and  this  may  often  be  done  by 
paracentesis  of  the  anterior  chamber  at  the  corneal  margin, 
the  artificial  evacuation  of  the  aqueous  humor  having  a  ten- 
dency to  prevent  the  extension  of  the  sloughing  process, 
and  arresting  it,  as  spontaneous  perforation  arrests  it,  prob- 
ably by  diminishing  the  pressure  from  within.  Paracentesis 
of  the  anterior  chamber  should  be  performed  at  the  corneal 
margin  on  the  outer  side,  by  a  puncture  from  any  sharp  in- 
strument, and  by  the  subsequent  insertion  of  a  blunt  probe, 
so  as  to  press  back  the  posterior  lip  of  the  little  wound,  to 
allow  the  aqueous  humor  to  escape.  It  is  most  safely  per- 
formed b}'  the  aid  of  the  special  needle  made  for  the  purpose, 
and  shown  in  Fig.  323.  This  neetUe  has  a  stop  or  shoulder 
to  arrest  its  penetration,  so  that  it  can  wound  neither  the 
iris  nor  the  lens ;  and  a  probe  for  opening  the  puncture  is 
mounted  on  the  same  handle.  It  is  best  to  have  the  patient 
recumbent,  and  the  operator,  standing  behind  his  head, 
should  raise  the  upper  lid  and  lock  it  under  the  orbital 
margin  with  two  fingers,  which  should  also  rest  against  the 
inner  side  of  the  eyeball  to  check  rotation  inwards.  The 
point  of  the  needle  should  then  be  thrust  through  into  the 
anterior  chamber  at  the  spot  indicated  ;  and,  in  most  cases, 
the  puncture  should  be  reopened,  either  with  the  needle  or 
with  the  probe,  twice  daily,  until  healing  of  the  ulcer  has 
commenced. 

FlalUuring  of  Cornea. — Whenever  there  is  considerable 
loss  of  corneal  substance,  even  although  there  may  be  no 


EPIDEMIC    OPHTHALIyri  A.  693 

perforation,  a  certain   amonnt  of  flattening  of  the   cornea  must  be  ex- 
pected ;  and  whenever  perforation   lias  taken   place  tlie  cicatrix  will  be 
likely   to   become  inoniiuent  under  the  influence   of  the  pressure  from 
within  whicli  is  produced  l\y  the  action  of  the  recti  muscles.     In  order 
to  obviate  this  tendency  the  eye  should  be  supported,  during  the  whole 
period  of  healing  of  an  ulcer  which  has  perforated,  by  the  careful  applica- 
tion of  a  pad  of  carded  cotton-wool,  retained  by  a  compressive  bandage. 
Epidemic  Ophthalmia. — The  purulent  ophthalmia  of  infancy,  and  the 
purulent  ophthalmia  of  gonorrhoea,  are  alike  highly  contagious,  and  would 
be  likely  to  be  communicated  in  their  most  virulent  forms  by  any  con- 
veyance of  their  discharges  to  the  conjunctiva  of  a  healthy  eye.     I3ut  as 
a  matter  of  fact,  on  account  of  the  precautions  taken  with  regard  to  them, 
they  are  seldom   propagated  in  this  way;  and  the  term   contagions  oph- 
thalmia is    used  almost  exclusively  to  denote  an  epidemic   form  of  con- 
junctivitis which  is  said  to   have  })revailed  in   Egypt  from   time  immemo- 
rial, and  to  have  been  introduced  into  Europe  by  the  Fi-ench  armj'  in  the 
beginning  of  this  century.     Epidemic  conjunctivitis  may  assume  every 
degree  of  severity,  from  the  most  trivial  catarrhal  form,  which  is  curable 
by  an  astringent  lotion  in  a  few  hours,  to  the  most  severe  and  destructive 
suppurative  inflammation.     In  hospital  practice  it  is  very  common  to  see 
conjunctivitis  of  no  great  severity  run  through  a  family,  or  even  to  see  it 
prevail  in  a  particular  street  or  group  of  buildings ;  and  the  tendency  to 
pus-formation  will  usually  be  much  more  marked  in  some  patients  than  in 
others.     When  the  maladj^  api)ears  in  large  communities  who  are  living 
under  insanitary  conditions  it  usually  spreads  with  great  rapidity,  and 
assumes  a  highly  dangerous  character.     The  most  remarkable  examples 
of  tliis  tendency  have  been  furnished  by  regiments  and  by  large  schools, 
more  especially  schools  for  pauper  children.     Both  in  regiments  and  in 
schools  it  has  been  found  that  circumstances  generally  prejudicial  to  health, 
such  as  overcrowding,  imperfect  ventilation,  want  of  cleanliness,  and  im- 
proper feeding,  have  a  tendency  to  produce  the  development  in  the  con- 
junctiva of  bodies  which  are  known  as  ''sago-grain,"  or  follicular  granu- 
lations ;  and  tliat  the  presence  of  these  granulations  involves  a  peculiar 
vulnerability  to  the  causes  by  which  contagious  ophthalmia  is  produced. 
The  granulations  themselves  are  chiefl}'  found  about  the  reflection  of  the 
conjunctiva  from  the  outer  part  of  the  lower  lid  to  the  surface  of  the  eye- 
ball; and  they  appear  as  small  rounded,  pellucid  prominences.     In  their 
essential  nature  they  are  strictly  analogous  to  enlarged  glands,  and  they 
consist  of  aggregations   of  lymph-cells,  the  connective  tissue  between 
which  has  undergone  absorption  or  displacement.    Sporadic  cases  of  follic- 
ular granulations  are  frequently  met  with  even  among  people  of  good  sur- 
roundings, and  the  granulations  may  shrink  and  disappear  without  pro- 
ducing ophthalmia.     But  the_y  are,  nevertlieless,  a  delicate  test  of  the 
sanitary  state  of  a  community  ;  and,  when  contagious  ophthalmia  appears 
in  a  school  or  regiment,  all  eyes  should   be  examined   for  granulations, 
and  all  in  which  tliey  are  present  should  at  once  l)e  taken  under  treat- 
ment.    For  the  granulations  themselves  it  is  only  necessary  to  touch  the 
conjunctiva  at  intervals  with  some  stimulating  application;  and  there  is 
probably  none  better  than  the  so-called  lapis  divinus^  a  mixture  of  equal 
parts  of  sulphate  of  copper,  nitrate  of  potash,  and  alum,  fused  together 
and  run  into  a  mould.     The  resulting  stick  may  be  heated  at  one  end 
over  a  gas-flame,  and  its  fused  external  parts  wiped  away,  until  it  is 
shaped  to  a  smooth  and  tapering  point,  which  can  be  applied  conveni- 
ently to  all  the  wrinkles  of  tlie  conjunctival  membrane.     The  lapis  occa- 
sions some  smarting,  especially  at  the  first  few  applications  ;  but  this  may 


694  DISEASES    OF    THE    EYE. 

be  diniiiiished  by  holding  down  the  lid  until  tlie  effect  has  exhausted  itself 
upon  the  i)alpebral  conjunctiva,  and  also  b}''  bathing"  with  cold  water  im- 
mediately afterwards.  It  is  sutticient  to  make  the  application  once  daily; 
and,  as  the  granulations  diminish  in  size,  the  intervals  maybe  increased. 
In  the  coarse  of  two  or  three  weeks,  in  favorable  cases,  the  enlargements 
will  be  absorbed  and  will  disappear. 

Treatment. — In  the  treatment  of  the  conjunctivitis  itself,  whether  or 
not  it  has  been  preceded  by  tlie  presence  of  granulations,  the  practitioner 
must  be  mainly  guided  by  the  severity  of  the  affection,  by  the  amount 
and  apparent  density  of  the  swelling  of  the  ocular  conjunctiva,  and  by 
the  presence  or  absence  of  turbidity  or  irregularity  of  the  corneal  epi- 
thelium, or  of  a  tendency  to  the  passage  of  vessels  from  the  conjunctiva 
to  the  cornea.  It  is  first  of  all  necessary  to  ascertain,  in  every  case,  that 
the  disease  is  not  due  to  tlie  presence  of  a  foreign  bod}-,  and  the  next 
point  is  to  observe  whether  the  inflammation  shows  an3'  tendency  either 
to  spread  to  the  cornea  or  to  interfere  with  its  nutrition.  In  very  acute 
forms,  with  much  swelling  and  profuse  discharge,  the  ocular  conjunctiva 
soon  overlaps  the  cornea,  as  in  gonorrhceal  ophthalmia;  and  in  propor- 
tion to  the  bulk  of  tlie  resulting  chemosis,  and  to  the  firmness  of  the 
effused  material,  it  threatens  the  life  of  the  corneal  tissue,  and  sometimes 
produces  rapid  necrosis,  without  antecedent  inflammation.  In  other 
cases,  less  severe  in  degree,  there  is  an  early  tendenc}'  to  the  develop- 
ment of  a  vascular  keratitis,  and  fine  twigs  and  loops  of  newly  formed 
vessels  may  be  seen  encroaching  upon  the  cornea,  especiall^^  at  its  upper 
and  lower  portions.  In  others,  again,  there  is  a  tendency  to  corneal 
ulceration  of  an  inflammatory  characier,  the  first  evidence  of  which  is 
furnished  by  irregularity,  roughness,  and  dulness  of  the  epithelium  at 
the  margin.  When  these  conditions  are  absent,  when  the  swelling  of  the 
lids  is  not  excessive,  and  when  the  corneal  epithelium  is  bright  and  undis- 
turbed, the  treatment  resolves  itself  into  the  employment  of  metallic 
astringents.  Among  these  a  solution  of  acetate  of  lead  is  perhaps  the 
best;  but,  on  account  of  the  already  mentioned  danger  of  applying  it  to 
any  case  in  which  the  corneal  epithelium  is  abraded,  and  in  which  it  would 
lead  to  the  formation  of  an  opaque  deposit  of  carbonate,  it  is  generally 
safer  to  use  tiie  sulphate  of  copper,  or  the  sulphate  or  chloride  of  zinc, 
or  the  nitrate  of  silver;  or  the  sulphate  of  copper  ma^'  be  applied  in  the 
form  of  lapis  divinus.  In  some  instances  it  will  be  found  desirable  to 
vary  the  astringent  from  time  to  time,  care  being  ulwa^'s  taken  not  to 
select  one  of  too  active  a  character,  and  to  limit  its  operation  as  far  as 
possil)le  to  the  eyelids  and  the  palpebral  folds. 

In  the  more  severe  forms,  with  i)rofuse  purulent  discharge  and  early 
and  considerable  swelling,  it  is  Ibund  that  the  stronger  astringents  are 
not  well  borne  at  the  commencement  of  the  disease,  and  that  sedatives 
are  first  required.  In  such  cases  Yon  (jJraefe  strongly  recommended  the 
application  of  liquor  chlori,  as  a  step  towards  astringents  of  a  more 
active  character;  and  this  remedy  apjx-ars  to  have  the  incidental  advan- 
tage of  dcstro3'ing  the  infective  (piality  of  the  secretion.  It  should  he 
dropped  into  the  eyes  twice  daily,  and  the  results  of  its  employment 
should  be  watched  with  the  greatest  care.  If  the  conjunctival  swelling 
shows  a  tendency  to  become  more  dense,  or  if  there  are  symptoms  threat- 
ening the  spreading  of  inflammation  to  the  cornea,  then  the  liquor  chlori 
must  be  laid  aside  in  favor  of  atropine  and  soothing  fomentations.  If, 
on  the  contraiy,  the  conjunctival  swelling  becomes  more  lax  and  vohuni- 
nous,  and  the  secretion  more  abuntlant,  then  the  liquor  chlori  should  be 
superseded  by  the  diluted  solid  niliale  of  silver,  ai)plicd  as  directed  for 


PAPILLARY    GRANULATIONS.  695 

the  gonorrhoea!  form  of  the  affection  ;  and  this  in  its  turn,  as  the  condi- 
tion of  the  patient  improves,  shouhl  be  superseded  by  soUitions  of  the 
salts  of  copi)er  or  zinc. 

Bearing  in  mind,  then,  that  it  is  impossil)le  to  draw  any  line  of  demar- 
cation between  the  mildest  form  of  conjunctivitis  and  the  most  severe 
purulent  ophthalmia,  and  that  the  successful  treatment  of  each  case  will 
depend  upon  a  correct  appreciation  of  its  stage  and  its  tendencies,  and 
upon  accurate  observation  of  the  effects  of  the  first  remedies  selected,  it 
may  be  laid  down  as  a  general  principle  that  all  mild  forms  will  bear 
metallic  astringents  from  the  beginning,  and  will  often  be  readil}'  cured 
by  them.  The  more  severe  forms  display  an  early  period  of  acute  irrita- 
tion, in  which  any  stimulation  would  be  mischievous,  and  would  increase 
the  severity  of  the  attack.  This  period  must  be  tided  over  by  the  local 
use  of  atroi)ine  and  hot  fomentations,  aided  by  such  regimen  and  general 
treatment  as  the  state  of  the  health  may  require.  It  may  lead  either  to 
a  brawny  swelling  of  the  conjunctiva,  witli  thin  discharge  and  a  tendency 
to  c(n'nenl  death  or  inflammation,  or  to  a  voluminous  and  lax  swelling, 
with  discharge  of  a  purulent  character.  The  former  condition,  when  of 
a  pronounced  kind,  forbids  the  use  of  local  stimulation  ;  the  latter  requires 
tiie  repeated  destruction  of  the  epithelium  by  caustic. 

Trealment  of  Corneal  Comijlicationx. — When  the  cornea  becomes  ulcer- 
ated, if  the  ulcers  threaten  to  perforate,  the  treatment  by  paracentesis 
must  be  had  recourse  to.  Ulcers  which  do  not  threaten  to  perforate 
require  at  first  no  modification  of  the  plans  already  mentioned  ;  but  as 
soon  as  a  process  of  repair  commences  it  may  be  promoted  b3^  various 
local  applications,  which  need  not  interfere  with  those  required  by  the 
conjunctiva.  Among  these  the  first  place  ma}'  be  given  to  Pagenstecher's 
yellow  oxide  of  mercurj'  ointment,  or  to  dry  calomel  sprinkled  over  the 
cornea  in  small  quantity;  or  Dr.  Williams's  citrine  ointment  may  be  tried 
(in  which  olive  oil  is  replaced  by  cod-liver  oil),  or  one  containing  a  little 
red  oxide  of  mercury  or  a  little  sulphuret  of  arsenic. 

Papillary  Granulations. — Whatever  may  be  the  fate  of  the  cornea,  the 
subsidence  of  the  acute  stage  of  the  disease  may  lead  either  to  perfect 
recovery  or  to  a  state  of  chronic  inflammation  of  the  conjunctiva,  in  which 
thqre  is  great  liability  to  frequent  relapses,  and  a  tendency  to  hyperplasia, 
which  shows  itself  in  an  exuberant  crop  of  secondary  granulations  in  the 
palpebral  folds  and  on  the  lining  of  the  lids.  These  granulations  differ 
from  the  follicular  or  sago-grain  granulations  both  in  appearance  and  in 
nature  ;  and  they  are  a  result  of  hypertroph}'  of  the  conjunctival  papill;>3, 
which  are  strictly  analogous  to  those  of  the  dermis.  Tlie  eyelids  become 
villous  over  their  whole  internal  aspect,  and  the  palpebral  folds  may  be 
almost  shaggy  with  enlarged  and  vascular  papilla?.  In  process  of  time 
the  tendency  to  relapse  dies  out,  but  the  papilla?  remain,  and  maj'  assume 
a  warty  appearance,  while  the  subconjunctival  tissue  becomes  tliickened 
and  indurated.  Such  a  state  is  apt  to  occasion  the  development  of  ves- 
sels beneath  the  corneal  epithelium,  and  these  vessels  are  sometimes  so 
numerous  and  so  closely  set  that  they  produce  opacity  and  loss  of  sight. 
In  order  to  prevent  such  an  occurrence  the  stage  of  improvement  from 
the  acute  attack  requires  to  be  carefully  watched,  and  the  application  of 
nitrate  of  silver  should  be  regularly  made  for  some  time  after  the  violence 
of  the  disease  is  exhausted.  When  the  nitrate  is  at  last  laid  aside  it  must 
be  replaced  by  the  long-continued  use  of  some  milder  application,  as  by 
a  lotion  containing  some  salt  of  zinc  or  lead  or  copper.  The  most  disas- 
trous results  are  often  produced  in  cases  in  which  granulations  in  the 
palpebral  folds  are  neglected  or  suffered  to  escape  notice,  because  they 


G96  DISEASES    OF    THE    EYE. 

undergo  in  course  of  lime  a  gradual  degeneration  and  contraction,  by 
wliich  tlie  cartilages  of  tlie  upper  lids  become  incurved,  and  tlie  cilia  are 
bronglit  into  contact  witli  the  eye.  Tlie  cases  of  chronic  trichiasis  which 
frequent  our  liospitals  liave  nearl}-  always  this  liistor\\  The  tarsal  car- 
tilages are  shortened,  thiclvcned,  and  unduly  convex ;  and  on  everting 
the  lids  the  conjunctiva  is  seen  to  be  crossed  by  hard  dense  lines  resem- 
bling cicatrices. 

Tfeatment  m  Public  Instifutions. — When  contagious  ophthalmia  makes 
its  appearance  in  any  public  institution,  or  in  any  body  of  people  living 
under  similar  conditions,  the  surgeonshould  at  once  recognize  the  gravity 
of  the  evil,  and  should  enforce  the  most  stringent  precautions  to  prevent 
the  spreading  of  the  malady.  In  the  first  place,  the  patients  should  be 
entirely  separated  from  the  unaffected  persons ;  and  tlie  latter  should  be 
examined  for  follicular  granulations,  which  should  be  subjected  to  local 
treatment  whenever  they  are  found.  The  general  conditions  of  living 
should  be  considered,  with  especial  reference  to  the  quantity'  and  quality 
of  food,  the  ventilation  of  dwelling-rooms  and  dormitories,  and  the  cubic 
space  allotted  to  each  person.  The  ordinary  means  of  communication  of 
ophthalmia,  especially  by  a  community  of  washing  arrangements,  should 
be  remembered  and  guarded  against ;  and  the  treatment  of  the  inflamed 
eyes  should  not  only  be  conducted  vvith  the  greatest  care,  to  discriminate 
the  special  requirements  of  each,  but  should  be  continued  until  no  trace 
of  mischief  is  left  lurking  in  the  palpebral  folds. 

Diphtheritic  Conjunctivitis. — In  every  epidemic  of  conjunctivitis  we 
meet  with  a  few  cases  in  which  the  discharge,  instead  of  resembling 
ordinary  pus,  is  coherent  or  fibrinous,  so  that  it  can  be  peeled  off  in 
strips  from  the  conjunctiva,  leaving  a  bright-red  surface,  which  is  usually 
dotted  over  with  bleeding  points.  These  cases  require  no  modification 
of  treatment,  but  they  are  worthy  of  notice,  because  they  have  often,  and 
erroneously,  been  termed  '^  diphtheritic."  True  diphtheritic  conjuncti- 
vitis does  not  appear  to  be  known  in  England,  but  it  is  not  uncommon 
in  Berlin  and  other  parts  of  Germany,  and  has  been  described  by  many 
German  writers.  The  diphtheritic  fibrinous  effusion  does  not  occur  on 
the  conjunctival  surfaces,  but  in  the  interstices  of  the  subconjunctival 
tissue.  The  prominent  symptoms  are  great  pain,  heat,  and  swelling  of 
the  eyelids,  with  distension  of  the  subconjunctival  tissue  by  a  pale,  firm, 
brawn}'  effusion,  which  arrests  the  local  circulation  and  threatens  the 
cornea  with  speedy  destruction  by  necrosis.  The  prognosis  is  exces- 
sively unfavorable,  and  the  treatment  must  be  conducted  on  the  general 
principles  already  laid  down,  with  the  addition  of  compresses  wrung  out 
of  iced  water  in  the  early  stages,  to  relieve  the  heat  and  pain.  At  a  later 
period  hot  fomentations  will  promote  vascularization  and  repair  of  tissue, 
and  the  internal  use  of  mercury  is  said  often  to  have  been  beneficial. 

Phli/clcnular  Conjunctivitis. — A  familiar  form  of  inflammation  of  the 
conjunctiva  is  that  which  is  associated  with  the  course  of  the  little 
pimples  known  as  ^'  phlycteiiuliE."  Phlyctcnuhxi  a[)pear  to  resemble  follic- 
ular granulations,  in  that  they  are  essentially  abnormal  aggregations  of 
lympli-cells,  but  they  are  seated  on  the  ocular  instead  of  the  pali)ebral 
conjunctiva,  and  they  undergo  inflammation  and  ulceration.  Each  phlyc- 
tenula  runs  its  course  in  al)out  eight  days.  The  elevation  throws  out 
fluid  at  its  summit  and  becomes  a  vesicle,  which  bursts  and  forms  a  small 
ulcer,  the  centre  of  which  is  covered  by  a  tenacious  film  of  buff-colored 
material.  This  undergoes  disintegration  and  is  cast  off',  and  then  the 
ulcer  heals.  The  phlyctenuUe  may  he  either  single  or  multiple,  and  they 
often  appear  in  successive  crops.    The  Ibrniation  of  each  vesicle  is  attended 


EPISCLERITIS.  697 

by  some  burning  or  stinging  pain,  which  subsides  when  rupture  has  taken 
place,  and  is  succeeded  only  by  such  sensations  of  itching  or  discomfort 
as  ma}'  be  due  to  the  amount  of  attendant  conjunctivitis.  Phlyctenulae 
may  occur  in  the  cornea,  but  their  most  common  seat  is  in  the  ocular 
conjunctiva,  just  beyond  the  corneal  margin.  A  single  one  hardly  re- 
quires any  other  treatment  than  rest  of  the  affected  eye  and  the  api)lica- 
tion  of  a  weak  astringent  lotion  ;  but  recurrent  phlyctenuUe  point  to 
disorder  of  the  general  nutrition,  and  either  to  something  faulty  in  the 
habits  of  life  or  to  some  unfairness  in  the  conditions  under  which  the 
e3'^es  are  exerted. 

Covjunctival  Groivths. — The  conjunctiva  may  be  the  seat  of  morbid 
growths  of  various  kinds,  among  which  may  be  mentioned  dermoid  and 
sarcomatous  tumors,  the  former  sometimes  bearing  hairs.  Such  growths, 
if  they  are  increasing,  or  unsightly  or  inconvenient,  may  be  pinched  up 
and  removed  by  scissors,  the  resulting  conjunctival  wound  being  closed 
by  a  point  of  fine  suture.  If  the  wound  is  large  the  conjunctiva  should 
be  dissected  from  the  sclerotic  on  either  side,  so  that  the  edges  may  come 
together  more  readily'.  It  is  not  uncommon  to  see  subconjunctival  col- 
lections of  fat  or  of  yellow  fibrous  tissue,  and  these,  which  are  mostly 
situated  on  either  side  of  the  cornea,  are  apt  to  be  nipped  and  moulded 
by  the  closure  of  the  lids,  so  as  to  form  little  tumors,  sometimes  almost 
pedunculated,  on  the  horizontal  meridian.  Such  growths  are  harmless 
but  unsiglitl_y,  and  they  also  may  be  excised  with  good  effect.  Another 
form  of  conjunctival  growth  is  pterygium,  which  consists  of  a  hypertrophy 
of  tissue,  sometimes  very  trifling  in  amount,  sometimes  ver^'  considerable, 
having  a  generally  triangular  outline,  with  its  apex  trespassing  more  or 
less  upon  the  cornea.  Pterygium  is  usually  a  final  result  of  long-con- 
tinued inflammation,  and  is  scarcely  at  all  amenable  to  treatment.  The 
hypertrophied  material  may  be  removed  by  excision  or  ligature,  but  the 
same  kind  of  action  is  often  renewed  in  the  cicatrix,  and  the  patient 
seldom  derives  lasting  benefit  from  any  operation.  A  pterygium  does 
no  harm  unless  it  extends  so  far  over  the  cornea  as  to  obsti'uct  vision, 
and  then  the  best  course  is  to  enlarge  the  pupil  b}'  iridectomy. 

Epinclerilis. — An  affection  which  is  apparently  conjunctival,  but  which 
is  really  seated  in  the  tissue  intervening  between  the  conjunctiva  and  the 
sclerotic,  is  that  which  has  received  the  name  of  Episcleritis.  It  appears 
as  a  patch  of  congestion,  gradually  fading  into  the  natura,l  appearance, 
and  seated  on  the  ocular  surface  near  the  corneal  margin,  most  frequently 
on  the  temporal  side  and  below  the  horizontal  meridian.  On  close  ex- 
amination the  congestion,  with  the  exception  perhaps  of  one  or  two 
dilated  vessels,  is  seen  to  be  subconjunctival,  and  to  be  attendant  upon 
a  circumscribed  but  not  sharply  defined  swelling  or  thickening,  which  is 
adherent  to  the  sclerotic,  and  which  presents,  in  the  interstices  between 
bloodvessels,  an  appearance  as  if  it  consisted  of  some  new  deposit  ex- 
ternal to  that  membrane.  The  swelling  is  indolent,  chronic,  and  gener- 
ally painless,  although  it  sometimes  produces  neuralgia.  The  subjects 
are  most  frequently  women,  and  generally  those  who  are  anaemic  or 
otherwise  out  of  condition.  P]i)iscleritis  may  last  for  months  with  little 
change,  and  it  seems  to  be  harmless  as  regards  the  other  structures  of 
the  eye.  I  have  found  it  resist  all  treatment  except  the  internal  admin- 
istration of  mercury,  and  to  this  it  will  often  yield  in  the  course  of  a  few 
weeks.  I  give  the  perchloride  in  solution,  in  the  dose  of  a  sixteenth  of  a 
grain  three  times  a  day,  usually  combined  with  five  or  ten  minims  of  the 
tincture  of  i)erchloride  of  iron.  With  this  treatment  I  am  accustomed  to 
combine  a  daily  sprinkling  of  dry  calomel  over  the  swelling ;  but  the 
internal  medication  is  that  which  is  most  to  be  relied  upon. 


698  DISEASES    OF    THE    EYE. 

The  diseases  of  the  cornea,  in  some  instances,  as  already  stated,  are 
resnlts  of  conjnnctival  aflections  ;  and  the  sloughing  ulcers  produced  by 
purulent  ophthalmia  have  already  been  mentioned.  When  the  period  of 
convalescence  from  purulent  ophtlialmia  has  been  neglected,  and  when 
papillary  granulations  have  been  suft'ered  to  lurk  in  the  palpebral  folds, 
and  ultimatel_v  to  undergo  shrinkage  and  degeneration,  these  conditions 
act  as  mechanical  irritants  to  the  corneal  surface,  and  produce  a  develop- 
ment of  vessels  under  the  epithelium  of  a  kind  whicli,  when  it  reaches  a 
certain  degree,  is  called'"  Pannus."  The  vascularization  of  pannus  dif- 
fers from  other  forms  of  vascularity  in  that  tlie  vessels  proceed  to  the 
cornea  from  the  conjunctiva  as  twigs  or  branches  of  some  magnitude, 
and  ramify  upon  the  cornea  in  an  irregular,  arborescent  fashion,  with 
considerable  intervals  between  them. 

In  these  intervals,  when  they  are  tolerabl}^  large,  the  cornea  may 
remain  transparent ;  but,  as  the  growth  of  vessels  increases,  the  inter- 
vals diminish  in  size,  and  the  epithelium  covering  them  becomes  cloudy 
and  disturbed.  When  a  vascular  development  of  this  kind  is  seen  in  the 
upper  part  of  the  cornea  the  upper  lid  should  always  be  everted  for  ex- 
amination, and  in  most  instances  its  inner  surface  will  be  found  rough- 
ened or  granular.  Where  the  upper  lid  only  is  at  fault  only  the  upper 
half  of  the  cornea  will  suffer ;  but,  if  there  are  granulations  also  in  the 
lower  palpebral  folds,  the  subepithelial  vessels  may  extend  over  the 
wiiole  cornea,  and  may  reduce  vision  to  a  mere  perception  of  light.  The 
aggravated  forms  of  pannus  are  chiefly  seen  among  discharged  soldiers, 
or  among  the  sufferers  from  a  great  wave  of  epidemic  ophthalmia  which 
swept  over  Ireland  a  few  years  ago,  or  among  persons  who  have  had  se- 
vere conjunctivitis  in  some  dust}'  locality,  away  from  medical  aid.  Cases 
come  to  the  London  hospitals  from  certain  parts  of  Australia;  and  there 
can  be  little  doubt  that  the  contagious  ophthalmia  of  the  Hanwell  Schools 
in  1862-65,  and  of  the  schools  at  Anerley  more  recently,  will  yield  a  crop 
of  cases  b}'  and  b}'.  In  order  to  be  successful  the  treatment  of  pannus 
must  be  continued  over  many  months,  and  it  consists  in  the  application, 
daily  or  at  short  intervals,  of  astringents  to  the  lining  membrane  of  the 
lids.  The  cornea  must  be  left  alone,  for,  if  the  condition  of  the  lids  can 
be  greatly  improved,  the  corneal  vessels  will  gradually  dwindle  and  dis- 
appear, and  the  transparency  of  the  membrane  will  be  restored.  I  have 
not  seen  benefit  arise  from  very  strong  applications,  nor  from  the  long- 
continued  use  of  any  single  one,  and  am  accustomed  to  ring  the  changes 
between  lapis  divinus,  gl3^cerole  of  tannin,  and  solutions  of  hj^drochlorate 
of  quinine,  nitrate  of  silver,  sulphate  of  copper,  sulphate  and  chloride  of 
zinc,  and  acetate  of  lead;  the  quantity  of  any  salt  not  exceeding  five 
grains  to  the  ounce  of  distilled  water.  In  order  to  make  the  application 
both  lids  should  be  everted,  and  their  exposed  inner  surfaces  either 
touched  or  j^ainted  with  the  selected  medicament.  If  no  benefit  is  ob- 
tained, and  if  the  cornea  is  so  generally  vascular  as  to  appear  tolerably 
safe  against  sloughing,  excellent  results  may  sometimes  be  produced  .I)}' 
inoculation  with  the  pus  of  infantile  o]jhtlialmia.  A  little  of  this  pus 
should  l)e  taken  up  by  a  probe  or  seoop,  and  i)laccd  in  the  conjunctival 
sac  of  tiie  patient.  The  resulting  purulent  ophlhaluiia  will  recpiire  no 
treatment  beyond  frequent  bathing  and  great  cleanliness;  and,  after  it 
lias  worn  itself  out,  the  cornea  will  usually  clear  in  a  very  remarkable 
manner.  It  must  be  remembered  that  tliis  treatment  is  not  wholly  free 
from  risk;  and  that,  notwithstanding  the  vascularity,  it  may  produce 
sloughing  of  tiie  cornea  and  total  loss  of  sight.  Inoculation  is  sometimes 
preceded  liy  peritom}-,  or  the  excision  of  the  annulus  of  conjunctiva  and 


DISEASES    OF    THE    CORNEA.  699 

subconjunctival  tissue  which  immediately  surrounds  the  cornea,  and 
which  is  dissected  off  the  sclerotic  as  completely  as  possible  with  forceps 
and  scissors.  In  this  proceeding  I  have  but  little  confidence,  and  do 
not  recommend  it  for  adoption. 

Co7'7ieal  Phlyctenulse. — The  phlyctenulte,  which  have  already  been  de- 
scribed as  occurring  upon  the  conjunctiva,  occur  also  upon  the  cornea, 
where  the  morbid  formation  in  which  they  originate  is  seated  imme- 
diately under  the  epithelium.  In  this  position,  partly  perhaps  on  ac- 
count of  the  comparatively  unyielding  character  of  the  tissnes  concerned, 
the  little  elevations  occasion  much  more  distress  than  wlien  they  are  lim- 
ited to  the  conjunctiva.  Even  during  their  period  of  formation,  it  is  con- 
jectured that  the}'  press  upon  or  otherwise  irritate  the  sensory  nerve- 
filaments  of  the  cornea;  and,  as  soon  as  the  elevations  ulcerate,  it  is  ob- 
vious that  nerve  filaments  ma}'  be  exposed  in  the  resulting  solutions  of 
continuity.  The  sensor}'  filaments  of  the  cornea,  when  irritated,  produce 
photopliobia,  or  intolerance  of  ligiit ;  eitiier  because  these  filaments  re- 
spond to  the  stimulus  of  light  by  common  sensation,  or  else  because  they 
convey  irritation  to  the  ciliary  region,  and  cause  the  reflex  movements 
produced  by  light — the  contraction  of  the  pupil,  and  so  forth — to  be 
acutely  painful.  Wliatever  may  be  the  explanation,  the  presence  of  even 
a  single  suiall  phlyctenula  on  the  cornea  may  occasion  intense  photopho- 
bia, and  this,  in  its  turn,  may  greatly  aggravate  the  condition  in  which 
it  has  its  origin.  Sometimes  before  the  elevation  ulcerates,  and  always 
afterwards,  a  little  leash  of  new  vessels  creeps  from  the  conjunctiva  to 
the  affected  spot,  and  these  vessels  only  dwindle  after  the  healing  of  the 
ulcer  is  complete.  Each  ulcer  leaves  behind  at  least  a  faint  nebula, 
sometimes  a  more  conspicuous  and  even  a  flattened  cicatrix  ;  and  tlie 
cicatrices  are  united  to  the  corneal  margin  by  linear  nebulae  marking  the 
track  of  the  vessels.  Phlyctenular  may  occur  in  successive  crops,  ex- 
tending over  a  long  period  of  time,  and  tliey  may  then  constitute  an  aflfec- 
tion  which  is  now  commonly  described  as  "  recurrent  vascular  ulcer"  of 
the  cornea,  and  which  is  apt  to  be  exceedingly  troublesome  and  obstinate. 
Recurrent  vascular  ulcer  is  prominent  among  the  group  of  diseases 
which  were  once  described  as  "strumous  ophthalmia,"  and  the  subjects 
are  more  frequently  strumous  children.  There  is,  indeed,  a  great  analogy 
between  the  history  of  follicular  granulations  or  phlyctenulse  and  that  of 
tubercle. 

Photophobia. — In  some  cases  of  recurrent  vascular  ulcer  the  photopho- 
bia is  excessive.  The  child  hides  its  head  in  the  darkest  corners  or  in 
its  mother's  dress,  contracts  its  orbicular  muscles  with  an  energy  by 
which  the  whole  face  is  spasmodically  contorted,  and  screams  and  strug- 
gles at  every  attempt  to  expose  it  to  the  light.  If  it  is  securely  held, 
and  its  eyelids  are  forcibly  separated,  a  gush  of  confined  tears  escapes, 
but  the  cornea  is  rolled  upwards  by  the  superior  rectus,  and  often  remains 
hidden  from  view.  Under  such  circumstances  the  proper  course  is  to 
relax  muscular  spasm  by  an  anaesthetic,  and  then  to  make  a  careful  and 
complete  examination  of  the  eye.  If  the  case  is  already  of  some  dura- 
tion, and  especially  if  the  photophobia  is  of  some  duration,  the  cure 
of  the  muscular  spasm  is  the  first  requirement,  because  this,  by  re- 
taining tears  and  by  exercising  hurtful  pressure  upon  the  eye,  is  itself 
a  serious  obstacle  to  improvement.  As  a  test  of  the  severity  of  photo- 
phobia, and  to  distinguish  it  from  voluntary  contraction  of  the  orbicu- 
laris, I  am  accustomed  to  place  reliance  on  the  presence  of  a  little  red 
chink,  extending  horizontally  outwards  from  the  external  canthus.  This 
chink  shows  that  the  muscular  spasm  has  been  suflScient  not  only  to  close 


700  DISEASES    OF    THE    EYE. 

the  palpebral  fissure,  but  also  to  hold  two  surfaces  of  skin  in  contact,  and 
to  convert  them  into  something  resembling  mucous  membrane.  When- 
ever I  see  this  chink  I  divide  all  the  tissues,  with  one  stroke  of  knife  or 
scissors,  from  the  external  canthus  right  up  to  the  margin  of  the  orbit, 
on  a  horizontal  line,  cutting  through  conjunctiva,  orbicularis  muscle, 
and  skin.  There  is  alwa_ys  free  bleeding  from  veins  which  had  been 
previously'  congested  by  the  muscular  action,  and  the  orbicularis  loses 
its  power  to  contract.  The  bleeding,  which  is  probably  highly  salutary, 
stops  of  itself  in  a  few  minutes  ;  and  the  only  treatment  required  is  to 
apply  compresses  wetted  with  cold  or  iced  water,  and  to  put  the  patient 
to  bed  in  a  dark  or  dimly  lighted  room.  At  the  end  of  twenty-four  hours 
it  will  almost  invariably  be  found  that  the  photophobia  has  disappeared, 
and  that  the  e^'es  are  accessible  to  inspection.  Tlie  incisions  heal  with- 
out leaving  any  visible  scars,  and  the  power  of  the  orbicularis  is  soon 
and  completely  restored. 

Local  Treatment. — When  the  photophobia  is  not  sufficient  to  require 
this  treatment,  but  yet  interferes  with  the  comfort  of  the  patient,  he  may 
be  confined  to  diml}"  lighted  rooms  when  at  home,  and  suftered  to  wear  a 
thick  veil  or  dark  blue  spectacles  when  abroad.  A  drop  of  a  solution  of 
neutral  sulphate  of  atropia,  of  the  strength  of  two  grains  to  the  ounce 
of  distilled  water,  should  be  applied  to  the  inside  of  the  lower  lid  twice 
daily,  by  means  of  a  goosequill  cut  to  a  blunt  scoop ;  and  a  good  deal  of 
time,  perhaps  two  or  three  hours  a  day,  should  be  devoted  to  bathing 
the  eyes  with  cold  or  iced  water.  When  the  stage  of  irritation  connected 
with  the  development  of  an  ulcer  has  terminated,  and  the  period  of  heal- 
ing is  commencing,  a  little  dr_y  calomel  may  be  sprinkled  over  the  cornea 
once  a  day,  or  a  morsel  of  Pagenstecher's  ointment  may  be  placed  in  the 
lower  conjunctival  sac. 

General  Treatment. — The  subjects  of  this  disorder  are  nearly  always 
feeble  children  of  strumous  tendencies,  and  they  are  often  rendered  even 
artificially  unhealthy  by  the  state  of  their  eyes.  Compelled  to  shun  light, 
they  have  been  deprived  of  its  beneficial  influence  as  a  stimulus  to  vital 
action,  and  they  have  acquired  a  habit  of  stooping  which  gives  them 
contracted  chests  and  congested  heads.  Deprived  of  mental  occui)ation, 
they  have  become  dull  and  listless,  and  want  of  outdoor  exercise  has  re- 
duced their  physical  powers  and  their  muscular  tone.  Very  frequently 
their  tempers  have  been  spoilt  by  foolish  indulgence,  and  their  digestions 
impaired  by  overfeeding.  Under  such  circumstances  it  is  often  neces- 
sar}'  for  the  surgeon,  for  a  time,  to  make  the  necessary  local  applications 
himself,  lest  they  should  go  anywhere  but  into  the  eyes;  and  it  is  always 
necessar}^  to  lay  down  minute  rules  for  diet,  habits,  and  exercise.  Cod- 
liver  oil,  with  or  without  steel  or  quinine,  ma,y  generally  be  administered 
with  advantage;  and  I  have  been  accustomed  to  recommend  skipping 
with  a  rope  as  a  means  of  bringing  the  limbs  into  activit}'.  It  requires 
no  vision,  may  be  practiced  in  any  darkened  but  well-ventilated  room, 
and  it  employs  many  muscles  at  once.  Care  must  he  taken,  however, 
not  to  occasion  overfatigue  at  the  beginning  of  the  treatment. 

Setons. — In  some  children,  notwithstanding  all  that  can  be  done,  the 
disease  is  very  obstinately  recurrent.  In  such  cases  Mr.  Ci'itchett  strongly 
recommends  the  use  of  setons  in  the  hairy  scalp,  just  above  the  ears.  He 
inserts  a  single  thread  of  rather  thick  silk  through  a  needle-track  about 
an  in(th  in  length,  and  knots  the  ends  loosely  together.  By  inserting  the 
seton  in  the  iiairy  scalp  not  only  is  the  looj)  itself  rendered  inconspicuous, 
and  the  resulting  scar  invisil)le,  l)nt  the  operator  is  able  to  lift  up  the 
skin  IVom  the  deep  fascia  by  tlie  haii-  before  passing  the  needle,  and  thus 


VASCUI^AR    KERATITIS.  701 

to  avoid  all  risk  of  wounding  the  temporal  vessels.  Some  persons  insert 
the  setons  below  the  hairy  scalp,  in  front  of  the  ear,  but  this  practice  is 
much  to  be  condemned,  especially  for  girls,  on  account  of  the  cicatrices 
which  are  produced.  Mr.  Critchett  l)elieves  that  the  setons  establish  an 
artificial  weak  place  in  the  neighborhood  of  the  eye,  and  that  they  thus 
break  the  habit  of  morbid  action.  He  leaves  them  in  the  temples  for  six 
months  or  longer,  and  reinserts  them  if  they  cut  their  way  out  prema- 
turely. In  a  small  number  of  cases  these  setons  are  extremely  useful, 
but  they  are  employed  in  many  instances  which  would  yield  perfectly 
well  to  the  judicious  use  of  milder  remedies. 

Iridectomii. — In  young  adults,  especially  in  young  women,  recurrent 
vascular  ulcer  sometimes  continues  even  for  years,  and  in  these  cases  the 
ulcers  are  often  sufficiently  deep  to  leave  permanent  and  flattened  cica- 
trices, so  that  tiie  corneoe  become  dotted  over  with  opacities  and  distorted 
in  outline.  Under  such  circumstances  the  chain  of  morbid  action  will 
usuall}^  be  broken  by  an  iridectomy,  and  for  this  purpose  it  is  sufficient 
to  excise  a  very  narrow  strip  of  iris,  which  should  generally  be  taken 
from  behind  a  clear  part  of  the  cornea.  When  this  has  been  done  not 
only  will  the  recurrence  of  ulceration  cease,  but  the  cornea,  in  the  course 
of  a  few  months,  will  often  clear  in  a  surprising  degree. 

We  meet  with  a  few  instances,  chiefly  in  strumous  children,  in  which 
conditions  analogous  to  recurrent  vascular  ulcer  produce  an  extension  of 
vessels  upon  the  cornea,  but  no  ulceration.  In  such  cases  we  find  here 
and  there  a  faint  corneal  nebula,  in  which  a  lens  will  still  discover  fine 
vessels,  and  in  another  place  there  is  an  arborescent  encroachment  of 
vessels  from  the  margin  towards  the  centre,  attended  with  some  intoler- 
ance of  light.  A  careful  scrutiny  will  generally  discover,  at  some  point 
of  the  corneal  margin,  a  narrow  zone  of  thickened  and  pellucid  tissue, 
formed  by  something  resembling  little  beads  or  dots,  and  clearly  of  the 
same  character  as  the  ordinary  phlyctenulte,  but  not  tending  to  ulcera- 
tion. In  all  such  cases  the  local  and  general  treatment  required  for  mild 
cases  of  vascular  ulcer  may  be  applied  with  advantage. 

Keratitis. — The  cornea  is  liable  to  several  forms  of  inflammation,  which 
are  grouped  together  under  thegeneral  term  keratitis,  and  are  conveniently 
divided  into  the  vascular,  the  interstitial,  and  the  suppurative.  All  these 
forms  of  inflammation  are  attended,  at  their  onset  and  throughout  their 
course,  by  hyperaemia  of  the  conjunctiva,  but  this  hypersemia  is  never 
limited  to  the  conjunctiva.  The  vessels  either  extend  over  the  corneal 
margin,  or  else  there  is  congestion  of  a  fine  vascular  zone  in  the  sclerotic, 
which  immediatel}'  surrounds  the  cornea,  so  that,  if  the  blood  is  pressed 
out  of  the  conjunctival  vessels  by  a  finger,  in  the  manner  alread}'  de- 
scribed, the  finger-track  is  not  white  but  pink.  It  is  very  important  to 
observe  and  to  attend  to  this  distinction  ;  for,  while  astringents  are  use- 
ful in  all  the  mild  forms  of  conjunctivitis,  they  are  always  hurtful,  and 
often  very  hurtful,  in  all  forms  of  keratitis. 

Vascular  keratitis  commences  by  the  development  of  two  fine  crescents 
of  vessels,  one  at  the  superior  and  the  other  at  the  inferior  margin  of  the 
cornea.  These  crescents  appear,  in  the  first  instance,  as  fine  red  lines, 
and  graduall^^  increase  in  size,  invading  more  and  more  of  the  corneal 
tissue.  Examined  by  a  lens  they  are  seen  to  consist  of  a  congeries  of 
minute  bloodvessels,  situated  immediately  beneath  the  epithelium,  and 
so  closely  packed  together  that  the  interstices  which  separate  them  are 
scarcely  discernible  by  the  naked  eye,  which  perceives  only  a  general 
effect  of  redness.  The  crescents  are  a  little  elevated  above  the  natural 
surface  of  the  cornea,  and  each  one  pushes  before  it,  so  to  speak,  a  belt 


702  DISEASES    OF    THE    EYE. 

of  precursoiy  epithelial  turbidity.  Unless  this  pvecnrsorv  turbidity 
reaches  the  central  portion  of  the  cornea,  so  as  to  cover  tlie  pupil,  sight 
is  scarcely  at  all  affected;  and,  as  a  rule,  there  is  little  or  no  pain,  and 
little  or  no  intolerance  of  light.  In  cases  of  a  severe  character,  or  which 
have  been  aggravated  by  improper  applications,  the  vascular  crescents 
ma}'  ultimately  coalesce  and  cover  the  whole  of  the  cornea,  whicli  then 
becomes  uniforral}'  red  and  opaque,  so  that  vision  is  almost  entire  abol- 
ished. After  a  longer  or  shorter  time  the  vessels  begin  to  dwindle,  and 
they  ultimatel}''  disappear,  leaving  behind  theui  a  dense  opacity  of  a  very 
enduring  nature.  When  the  whole  of  the  cornea  has  been  invaded  the 
oiDacity  is  usually  most  dense  over  the  central  parts  ;  and,  in  consequence 
of  the  greater  distance  of  the  centre  from  the  sources  of  blood-supply, 
absorption  progresses  more  slowly  there  than  elsewhere  ;  so  that  a  bad 
case,  even  under  the  most  favorable  circumstances,  must  involve  loss  of 
sight  for  a  very  considerable  period  of  time.  Vascular  keratitis  some- 
times attacks  both  eyes  at  once,  and  sometimes  one  onl}' ;  but  in  cases 
of  the  latter  class  I  have  frequentl}^  seen  the  second  eye  become  affected 
in  the  course  of  time,  even  after  an  interval  of  three  or  four  years. 

Treatment. — The  great  object  of  treatment,  in  vascular  keratitis,  is  to 
arrest  the  pi'Ogress  of  the  disease  before  it  has  reached  the  central  region 
of  the  cornea,  and  for  this  purpose  the  first  essential  is  a  negative  one, 
namely,  the  avoidance  of  all  irritants.  If  the  case,  in  its  earl}'-  stages,  is 
mistaken  for  simple  conjunctivitis  on  account  of  tlie  conjunctival  hy- 
peremia which  attends  it,  and  if  this  error  leads  to  the  application  of 
nitrate  of  silver  or  of  sulphate  of  zinc  lotion,  or  of  any  of  the  other  stimu- 
lants or  astringents  which  conjunctivitis  would  require,  the  keratitis  will 
always  be  much  aggravated,  and  will  often  be  rendered  uncontrollable. 
In  ever}'  case  of  apparent  conjunctivitis  it  is  necessary  to  scrutinize  care- 
fully the  upper  and  lower  margins  of  the  cornea;  and  whenever  a  fine  net- 
work of  vessels  can  be  seen  creeping  over  either  of  these  margins  all  astrin- 
gents must  be  witiiheld.  The  only  local  application  which  should  be  used 
in  such  cases  is  atropine,  and  it  should  be  applied  in  the  form  of  a  two- 
grain  solution,  two  or  three  times  a  day.  It  is  not  only  valuable  as  a  local 
sedative,  but  it  paralyzes  for  a  time  the  muscle  of  accommodation  and 
the  sphincter  of  the  pupil,  and  thus  procures  functional  rest  for  the  eye. 

Gompresaion  Bandage. — In  addition  to  functional  rest,  the  movements 
of  the  eyelids  over  the  affected  surface  should  be  restrained  by  the 
careful  application  of  a  compress  of  carded  cotton-wool,  retained  by  a 
bandage.  The  closed  lids  should  first  be  covered  by  a  small  piece  of  fine 
soft  linen  rag,  in  order  to  prevent  mechanical  irritation  of  the  eye  by 
fibres  of  avooI,  and  over  this  rag  tlic  wool  should  be  so  adjusted  as  to  fill 
the  orbital  hollows,  and  to  form  a  covering  through  which  a  bandage 
will  exert  uniform  compression.  Tiie  bandage  should  be  nearly  two 
yards  long,  about  an  inch  and  a  half  wide,  and  made  of  some  loose 
elastic  texture,  what  is  called  "water-dressing  bandage  "  being  the  best 
for  the  purpose.  The  end  of  the  roller  is  placed  on  the  forehead,  imme- 
diately above  the  affected  eye,  and  is  secured  by  one  horizontal  turn, 
which  passes  across  the  forehead  and  round  the  head.  When  the  roller 
readies  the  forehead,  over  the  sound  eye,  for  the  second  time,  it  is  in- 
clined downwards  under  the  lobe  of  the  ear  on  the  same  side,  round 
the  occii)ut,  under  tlie  loVie  of  the  ear  on  the  affected  side,  and  over 
the  wool-pad  to  the  horizontal  turn,  to  whicli,  when  tlie  degree  of  pres- 
sure is  properly  regulated,  it  is  secured  by  a  pin.  Another  horizontal 
turn  is  then  made  over  all,  and  the  bandage  is  complete.  If  proiierly 
applied,  it  is  scarcely  at  all  liai)l('  to  slii),  but  when  it  is  required  at  night 


TREATMENT.  703 

it  is  the  safest  plan  to  stitcli  the  fokls  together  at  intervals.  This  ap|)lies 
chiefly  to  operation  cases  ;  and  in  inflammation  of  the  cornea  the  bandage 
may  generally  be  laid  aside  during  sleep,  when  the  lids  will  be  quiescent 
without  its  aid. 

Cold  Applicalion. — An  important  influence  upon  the  development  of 
vessels  in  the  cornea  ma}'  often  be  exerted  by  temperature,  cold  applica- 
tions being  highly  valual)le  to  diminish  vascularity-,  and  hot  applications 
to  increase  it.  In  the  early  stages  of  vascular  keratitis  it  will  often  be 
useful  to  bathe  the  closed  lids  with  cold  or  iced  water,  or  even  to  apply 
to  them  small  linen  compresses  wetted  with  iced  water,  and  fi'e(iuently 
renewed.  For  these  puri)oses  the  compressive  bandage  may  be  laid  aside 
for  half  an  hour  or  an  hour,  two  or  three  times  a  day,  the  use  of  cold  for 
longer  periods  being  seldom  desirable. 

Counter-irritation. — In  many  cases  I  have  seen  great  benefit  arise 
from  counter-irritation  ;  and  the  agent  which  I  commonly  employ  for  this 
purpose  is  an  iodine  liniment,  of  a  strength  adapted  to  the  degree  of  irri- 
tabilit}'  of  the  skin,  and  in  which  a  little  morphia,  perhaps  a  grain  to 
the  ounce,  is  dissolved.  I  usually  begin  with  the  tincture  of  iodine, 
painted  over  the  brow  and  temple  of  the  afl'ected  side  every  night,  and 
strengthened  if  it  fails  to  irritate  after  one  or  two  applications. 

General  Health  to  be  considered. — In  nearly  every  case  of  vascular 
keratitis  the  general  health  of  the  patient  will  require  careful  considera- 
tion and  treatment;  and  in  a  considerable  proportion  there  will  be  evi- 
dence of  a  syphilitic  taint,  either  inherited  or  acquired.  In  such  instances 
the  administration  of  mercury  or  of  iodide  of  potassium,  according  to 
the  circumstances  of  the  case,  will  be  imperative!}-  called  for  ;  while  in 
others  iron,  or  quinine,  or  bromide  of  potassium,  or  cod-liver  oil,  may 
be  the  more  appropriate  remedies.  It  may  be  laid  down  as  a  general 
principle  that,  Avhen  the  disease  is  spreading  over  the  cornea  notwith- 
standing the  administration  of  any  of  the  latter,  they  should  be  experi- 
mentall}'  laid  aside  in  favor  of  an  anti-syphilitic  medication  ;  and  also 
that  the  surgeon  should  not  persevere  too  long  in  any  plan  which  does 
not  appear  to  be  beneficial,  but  should  reconsider  the  whole  case  with  a 
view  to  more  effectual  action. 

Iridectomy. — When  the  inflammation  extends  in  spite  of  all  treatment, 
and  covers  the  central  portions  of  the  cornea  with  vessels,  or  even  with 
the  turbidit}-  precursory  to  the  advancing  vascular  crescents,  iridectomy 
should  be  performed  in  a  direction  inwards  and  a  little  downwards. 
The  operation  appears  to  exercise  a  distinctly  controlling  eff'ect  over  the 
course  of  the  malady,  and  it  leaves  a  lateral  pupil  through  which,  as  the 
opacity  of  the  cornea  diminishes,  vision  will  be  obtained  long  before  the 
central  parts  are  clear. 

Treatment  of  the  residual  Corneal  Opacity. — When  the  progress  of 
the  disease  is  arrested,  the  disappearance  of  the  new  vessels  leaves  the 
parts  which  they  occupied  in  a  state  of  peculiarly  dense  opacity.  As 
soon  as  the  stage  of  progressive  increase  is  over,  and  that  of  decline  has 
commenced,  the  atropine  and  the  closure  of  the  eyelids  ma}"  be  discon- 
tinued, and  the  cold  compresses  may  be  replaced  by  hot  fomentations, 
which  will  tend  to  diminish  the  density  of  the  opacity  by  promoting 
absorption  and  tissue-change.  During  the  period  of  recovery  and  of 
convalescence  tlie  general  treatment  must  be  continued,  and  the  health 
of  the  patient  promoted  by  suitable  air,  exercise,  and  habits  of  life. 
When,  all  inflammatory  action  has  ceased  the  absorption  of  residual 
opacity  may  often  be  greatly  promoted  by  injecting  under  the  conjunctiva 
a  few  minims  of  a  solution  containina:  ten  o-rains  of  common  salt  to  an 


704  DISEASES    OF    THE    EYE. 

ounce  of  water.  The  injection  may  be  made  with  an  ordinary  h3'po- 
derraic  S3'ringe  (a  fold  of  conjunctiva  being  pinched  up  with  forceps  to 
allow  the  neinlle-point  to  pass  freely  between  that  membrane  and  the 
sclerotic),  and  it  may  be  repeated  ever}-  fortnight  or  three  weeks.  If 
iridectomy  has  not  been  performed  during  the  acute  stage  it  will  often 
be  required  afterwards,  on  account  of  the  more  rapid  clearing  of  the 
marginal  parts  of  the  cornea,  for  the  restoration  of  vision  at  an  earlier 
period  than  by  natural  processes,  or  even  on  account  of  the  central  parts 
of  the  cornea  being  altered  in  curvature  b}'  the  disease.  Such  alteration 
may  be  of  two  kinds,  flattening  from  the  shrinkage  of  the  effused  mate- 
rial, or  increased  convexity  from  the  general  yielding  of  the  softened 
membrane  to  the  intraocular  tension.  From  its  long  duration,  and  from 
the  character  and  permanence  of  the  changes  which  it  ma}'  produce, 
severe  vascular  keratitis  is  a  most  formidable  affection,  and  one  which 
can  hardly  be  too  carefull^y  treated  in  its  incipient  stages,  so  that,  if 
possible,  it  may  be  arrested  before  the  i^art  of  the  cornea  directly  con- 
cerned in  vision  is  involved. 

Interstitial  keratitis  is  the  form  of  inflammation  of  the  cornea  which 
occurs  in  children  and  3-oung  persons  who  are  the  subjects  of  inherited 
s^'philis.  It  was  first  accuratel}-  studied,  and  its  specific  character  made 
known,  by  Mr.  Jonathan  Hutchinson,  who  has  described  it  in  the  follow- 
ing words : 

"  Chronic  interstitial  keratitis  usually  commences  as  a  diffuse  haziness 
near  the  centre  of  the  cornea  of  one  eye.  There  is  at  this  stage  no 
ulceration,  and  exceedingl}-  slight  evidence  of  the  congestion  of  any 
tunic.  The  patient,  however,  almost  always  complains  of  some  irrita- 
bility of  the  e^'e,  as  well  as  of  dim  sight.  If  looked  at  carefull}^  the  dots 
of  haze  are  seen  to  he  in  the  structure  of  the  cornea  itself,  and  not  on 
either  surface ;  the}^  are  also  separate  from  each  other,  like  so  many  mi- 
croscopic masses  of  fog.  In  the  course  of  a  few  weeks,  or  it  may  be 
more  rapidly,  the  whole  cornea,  excepting  a  band  near  its  margin,  has 
become  densely  opaque  by  the  spreading  and  confluence  of  these  inter- 
stitial opacities.  Still,  however,  the  greater  density  of  certain  parts — 
centres,  as  it  were,  of  the  disease — is  clearl}'  perceptible.  Early  in  this 
stage  the  comparison  to  ground-glass  is  appropriate.  There  is  now 
almost  always  a  zone  of  sclerotic  congestion,  and  more  or  less  intoler- 
ance of  light,  with  pain  around  the  orbit.  After  from  one  to  two  months 
the  other  cornea  is  attacked  and  goes  through  the  same  stages,  but  rather 
faster  than  the  first.  A  period  in  which  the  patient  is  so  far  blind  that 
there  is  but  bare  perception  of  light  now  often  follows,  after  which  the 
eye  first  affected  begins  to  clear.  In  the  course  of  a  year  or  eighteen 
months  a  very  surprising  degree  of  improvement  has  probabl}'  taken 
place.  In  milder  cases,  and  under  suitable  treatment,  the  duration  may 
be  very  much  less  than  this,  and  the  restoration  to  transi^arenc}'  com- 
plete, but  in  man}'  instances  patches  of  haze  remain  for  years,  if  not  for 
life.  In  the  worst  stage  the  corneal  surface  looks  slightly  granular,  and 
from  the  very  beginning  it  has  lost  its  polish,  and  does  not  reflect  images 
with  definite  outlines.  In  certain  cases,  after  the  ground-glass  stage  is 
passed,  a  yet  more  severe  one  ensues,  in  which  the  wliole  structure  of 
the  cornea  becomes  pink  or  salmon-colored  from  vascularity,  and  in  these 
crescentic  fringes  of  vessels  are  often  noticed  at  its  circumference.  In 
the  best  recoveries  tiie  eye  usually  remains  somewhat  damaged  as  to 
vision,  and  often  a  degree  of  abnormal  expansion  of  the  cornea,  is  ap- 
parent.    Only  in  one  or  two  cases  have  I  ever  observed  ulcers  of  distin- 


SUPPURATIVE    KERATITIS.  705 

guisliable  size  on  the  surface  of  the  cornea,  and  T  have  scarcely  ever  seen 
pustules  on  any  part  of  it." 

Gharactem  of  Inherited  Sy])hili^. — Mr.  Hutchinson  has  also  described 
the  facial  and  other  characteristics  by  which  the  subjects  of  inherited 
syphilis  may  be  known,  and  the  most  imiiortant  of  these  characteristics 
is  a  peculiar  malformation  of  tlie  teeth,  and  especially  of  the  two  central 
permanent  incisors  of  the  upper  jaw,  which  are  bounded  laterally  by 
curved  outlines  with  their  convexMties  outward,  and  present  crescentic 
notches  on  their  lower  borders.  The  lateral  incisors  of  the  upper  jaw 
are  often  similarly  deformed,  and  the  incisors  of  the  lower  jaw  misshapen, 
dwarfe<l,  and  "  peggy ;"  but  the  up})er  central  incisors  are  those  in  which 
the  peculiar  shape  may  be  regarded  as  pathognomonic.  Together  with 
the  altered  teeth  there  is  often  a  peculiar  flattened  or  almost  concave 
physiognomy,  arising  from  projection  of  the  frontal  eminences  and  im- 
perfect development  of  the  nose,  the  alsE  of  which,  as  well  as  the  angles 
of  the  mouth,  are  frequently  seamed  by  cicatrices.  The  complexion  is 
earthy  and  peculiar,  the  frame  often  stunted,  the  whole  aspect  withered 
and  prematurely  senile.  In  such  children  the  interstitial  keratitis  usually 
makes  its  appearance  at  about  the  tenth  year  of  age — sooner  or  later, 
according  to  the  degree  of  the  inherited  taint;  and,  where  this  degree  is 
slight,  the  keratitis  may  be  postponed  even  until  adult  age,  or  until  it  is 
developed  by  circumstances  which  affect  the  health  injuriously. 

TreaimeiU. — The  general  treatment  of  interstitial  keratitis  is  that  of  a 
chronic  syphilitic  affection,  which  requires  mercury,  or  perhaps  iodide  of 
potassium,  combined  with  tonics  and  wholesomie  living.  The  perchloride 
of  mercury  is,  perhaps,  the  best  preparation,  and  it  may  be  combined 
with  perchloride  of  iron  and  with  cod-liver  oil.  After  a  time  it  may  be 
laid  aside  for  iodide  of  potassium,  or  given  alternately  with  it,  and  this 
salt  may  be  combined  with  the  ammonio-citrate  of  iron.  The  local  treat- 
ment must  be  entirely  of  a  soothing  character.  Atropine  should  be  ap- 
plied, either  in  the  usual  watery  solution  or  dissolved  in  castor  oil ;  strict 
rest  of  the  e^'es  should  be  enjoined,  and  they  should  be  protected  from 
strong  light,  heat,  dust,  and  cold  winds.  If  any  irritant  is  api)lied  to 
them  there  will  be  great  danger  of  the  development  of  an  acute  vascular 
keratitis,  which  will  often  be  attended  by  iritis.  If  any  intolerance  of 
light  should  occur  under  proper  treatment  it  will  call  for  a  short  period 
of  confinement  to  a  darkened  chamber,  and  for  frequent  bathing  with 
cold  water.  It  is  always  proper  to  warn  friends  and  parents,  at  the  be- 
ginning, of  the  constitutional  character  of  the  malady,  of  its  chronicity, 
and  of  the  high  probability  that  the  second  eye  will  be  attacked  subse- 
quently to  the  first ;  but  it  will  seldom  be  desirable  to  raise  the  question 
of  sypliilis.  With  due  care  as  to  what  is  avoided,  as  well  as  to  what  is 
done,  the  prognosis  may  in  nearly  all  cases  be  favorable. 

Su'P'puralive  Key-atitia. — The  suppurative  or  destructive  form  of  kera- 
titis may  commence  in  tiie  anterior  layers  of  the  membrane,  producing 
ulcer,  or  in  the  central  layers,  producing  abscess.  Abscess  of  the  cornea 
appears  as  a  circumscribed  opaque  spot,  originally  of  a  grayish  color, 
attended  by  hyperajmia  of  the  conjunctiva,  usually  with  slight  encroach- 
ment of  vessels  upon  the  corneal  margin,  by  a  good  deal  of  neuralgic 
pain,  not  only  in  the  eye  but  in  and  around  the  orbital  region  geneially, 
and  by  impairment  of  sight  corresponding  to  the  size,  the  color,  and  the 
situation  of  the  opacit}'.  The  encroachment  of  vessels  is  not  in  crescents, 
as  in  vascular  keratitis,  but  is  either  all  round  the  margin  or  else,  when 
the  opacity  is  eccentric,  at  the  part  of  the  margin  to  which  it  is  nearest. 

45 


706  DISEASES    OF    THE    EYE. 

The  opacity  itself  is  often  very  tender  to  the  touch  of  a  [)robe;  and,  es- 
pecially in  patients  past  middle  age,  there  is  often  a  good  deal  of  consti- 
tutional disturl)ance.  As  the  case  progresses,  the  color  of  the  centre  of 
the  opacity  changes  from  gray  to  a  pus-yellow,  and  the  pus  may  either 
separate  tlie  laminje  and  gravitate  between  them,  forming  the  condition 
called  *'onyx;"  or  it  may  discharge  itself  externally,  leaving  an  ulcer; 
or  it  may  discharge  itself  internally  into  the  anterior  chamber,  forming 
there  a  collection  known  as  "  hypopyon." 

Tlircatcned  Ahxecas  of  Cornea. — When  abscess  of  the  cornea  is  only 
threatened,  the  objects  of  treatment  are  to  prevent  the  formation  of  pus 
and  to  procure  resolution.  When  pus  is  actually  formed  the  object  is  to 
permit  its  discharge  with  the  least  possible  injury  to  the  corneal  tissue. 
The  abscess  usually  resembles  a  boil  in  its  essential  characters,  the  sup- 
puration being  due  to  the  formation  of  a  core  or  slough,  and  the  pus  of 
hypopyon  is  often  of  a  firm  and  tenacious  consistence. 

Treatment. — In  order  to  prevent  or  to  limit  suppuration,  the  ordinaiy 
requirements  are  atropine,  rest,  and  shelter,  together  with  such  local  and 
general  treatment  as  the  state  of  the  patient  may  demand.  If  there  is 
active  local  congestion,  with  elevation  of  temperature,  a  leech  may  be 
applied  just  outside  the  orbital  margin,  near  the  outer  canthus,  and  cold 
or  iced  compresses  over  tlie  closed  lids  ;  while,  if  there  is  a  more  passive 
state  of  tlie  circulation,  hot  fomentations  may  be  advisable.  If  the  tongue 
is  at  all  foul,  or  if  the  bowels  are  loaded,  a  purgative  should  be  given  ; 
and  this  should  generally  be  followed  by  some  active  tonic,  such  as  iron 
or  quinine,  or  both  in  combination.  If,  notwithstanding  treatment,  the 
local  pain  continues,  and  the  centre  of  the  opacity  assumes  a  yellow 
color,  which  indicates  the  presence  of  pus,  the  abscess  should  be  opened 
without  delay.  For  this  purpose,  if  the  purulent  deposit  is  near  the  an- 
terior surface  of  the  cornea,  a  cut  may  be  made  through  this  surface  with 
the  point  of  a  cataract  knife  ;  and,  if  the  pus  appears  to  be  nearer  to  the 
posterior  surface  of  the  cornea,  a  fine  flat  two-edged  needle  may  be 
passed  into  the  anterior  chamber  from  near  the  corneal  margin,  and  its 
point  made  to  enter  the  cavity  of  the  abscess.  When  this  course  is 
adopted  a  probe  should  be  introduced  into  the  external  wound  after  the 
needle  is  withdrawn,  as  in  paracentesis,  to  permit  the  complete  escape  of 
the  aqueous  humor  and  of  an}- purulent  matter  which  it  may  contain,  and 
this  should  be  repeated  at  least  once  a  day,  until  the  cavity  of  the  abscess 
is  completely  evacuated  and  healing  has  commenced.  Whether  an  in- 
ternal or  an  external  opening  is  made,  the  eyelids  should  be  separated 
by  a  spring  speculum,  and  the  eyeball  should  be  securely  fixed  by  for- 
ceps, as  witiiout  these  precautions  the  surgeon  would  be  liable  not  onl}'' 
to  open  the  abscess  but  also  to  divide  the  whole  thickness  of  the  cornea, 
a  proceeding  which  it  is  one  of  the  objects  of  an  early  incision  to  avoid. 

Extended  Suppuration. — When  an  early  incision  has  not  been  prac- 
ticed the  limits  of  the  al»scess  may  extend  themselves  by  separation  of 
the  corneal  lamina?,  in  which  case,  however,  the  general  tendency  of  the 
pus  will  ])(;  to  gravitate  downwards  towards  the  lower  margin,  where  it 
has  been  called  "  onyx,"  from  a  fancied  resemblance  to  the  lunula  at  the 
base  of  a  finger-nail.  It  is  not  always  easy  at  first  sight  to  distinguish 
onyx  from  hypojjyon,  or  pus  in  the  anterior  chamber,  but  the  point  may 
generally  be  determined  by  an  examination  of  the  eye  in  profile;  and, 
when  seen  from  the  front,  the  diagnosis  rests  upon  obvious  physical 
characters.  The  pus  of  an  onyx,  supported  by  the  corneal  laminjie,  may 
have  an  irregular  or  convex  superior  boundary,  while  that  of  an  hypopyon 
must  have  a  level  and  horizontal  superior  boundary,  except  that  when 


ULCERATION    OF    THE    CORNEA.  707 

very  small  in  amount  it  may  be  a  mere  crescentic  line  along  the  lower 
margin  of  the  anterior  chaml)er.  In  the  case  of  onyx  the  wider  extension 
of  the  pus  is  only  an  additional  reason  for  its  evacuation  before  it  has 
had  time  to  do  more  mischief,  and  it  should  generall}^  be  let  out  through 
the  external  surface.  When  pus  has  escaped  from  the  cornea  into  the 
anterior  chamber  it  will  often,  in  the  case  of  children,  be  absorbed  with- 
out doing  mischief;  but  in  adults,  and  especially  in  persons  past  middle 
age,  it  is  apt  to  set  up  acute  iritis,  and  greatly  to  aggi-avate  the  pre-exist- 
ing conditions.  In  such  persons  the  pus  should  be  immediately  evacuated 
by  a  free  incision  into  the  anterior  chamber,  from  which,  if  coherent,  it 
should  be  removed  with  forceps;  and  at  the  same  time,  if  iritis  has  com- 
menced, a  large  piece  of  iris  should  be  excised.  The  incision  should 
always  be  so  placed  that  the  iridectomy,  if  required,  may  be  behind  a 
clear  part  of  the  cornea,  so  that  it  will  be  useful  as  an  artificial  pupil  if 
the  opacity  left  by  the  abscess  should  obscure  the  natural  one. 

Acute  Ulcer  of  the  Cornea. — When  abscess  of  the  cornea  discharges 
itself  internalh^  it  does  so  in  most  instances  by  a  minute  fistulous  track, 
which  can  often  be  seen  as  a  faint  white  line  leading  downwards  from 
the  original  depot.  But  when  it  discharges  itself  externally  the  whole 
of  the  corneal  tissue  in  front  of  the  abscess  usually  perishes,  leaving  an 
ulcer  of  corresponding  extent.  Such  an  ulcer,  when  fully  formed,  is  not 
distinguishable  from  one  in  which  the  process  of  disintegration  has  com- 
menced upon  the  surface,  either  without  apparent  cause  or  as  the  result 
of  injury.  Traumatic  ulcers  of  the  cornea  are  most  frequent  in  old 
people,  in  whom  wounds,  instead  of  undergoing  speedy  repair,  take  on 
sloughing  action  ;  and  they  are  most  common  among  men  who  are  em- 
ployed in  trimming  hedges  or  in  cutting  down  copse-wood,  and  who  are 
very  liable  to  be  struck  upon  the  eye  by  a  twig  or  thorn.  However  oc- 
casioned, corneal  ulcers  differ  much  in  their  rate  of  progress  ;  but  the^^ 
present  three  chief  types,  in  the  first  of  which  there  is  a  very  rapid  dis- 
integration of  tissue,  the  floor  and  edges  of  the  ulcer  remaining  trans- 
parent, or  nearly  so.  In  the  second,  in  which  the  disintegration  is  less 
rapid,  the  floor  and  margins  of  the  ulcer  are  turbid,  a  certain  amount  of 
effusion  or  cell-proliferation  surrounding  and  anticipating  the  destructive 
process.  In  the  third,  vessels  are  seen  running  across  the  cornea  to  the 
margin  of  the  ulcer,  and  these  vessels  indicate  the  commencement  of  the 
repair  for  which  they  convey  the  nutritive  materials.  In  ulcers  of  the 
first  type  the  appearance  of  turbidity  around  the  margin  is  the  first  in- 
dication of  the  commencement  of  the  healing  process,  and  to  this,  if  the 
progress  of  events  is  favorable,  the  development  of  vessels  is  soon  super- 
added. 

Their  Situation  and  Progren^. — The  situation  of  corneal  ulcers  differs 
much  in  diflTerent  cases,  but  when  they  occur  independently  of  injury 
the}'^  are  most  frequent  in  the  lower  half  of  the  cornea,  which  is  not  under 
the  shelter  of  either  lid.  When  traumatic,  the  locality  of  their  occur- 
rence is  necessarily  that  of  the  injury,  and  there  is  a  form  of  spontaneous 
ulcer  which  cuts  out  a  circular  groove  around  the  margin  of  the  membrane, 
and  trephines,  so  to  speak,  its  central  portion.  Another  form  of  ulcer, 
which  Prof.  Saemisch  has  thought  worthy  of  the  special  designation  of 
"creeping"  (ulcus  serpens),  is  described  by  him  as  extending  itself  in 
one  direction  only,  so  that  in  section  its  outline  would  be  precipitous  on 
one  side  and  sloping  down  to  the  uninjured  tissue  on  the  other.  The  ill 
effects  of  corneal  ulcers  depend  partly  on  their  superficial  extent,  partly 
on  their  tendency  to  perforate.  The  lost  tissue  is  never  reproduced,  but 
is  replaced  by  an  opaque  cicatrix,  which  undergoes  gradual  contraction, 


708  DISEASES    OF    THE    EYE. 

SO  that,  in  proportion  to  the  size  of  the  ulcer,  there  will  be  an  nnsightly 
white  spot  and  a  flattening  of  the  corneal  curvature.  In  proportion  to  the 
depth  of  the  ulcer  will  be  the  loss  of  power  of  its  floor  to  resist  the  pres- 
sure of  the  intraocular  tension,  and  hence  the  floor  will  become  convex 
and  prominent,  and  will  ultimately  yield,  and  permit  the  escape  of  the 
aqueous  humor  and  the  contact  of  the  iris  with  tlie  perforation.  The 
structureless  lining  membrane  of  the  cornea  (membrane  of  Descemet)  is 
never  destroyed  by  ulceration,  and  if  it  is  allowed  to  burst,  its  shreds 
may  line  the  sides  of  tlie  opening  in  such  a  manner  as  to  prevent  their 
adhesion,  and  to  occasion  the  formation  of  a  troublesome  fistula.  Unless 
this  sliould  occur  the  perforation  of  an  ulcer  is  near!}'  always  the  end  of 
the  destructive  stage,  and  the  signal  for  healing  to  commence. 

Cicatrices. — The  cicatrix  which  follows  a  perforating  ulcer  is  formed, 
in  the  first  instance,  by  the  iris,  which  falls  against  the  opening  and 
becomes  adherent  to  it,  and  is  presently  coated  with  effused  lymph,  which 
gradually  becomes  organized  and  forms  a  cicatricial  tissue  through  which 
the  color  of  the  foundation  of  the  iris  can  be  seen.  If  the  opening  is  very 
large,  as  when  the  whole  or  the  greater  part  of  the  centre  of  the  cornea 
is  destroyed,  the  resulting  cicatrix  has  a  bluish,  serai-transparent  aspect, 
and,  by  reason  of  its  want  of  firmness,  a  tendenc}'  to  bulge  under  the 
pressure  of  the  ocular  muscles.  The  resulting  protrusion,  from  some 
fancied  resemblance  to  a  grape,  was  called  "staphyloma"  by  old  writers, 
and  the  name  may  be  looked  upon  as  established  l)y  long  usage.  A  staphy- 
loma tends  to  increase  by  gradually  undergoing  extension,  and  by  talking 
up  into  itself  any  margin  of  sound  cornea  by  which  it  may  be  surrounded, 
until  it  often  becomes  very  large  and  unsightly.  When  the  perforating 
ulcer  is  small  the  resulting  cicatrix  may  be  a  mere  dot,  with  less  tendency 
to  contraction  than  it  would  have  if  formed  entirelj^  of  corneal  tissue  ;  and 
when  the  ulcer  is  of  middle  size  the  cicatrix  may  incline  to  either  of  the 
foregoing  characters.  It  may  be  firm  and  strong,  maintaining  its  level 
and  leaving  the  other  parts  of  the  eye  only  little  injured;  or  it  may  be 
weak  and  distensible,  inclined  to  increase  in  size  at  the  expense  of  the 
remaniing  parts  of  the  cornea.  In  the  latter  case  it  is  often  called  a 
"partial"  staphyloma. 

Tt'eatment. — The  principles  of  treatment,  in  all  forms  of  corneal  ulcer, 
are  to  arrest  the  destructive  stage  and  to  promote  the  commencement 
and  progress  of  repair,  to  support  the  cicatrix  against  the  tension  of  the 
muscles,  and  to  aid  in  its  consolidation,  and  eventually,  as  far  as  may  be 
either  necessary  or  practicable,  to  improve  vision  and  to  conceal  dis- 
figurement. 

For  the  fulfilment  of  the  first  of  these  indications  it  is  necessary  to 
obtain  repose  of  tiie  si)hincter  of  the  pupil  and  of  the  muscle  of  accom- 
modation by  atropine,  to  prevent  friction  of  the  lids  by  a  well-applied 
com])ressive  bandage,  to  promote  vascular  development  by  the  emi)loy- 
ment  of  hot  fomentations,  and  to  sustain  the  general  nutrition  by  suit- 
able diet  and  l)y  the  use  of  stimulants  and  tonics.  If,  in  spite  of  these 
precautions,  the  ulcer  should  deej)en  ami  extend,  it  is  proper  to  antici- 
pate perforation,  and  to  bring  about  the  healing  by  which  it  is  followed, 
by  means  of  an  artificial  opening.  If  perforation  is  imminent,  and  the 
membrane  of  Descemet  is  actually  bulging  through  the  floor  of  the  ulcer, 
it  may  l)e  rui)tured  by  thrusting  a  probe  oblicpicly  through  the  promi- 
nence into  the  anterior  chamber,  so  carefully  as  to  run  no  risk  of  wound- 
ing the  lens,  and  so  as  to  direct  the  shreds  of  the  torn  membrane  inwards, 
and  to  prevent  them  fir)m  lining  the  ai)erture.  Tint  in  most  cases  the 
artificial  opening  slioniil  be  made  at  an  earlier  period.     Prof.  Saemisch 


TREATMENT    OF    STAPHYLOMA.  709 

has  advocated  the  division  of  the  floor  of  the  ulcer  by  transfixing  the 
cornea  with  a  linear  cataract  knife  and  then  cutting  outwards  through  the 
intervening  tissue;  tlie  lips  of  the  wound  to  be  sei)arated  daily, .for  the 
first  few  days,  by  means  of  a  probe  or  other  suitable  blunt  instrument. 
My  own  experience  is  not  favorable  to  this  plan,  which  in  my  hands  has 
produced  weak  and  irritable  cicatrices,  and  I  much  prefer  the  performance 
of  iridectomy,  the  piece  of  iris  excised  being  behind  the  broadest  part 
of  clear  cornea,  where  the  resulting  artificial  pupil  is  most  likel}'  to  be 
useful  for  purposes  of  vision.  In  some  cases  I  have  seen  an  iridectomy, 
almost  or  altogether  without  other  treatment,  check  the  progress  of  an 
ulcer  and  lead  to  favorable  healing.  When  repair  has  commenced,  it 
must  be  remembered  that  the  chief  remaining  danger  is  that  the  cicatrix 
will  yield  to  the  pressure  from  within  and  become  staphylomatous ;  and 
this  must  be  guarded  against  by  a  firmly  applied  compressive  liandage, 
worn  not  only  until  healing  is  complete,  but  also  until  a  certain  amount 
of  consolidation  of  the  cicatrix  has  taken  place.  If  the  scar  constitutes 
a  conspicuous  deformit}',  which  is  either  disfiguring  in  ai)pearance  or 
likely  to  be  an  obstacle  in  the  way  of  the  patient's  prospects  in  life,  it 
may  be  almost  entirely  concealed  by  being  carefully  tattooed  with  Indian 
ink,  which  must  be  mixed  with  water  to  a  creamy  consistency,  and  then 
pricked  into  the  mark  by  repeated  punctures  with  a  fine  needle.  If  vision 
Is  much  impaired,  and  if  iridectomy  has  not  been  performed,  or  has  been 
performed  in  an  unsuitable  position,  an  artificial  pupil  may  be  made 
behind  a  selected  part  of  the  cornea;  but  neither  the  artificial  pupil  nor 
the  tattooing  should  be  attempted,  as  a  rule,  for  six  months  after  the 
formation  of  the  cicatrix. 

Trealment  of  Complete  Staph  ijloma.- — When  a  corneal  ulcer  produces 
complete  staphyloma,  the  prominence  is  often  painful  as  well  as  unsightly; 
and  it  is  usually  desirable  to  remove  it,  in  order  to  make  room  for  an 
artificial  eye.  Enucleation  of  the  eyeball  should  not  be  practiced  in  these 
cases,  but  the  portions  posterior  to  the  ciliary  body  should  be  left,  in 
order  to  aflfbrd  a  better  foundation  for  the  artificial  eye  than  can  be 
obtained  from  the  muscles  alone.  The  original  operation  for  staphyloma 
consisted  simply  in  shaving  off  the  projection  with  a  Beer's  cataract  knife, 
the  gaping  wound  being  left  to  close  in  its  own  time.  Mr.  Critchett 
improved  on  this  method  by  inserting  three  or  four  semicircular  threaded 
needles  behind  the  projection,  then  cutting  it  off,  drawing  the  needles 
through  and  tying  the  threads,  so  as  to  obtain  prompt  union  "in  a  hori- 
zontal line.  Other  surgeons  have  passed  sutures  through  the  conjunctiva 
onl}^;  but  the  union  thus  produced  is  apt  to  be  feeble,  and  I  have  seen 
Mr.  Critchett's  operation  followed  by  sympathetic  ophthalmia  of  the 
remaining  eye,  probably  because  a  ciliary  nerve  was  lacerated  by  one  of 
the  needles.  The  plan  which  I  prefer  is  to  divide  the  conjunctiva  all 
round,  close  to  the  margin  of  the  staphyloma,  and  to  dissect  it  from  the 
sclerotic  nearly  to  the  equator;  then  to  detach  the  four  recti  muscles,  and 
to  cut  off  the  front  portion  of  the  eyel)all,  well  behind  the  ciliary  region. 
The  superior  and  inferior  recti  should  then  be  united  in  front  of  the  wound 
by  a  catgut  suture,  and  the  internal  and  external  recti  in  front  of  them  ; 
and  the  conjunctival  incision  should  be  brought  together  in  a  horizontal 
line  by  silk  sutures.  The  resulting  stump  is  of  good  size  and  very  mobile, 
so  that  an  artificial  eye  placed  upon  it  will  scarcely  betray  itself  even  to 
a  not  wholly  unskilled  observer. 

IVeatmenf  of  Partial  Staphyloiua. — The  formation  of  a  partial  staphy- 
loma, instead  of  a  firm  cicatrix,  is  generally  due  to  neglect  of  support 
during  the  healing  process,  or  to  its  premature  abandonment.    An  attempt 


710  DISEASES    OF    THE    EYE. 

ma^-  be  made,  in  such  cases,  to  check  yiehling  by  a  large  iriclectomy 
(which  will  diminish  pressure  from  within)  and  by  renewed  and  per- 
severing bandaging;  but  in  the  majority  of  cases  the  protrusion  will  in- 
crease, will  take  up  into  itself  more  and  more  of  the  cornea,  and  will 
become  irritable  or  painful,  and  threatening  to  the  sound  eye.  Under 
such  circumstances,  even  although  some  imperfect  vision  may  remain,  it 
is  best  to  treat  the  case  as  if  the  staphyloma  were  complete,  and  to  remoA'e 
the  diseased  parts  by  one  of  the  operations  last  described. 

Conical  Cornea. — The  only  other  affection  of  the  cornea  which  requires 
description  in  these  pages  is  the  malformation  which  is  known  as  "  conical 
cornea."  This  is,  in  etfect,  an  atrophy  of  the  central  portion  of  the  mem- 
brane, wiiich  becomes  thinned  and  weakened,  loses  its  natural  curvature, 
and  projects  as  an  obtusely  pointed  prominence.  When  seen  in  profile  the 
distortion  of  shape  is  ver^-  apparent ;  and  when  seen  from  the  front  it  has 
a  curious  pellucid  appearance,  almost  as  if  a  drop  of  some  highl}-  refract- 
ing liquid  were  adherent  to  the  corneal  surface.  When  the  prominence 
attains  large  dimensions  its  apex  loses  the  protection  of  the  lids,  and  is 
exposed  to  many  sources  of  irritation,  so  that  it  often  loses  its  trans- 
parency, and  becomes  cloudy  and  opaque.  When  once  established,  coni- 
cal cornea  tends  to  progressive  increase  under  the  pressure  of  the  recti 
muscles,  and  it  soon  becomes  highlj^  disturbing  to  vision.  On  account 
of  the  elongation  of  the  eyeball  it  produces  a  high  degree  of  myopia,  or 
near  siglit ;  and,  on  account  of  the  irregularity  of  the  elevation,  this  near 
sight  cannot  l)e  materially  assisted  by  any  concave  lens.  AVhenever  near 
sight  is  attended  by  unusual  diminution  of  the  acuteness  of  vision,  and  is 
not  relieved  by  spectacles,  conical  cornea  should  be  suspected  and  looked 
foD.  In  its  early  stages  it  may  easily  escape  detection  ;  but  Mr.  Bowman 
has  pointed  out  that  it  may  be  easily  discovered  by  an  examination  with 
the  mirror  of  an  ophthalmoscope.  The  area  of  the  pupil  does  not  present 
an  unbroken  circle  of  equal  illumination,  but  some  part  of  the  base  of  the 
prominence  will  appear  to  lie  in  shadow,  and  this  shadow  will  play  around, 
from  side  to  side,  in  response  to  slight  movements  of  the  mirror. 

Treatment. — The  treatment  of  conical  corneals  based  upon  the  ten- 
dency of  an  ulcer  to  flatten  the  curvature  of  the  membrane  during  the 
healing  process.  The  idea  of  utilizing  this  tendency  occurred  first  to 
Yon  Graefe,  who  shaved  olf  the  apex  of  tlie  cone  without  penetrating  the 
anterior  chamber,  cauterized  the  wound  until  he  had  produced  an  ulcer 
of  sufficient  extent,  and  then  promoted  healing.  Otlicr  surgeons  have  cut 
off  the  thinned  central  portion  of  cornea,  and  some  have  united  the  edges 
of  the  incision  by  a  point  of  suture.  Mr.  Bowman  has  contrived  an  iinge- 
nious  trephine  by  which  it  is  possible  either  to  cut  out  a  circular  disk  of 
the  anterior  layer  of  the  cornea,  and  to  peel  this  off,  leaving  the  membrane 
of  Descemet  intact  and  the  anterior  chamber  unopened,  or  to  carry  the 
cut  deeper,  so  as  to  remove  the  whole  tliickness.  My  own  practice  is  to 
transfix  the  apex  of  the  projection  with  a  narrow  two-edged  knife,  so  as 
to  cut  off,  l)y  a  single  thrust,  the  small  portion  of  cornea  which  remains 
in  front  of  the  blade,  and  which  should  seldom  exceed  aline  in  diameter. 
Pi'ior  to  the  operation  the  i)upil  must  he  fully  dilated  by  atroiune,  in 
order  to  i)revent  its  margin  from  becoming  adherent  to  the  cicatrix.  The 
lids  should  l)e  closed  by  a  compressive  bandage,  and  a  liniment  of  glyc- 
erin and  belhulonna  api)li(!d  to  tlie  brow,  so  as  to  maintain  dilatation. 
When  the  case  progresses  favoial)ly  tiie  result  will  l)e  a  firm  central  cica- 
trix, which  will  restore  the  cornea  to  normal  curvature,  or  nearly  so,  and 
will  arrest  the  further  increase  of  the  conicity,but  vvliich  is  both  unsightly 
and  an  obstacle  in  the  way  of  vision.    In  order  to  restore  sight  it  is  neces- 


IRITIS. 


711 


sary  to  make  an  artificial  pupil  behind  some  transparent  part  of  the 
cornea  ;  and  the  cicatrix  may  be  concealed  by  tattooing  it  with  Indian  ink 
in  the  manner  already  described. 

DiseaseH  of  the  Iris. — The  iris  is  liable  to  be  the  seat  of  tumors  or  cysts 
of  various  kinds,  which,  when  tiiey  are  increasing,  may  produce  destruc- 
tive changes  in  the  eyeball  by  their  pressure  upon  the  lens  and  ciliary 
body,  by  projecting  into  the  pupillary  space,  and  by  general  interference 
with  the  circulation  and  nutrition,  and  which  should  be  completely 
removed,  together  with  the  portion  of  iris  on  which  they  are  seated,  as 
soon  as  their  character  is  declared,  and  before  they  have  attained  suffi- 
cient magnitude  to  be  seriously  injurious.  Many  endeavors  have  been 
made  to  destroy  cysts  by  simple  laceration  ;  but  these  endeavors  have 
scarcely  ever  been  successful,  and  have  sometimes  set  up  inflamn*iation  of 
a  destructive  character.  When  any  morbid  growth  of  the  iris  has  been 
removed,  it  should  be  made  the  subject  of  careful  microscopic  examina- 
tion ;  and,  if  it  appears  to  be  malignant,  enucleation  of  the  eyeball  should 
generally  be  recommended. 

Goloboma. — The  iris  is  also  liable  to  a  congenital  malformation  by  de- 
ficiency, usually  in  a  direction  downwards.  The  resulting  gap  is  called  a 
coloboma,  and  may  vary  in  extent  from  a  mere  notch  in  the  margin  of  the 
pupil  to  a  loss  of  substance  which  may  extend  tlirough  the  ciliary  body 
and  choroid  to  the  border  of  the  optic  nerve.  Coloboma  may  affect  either 
one  or  both  eyes  ;  and,  as  usually  seen,  it  almost  precisely  resembles  the 
effect  of  an  iridectomy. 

Iritis. — The  most  important  disease  of  the  iris,  and  also  one  of  the 
most  common  of  the  affections  of  the  eye,  is  inflammation  of  the  substance 
of  the  membrane,  or  iritis.  Iritis  is  seen  under  two  chief  forms,  the  plastic 
and  the  serous,  of  which  the  first  named  is  much  the  more  frequent. 
Plastic  iritis,  in  its  earl}^  stages,  is  liable  to  be  mistaken  for  simple  inflam- 
mation of  the  conjunctiva,  from  which  it  may  be  distinguished  by  three 
chief  signs,  namely,  that  there  is  always  some  loss  of  lustre  of  the  iris, 
some  impairment  of  vision,  and  some  congestion  of  the  zone  of  fine 
sclerotic  vessels  which  surrounds  the  cornea,  so  that  the  pressure  of  the 
finger  through  the  eyelid  does  not  leave  a  perfectly  white  track  behind. 
In  every  case  of  apparentl}"  trivial  conjunctivitis,  it  is  ne(!essary  to  ascer- 
tain the  absence  of  iritis  with  scrupulons  care,  because  the  astringent 
lotion  which  would  cure  the  former  affection  would  be  certain  to  stimu- 
late the  latter  to  greatly  increased  activity. 

The  early  progress  of  iritis  is  somewhat  rapid,  and,  as  a  rule,  when  a 
case  comes  before  the  surgeon  the  diagnosis  is  no  longer  doubtful.  In 
addition  to  the  symptoms  already  mentioned  the  iris  will  appear  dull  and 


Effects  of  atropine  in  iritis. 

discolored,  in  consequence  of  discoloration  of  the  aqueous  humor  in  front 
of  it,  and  the  movements  of  the  pupil  in  response  to  variations  of  light 
will  be  sluggish,  or  even  altogether  arrested.  In  order  to  determine  this 
point  the  sound  eye  should  be  effectually  covered,  and  then  tlie  surgeon, 
without  touching  the  affected  one,  should  shade  it  with  his  hand,  removing 


712  DISEASES    OF    THE    EYE. 

and  replacing  the  hand  two  or  three  times,  and  carefully  watching  the 
pupillar}'  margin.  If  expansion  and  contraction  should  not  take  place,  a 
drop  of  solution  of  atropine  should  lie  applied  to  the  lining  membrane 
of  the  lower  lid,  and  this,  in  most  instances,  will  bring  to  light  irregu- 
larity of  the  pupil,  showing  that  it  is  iu  i)oints  adherent  to  the  surface  of 
the  crystalline  lens,  and  that  it  can  only  dilate  in  the  intervals  between 
such  adhesions,  and  in  some  such  manner  as  that  which  is  shown  in  the 
preceding  diagrams.  A  deceptive  resemblance  to  iritis  is  produced  in  some 
cases  of  turbidity  of  the  cornea;  but  if  a  drop  of  four-grain  solution  of 
atropine  produces  complete  dilatation  of  the  pupil  within  twenty  minutes 
or  so,  it  may  be  concluded  that  no  iritis  is  present;  and,  on  the  other 
hand,  the  appearance  of  points  of  adhesion  establishes  the  diagnosis  of 
iritis  with  certaint}'.  Tlie  only  exception  would  be  in  a  case  in  which  the 
adhesions  had  been  left  behind  b}-  some  former  attack,  and  in  which  the 
condition  actually  present  might  be  simple  conjunctivitis  or  keratitis. 

Caui^es. — The  causes  of  iritis  are  very  numerous ;  but  the  malad}'  is  so 
frequent  an  attendant  upon  the  earlier  stages  of  secondary  syphilis  that 
the  syphilitic  forms  have  rather  eclipsed  others,  and  the  first  question 
which  presents  itself  in  any  case  of  iritis,  is  whether  it  should  be  attributed 
to  a  syphilitic  origin.  Rheumatism  is  another  dyscrasia  which  involves 
a  special  liability  to  iritis  ;  and  the  disease  also  occurs  in  connection  with 
overwork,  exhaustion,  and  mental  anxiet}'.  It  has  been  said  by  some 
writers  that  the  syphilitic  varieties  of  iritis  present  recognizable  peculi- 
arities, one  of  which  is  the  deposit  of  lymph  in  lumps  or  nodules  upon 
the  surl'ace  of  the  iris  ;  and  there  are,  undoubtedly,  certain  cases  in  which 
such  nodules  are  seen,  in  which  tliey  are  simply  syphilitic  gummata,  and 
in  which  the  attendant  inflammation  is  rather  a  consequence  of  their 
presence  than  a  cause  of  their  formation.  Putting  such  cases  aside, 
writers  are  by  no  means  agreed  touching  the  precise  nature  of  tiie  differ- 
ences which  distinguish  syphilitic  iritis  from  other  forms  ;  and  as  a  matter 
of  fact  it  would  be  very  hard  to  define  syphilitic  iritis  in  any  satisfactory 
manner.  We  cannot  say  that  every  case  of  iritis  which  occurs  in  a  syphi- 
litic person  is  syphilitic,  unless  we  are  prepared  to  affirm  that  s_yphilis 
affords  an  immunity  from  all  the  forms  of  iritis  wliicli  may  occur  in  non- 
syphilitic  })eople.  Practically  speaking,  the  question  is  one  of  little 
moment,  whicli  has  scarcely  any  bearing  either  upon  prognosis  or  upon 
ti'eatment. 

Course. — In  a  few  cases,  in  which  iritis  is  originally  of  great  severity, 
or  in  which  it  has  from  the  first  been  aggravated  by  maltreatment,  it 
displays  a  tendency  to  spread  to  the  ciliary  body  and  to  the  choroid,  and 
to  produce  changes  which  are  speedily  destructive  to  vision,  and  which 
are  followed  by  wasting  of  the  eyeball.  But  in  the  great  majority  of 
instances  the  tendency  of  a  first  attack  is  towards  resolution  and  ultimate 
recovery.  If  lymph  has  been  poured  out  in  large  quantity,  so  as  to  form 
a  continuous  film  over  the  surface  of  the  crystalline  lens,  this  film  may 
be  left  as  a  semitransparent  membrane,  presenting,  according  to  the 
degree  of  its  opacity,  more  or  less  impediment  to  vision,  and  unitrcd  to 
the  pu|)illary  margin  either  at  its  entire  circumference  or  partially. 
Wi)en  the  effusion  has  been  smaller  in  amount,  and  does  not  cover  the 
pupil,  it  will  nevertheless  leave  the  pupillary  margin  adherent  at  certain 
points,  and  in  such  cases  vision  may  be  noruuil.  If  the  adiiesions  occupy 
the  greater  pait  of  the  pupillary  margin,  so  that  they  practically  fix  the 
greater  part  of  the  iris  to  the  lens,  they  may  be  i)roductive  of  no  more 
inconvenienc^e  than  su(!li  as  attends  the  inability  of  the  pupil  to  expand 
under  a  feeble  illuminati<;n,  and  thus  to  compensate  in  some  degree  for 


IRITIS.  713 

a  defifiency  of  li^lit ;  but  if  there  are  only  a  few  scattered  points  of 
adhesion,  so  that  the  pupil  is  generally  mobile,  and  is  constantly  checked 
in  its  attemijts  at  dilatation,  such  adhesions  maintain  a  perpetual  irrita- 
tion, which  is  almost  certain  to  excite  a  second  attack  of  iritis.  Wiien 
this  hai)pens,  still  more  of  the  membrane  is  tied  <lown,  and  its  nutrition 
becomes  seriously  affected.  The  iritis,  under  such  circumstances,  be- 
comes recurrent,  returning  again  and  again  at  variable  intervals,  under 
the  inlluence  of  any  constitutional  indis[)osition  or  any  source  of  local 
irritation.  In  time  it  ties  down  the  whole  of  the  pu|)illary  margin  to  the 
lens,  so  that  the  lens  and  iris  together  form  an  absolute  and  impermeable 
barrier  which  separates  the  anterior  chamber  from  the  deeper  i)arts  of 
the  eye.     This  state  is  called  "exclusion  "  of  the  pupil. 

In  the  natural  condition,  when  the  puijillary  aperture  is  freely  movable, 
its  margin,  when  moderately  contracted,  lies  in  contact  with  the  surface 
of  the  crystalline  lens,  but  loses  this  contact,  on  account  of  the  curvature 
of  the  lens  surface,  as  soon  as  the  pupil  is  dilated.  There  is,  therefore, 
a  free  passage  of  tluid  through  the  pupil;  and  hence  exhalation  through 
the  cornea  jjlays  an  important  part  in  regulating  the  quantity  of  Huid 
which  is  contained  not  only  in  the  anterior  chambei",  but  also  in  the 
deeper  parts  of  the  e3e.  As  soon  as  the  pupil  is  excluded  no  tluid  can 
pass  into  the  anterior  chamber  from  beliind  the  iris ;  and  consequently, 
as  secretion  beliind  the  iris  continues,  accumulation  must  necessarily 
take  place.  Very  soon  after  exclusion  is  complete  the  peripiieral  parts 
of  the  iris  may  be  observed  to  become  prominent,  bulging  forwards 
towards  the  cornea,  and  leaving  the  central  parts  conn)aratively  de- 
pressed. The  eyeball  as  a  whole  becomes  distended  and  hard,  the  in- 
ternal circulation  is  impeded,  the  vitreous  passes  into  a  liquid  condition, 
the  retina  perishes  from  the  combined  effects  of  blood  stasis  and  of  com- 
pression, and  the  eye  is  destroyed  as  an  organ  of  vision.  When  iritis 
leaves  an  adhesion  of  the  pupil  recurrence  of  the  inflammation  is  to  be 
expected  ;  and  recurrent  iritis,  unless  the  chain  of  morl)id  action  can  Ite 
broken,  can  scarcely  have  any  other  termination  tiian  loss  of  sight. 

Treat inenl  of  Iri/is. — It  follows  that  the  chief  object  to  be  kept  in  view, 
in  the  treatment  of  iritis,  is  to  prevent  the  formation  of  adhesions,  or  to 
detach  them  if  they  have  formed  ;  and  that  in  no  case  in  which  adhesions 
are  left  behind,  even  though  all  inflammation  may  have  subsided,  and 
although  vision  may  be  perfect,  can  the  result  be  considered  satisfactory 
or  complete.  In  order  to  bring  about  complete  recovery  it  is  necessar}^, 
first,  to  shelter  the  eye  from  all  sources  of  irritation  ;  secondly,  to  endeavor 
to  procure  full  dilatation  of  the  pupil;  and,  tlnrdly,  if  the  pupil  resists 
dilatation,  to  have  recourse  to  mercury.  Various  details  will  offer  them- 
selves for  consideration  in  different  cases,  but  they  will  all  be  subordinate 
to  the  principles  of  action  above  laid  down. 

Avoidance  of  A.'itritigents.  —  Among  the  sources  of  irritation  which  are 
to  be  avoided  the  most  formidable  are  the  various  astringents,  such  as 
lotions  of  nitrate  of  silver  or  of  sulphate  of  zinc,  which  are  sometimes  sold 
as  a  cure  for  inflamed  eyes  by  druggists,  or  which  may  be  prescribed 
when  an  early  stage  of  iritis  is  mistaken  for  conjunctivitis.  Next  to  these 
would  come  the  sources  of  irritation  incitlental  to  functional  use  and  to 
movement  in  the  world,  such  as  exercise  of  the  accommochilion,  and  ex- 
posure to  variations  of  light,  variations  of  temi)erature,  and  atmospheric 
impurities.  Whenever  possible,  a  patient  with  iritis  should  abandon  his 
occupation,  should  abstain  almost  entirely  from  reading,  writing,  or  other 
visual  occupation  of  the  sound  eye,  and  should  confine  himself  to  a  well- 
ventilated  and  dimly  lighted  apartment.    When  these  precautions  cannot 


714  DISEASES    OF    THE    EYE. 

be  observed  the  affected  eye  should  be  covered  by  a  compressive  bandage, 
with  suflicient  padding-  to  exchide  variations  of  liglit  and  of  temperature. 
Use  of  Atropine. — Tiie  solution  of  atropine  should  usually  be  of  tlie 
strength  of  four  grains  of  the  neutral  sulphate  to  an  ounce  of  distilled 
water,  aiid  a  drop  of  this  solution  should  be  applied  to  the  lining  mem- 
brane of  the  lower  lid  with  a  quill  scoop  or  a  dropping-tube.  It  is  a 
good  rule  to  direct  the  application  to  be  made  three  times  a  da}',  and 
each  api)lication  to  consist  of  three  drops,  with  intervals  of  five  minutes 
between  them.  A  droj)  is  applied,  after  five  minutes  another,  after  an- 
other five  minutes  a  third  ;  and  this  must  be  done  three  times  a  day.  If 
a  compressive  bandage  is  worn,  it  must  be  laid  aside  for  a  quarter  of  an 
hour  after  each  application  of  the  atropine,  in  order  that  it  may  not  ab- 
sorb and  remove  the  solution.  In  cases  of  only  moderate  severit}',  whicii 
are  seen  early,  this  treatment  will  often  produce  considerable  dilatation 
of  the  pupil,  with  diminution  of  congestion  and  of  uneasy  sensations, 
within  twenty-four  hours,  and  complete  dilatation  of  the  pupil  within 
forty-eight  hours.  When  this  is  the  course  of  events  it  is  only  necessary 
to  maintain  the  dilatation,  and  the  iritis  will  die  out  harmlessly,  because, 
when  the  pupil  is  dilated,  its  margin  is  no  longer  in  contact  with  the  lens, 
and  lymph,  even  if  it  should  be  poured  out,  cannot  form  adhesions,  but 
will  be  diffused  among  the  aqueous  humor.  Apart  from  this,  the  atro- 
pine, probably  by  virtue  of  its  influence  upon  the  vaso-motor  nerves, 
seems  to  be  distinctly  antiphlogistic  in  its  action.  When  all  congestion 
has  subsided,  and  when  the  absorption  of  any  turbidity  in  the  aqueous 
humor  has  restored  the  iris  to  its  natural  color  and  lustre,  the  atropine 
may  be  laid  aside;  but  the  eye  must  be  carefully  watched  for  a  few  da^'s, 
and  especially  when  it  is  again  taken  into  use,  in  order  that  the  slightest 
appearance  of  relapse  or  of  returning  irritation  ma}'  be  met  by  a  renewed 
application  of  the  remedy. 

Ilercury. — Under  three  sets  of  circumstances — first,  when  the  action 
of  atropine,  after  twenty-four  liours,  fails  to  produce  any  marked  abate- 
ment of  the  symptoms  ;  secondly,  when,  after  forty-eight  hours,  although 
the  symptoms  have  abated,  the  pupil  is  not  circular,  but  is  rendered  ir- 
regular by  broad  bands  of  adhesion  ;  thirdly,  when  the  iritis  is  already  of 
some  duration  before  it  is  submitted  to  treatment — it  is  necessary  to  have 
recourse  to  mercury,  and  to  obtain  its  effect  with  as  little  delay  as  possi- 
ble. Every  practitioner  will  choose  his  own  preparation  and  mode  of 
administration,  but  perhaps  the  form  most  generally  applicable  is  blue 
pill,  in  doses  of  two  or  three  grains  three  times  a  day,  and  in  combina- 
tion witli  a  small  quantity  (say  a  quarter  of  a  grain)  of  opium.  As  soon 
as  the  faintest  mercurial  line  aj)pcars  upon  the  gums  the  dose  should  be 
greatly  diminished,  so  that  this  slight  effect  may  be  maintained,  but  not 
exceeded  ;  and  under  its  influence  we  often  see  lymph  absorbed,  and  ad- 
hesions disappear,  with  great  rapidity.  I  am  accustomed  to  take  resist- 
ance to  atropine  as  the  sole  indication  for  mercury  in  iritis  (such  resist- 
ance being  a  matter  of  course  when  the  inflammation  has  remained  un- 
checked for  two  or  three  days,  and  adiiesions  have  had  time  to  become 
firm)  ;  and  I  do  not  regard  either  the  need  of  mercury,  or  the  rapid  im- 
provement when  it  is  administered,  as  any  certain  evidence  of  syphilis. 
Neither  does  it  follow  that  the  iritis  of  a  syphilitic  person  will  resist 
atropine  and  will  re(piire  mercur} ,  even  although  the  use  of  the  mincial 
may  be  indicated  for  some  other-  sypliilitic  manifestation.  As  regards 
the  eye  only,  the  mercury  must  be  continued  as  long  as  improvement 
takes  place  under  its  use,  and  then,  together  with  the  atropine,  it  must 
be  discontinued  carefull}'  and  watciifiiUy. 


IRITIS.  715 

Complications. — Iritis  may  be  complicated,  or  attended,  with  an  un- 
usual degree  of  pain,  or  with  an  unusual  degree  of  vascular  excitement, 
and  both  of  these  conditions  may  interfere  with  the  action  of  atroi)ine, 
M'ithont  demanding  that  of  mercury.  When  there  is  much  conjunctival 
congestion,  together  with  elevation  of  local  temi)erature  and  fulness  of 
the  temporal  vessels,  two  or  three  leeches  should  be  applied  round  the 
margin  of  the  orbit,  and  their  bites  suffered  to  bleed  freely.  In  the 
greater  number  of  cases  the  morbid  sensations  hardly  amount  to  any- 
thing more  than  uneasiness,  and  when  actual  pain  is  suffered  it  must  be 
relieved  or  subdued  before  healthy  reparative  action  can  be  expected. 
Pain  may  be  tensive,  due  to  the  stretching  of  the  ocular  tunics  by  in- 
creased secretion  (a  form  that  is  scarcely  met  with  excepting  in  serous 
iritis);  or  it  may  be  an  expression  of  exalted  nervous  sensibility.  The 
former  variety  will  be  considered  presentl}^ ;  the  latter  calls  for  the  un- 
stinted employment  of  anodynes.  Especially  when  pain  shoots  along 
the  various  branches  of  the  first  division  of  the  fifth  nerve  on  the  affected 
side,  it  is  generally  desirable  to  have  recourse  to  the  subcutaneous  in- 
jection of  morphia,  in  such  doses  and  at  such  intervals  as  may  afford  im- 
munity fi'om  suff'ering,  while  the  atropine,  and  if  necessary  the  mercury 
also,  are  employed  in  the  manner  which  has  been  described. 

Remaining  AdheHiom^. — When  the  subsidence  of  iritis  leaves  an  ad- 
hesion which  has  resisted  treatment,  the  use  of  atropine  and  of  mercury 
must  be  cautiously  continued  for  a  time,  in  the  hope  that  the  former  may 
mechanically  stretch  and  break  the  new  tissue,  while  the  latter  causes  it 
to  undergo  disintegration  and  absorption.  If  no  declared  effect  is  pro- 
duced within  a  month,  the  medicines  should  generally  be  discontinued, 
and  tb.e  adhesion  regarded  as  permanent.  The  patient  should  be  fore- 
warned of  his  liability  to  another  attack  of  inflammation,  and  should  be 
cautioned  to  seek  advice  immediately  if  such  an  event  should  occur.  In 
a  certain  small  proportion  of  cases  no  harm  will  follow,  but  in  others  the 
patient  remains  conscious  of  the  adhesion,  which  produces  sensations  of 
dragging  or  discomfort,  and  in  the  great  majority  a  second  attack  of 
iritis  will  sooner  or  later  occur.  When  this  happens  it  must  be  treated 
in  the  ordinary  way,  with  atropine,  before  having  recourse  to  mercury; 
for,  although  the  existing  adhesions  will  forbid  complete  dilatation  of  the 
pupil,  the  atropine  will  nevertheless  exert  considerable  antiphlogistic 
action.  After  the  second  attack  has  subsided,  means  should  be  taken 
without  delay  to  destroy-  the  injurious  effect  of  the  adhesions,  for  recur- 
rence is  then  no  longer  doubtful,  and  if  the  adhesions  are  left  the  eye 
will  certainly  be  disorganized  by  rei)eated  inflammation.  Two  methods 
offer  themseives, — either  to  break  the  continuity  of  the  iris,  and  to  pre- 
vent closure  of  the  pupil,  by  a  sufficient  iridectomy,  or  to  detach  the  ad- 
hesions by  traction  with  a  hook  or  forceps  introduced  into  the  anterior 
chamber.  Of  these  methods  the  former  is  generally  to  be  preferi-ed,  as 
being  the  more  effectual  and  the  less  dangerous  of  the  two,  the  detacli- 
ment  by  traction  being  open  to  the  objection  that  the  adliesions  may  re- 
unite, and  that  the  instrument  employed  or  the  traction  exercised  may 
injure  the  capsule  of  the  lens  and  produce  traumatic  cataract.  After  the 
performance  of  an  iridectomy  it  rarely  happens  that  iritis  will-  occur 
again  ;  and  its  occurrence  would  be  comparatively  harmless,  on  account 
of  the  large  and  free  opening  that  would  exist  between  the  antericn-  and 
the  posterior  chamber.  The  rule  of  practice,  therefore,  would  be  to  per- 
form an  iridectom}^  in  ever}-  case  in  which  adhesions  left  by  iritis  were 
sources  of  discomfort  to  the  patient,  or  in  which  the  patient  was  about 
to  travel  to  remote  places,  where  he  might  be  unable  to  procure  surgical 


716  DISEASES    OF    THE    EYE. 

aid,  or  in  which  the  adhesions  had  already  produced  a  second  attack  of 
inflammation.  If  the  natural  pupil  is  free  from  lymph  and  the  vision 
good,  tiie  iridectomy  may  he  placed  under  tiie  shelter  of  the  upper  lid, 
where  it  will  be  out  of  sight ;  but  if  the  pupil  is  at  all  covered  it  is  best  to 
remove  a  piece  of  iris  which  is  non-adherent,  and  which  will  therefore  leave 
a  clear  ajjcrture  for  visual  puriioses.  If  the  piece  removed  is  adherent  it 
will  often  leave  opaque  lymph  or  pigment  upon  the  capsule  of  the  lens. 

When  only  two  attacks  of  iritis  have  occurred  there  is  seldom  an}^  dif- 
ficulty in  performing  iridectomy  in  an  effectual  manner;  but  after  re- 
peated attacts  the  operation,  although  still  indicated  as  the  best  or  even 
the  only  resource,  is  very  ditticult  of  accomi)lishment.  The  stroma  of 
the  iris  is  often  so  weakened  that  it  \vill  tear  under  the  forceps'  traction, 
so  that  no  large  opening  can  be  made,  and  the  inflammation  has  often 
spread  by  continuity  to  the  choroid,  and  has  occasioned  effusions  which 
prevent  the  restoration  of  useful  vision. 

Sei-ous  IrittH. — The  other  chief  variety  of  iritis — the  serous — is  com- 
paratively of  rare  occurrence,  and  is  seldom  met  with  except  in  persons 
of  disordered  health,  and  especiall}',  I  think,  in  cases  of  renal  disease. 
It  differs  from  the  plastic  in  the  morbid  product  being  a  turbid  liquid 
instead  of  lymph  ;  and  this  liquid,  while  it  obscures  the  iris  and  renders 
it  dull,  and  while  it  overfills  and  distends  the  eyeball,  has  no  tendency  to 
the  formation  of  adhesions.  In  general  appearance  the  e3'e  resembles 
one  which  is  suffering  from  iritis  of  the  ordinary  kind ;  but  the  pupil  is 
usually'  quite  insensible  to  the  action  of  atropine  (probably  because  the 
overfilled  state  of  the  eye  prevents  absorption),  and  the  plane  of  the  iris 
is  in  some  degree  pushed  backwards,  so  that  the  anterior  chamber  seems 
to  be  deeper  than  usual.  At  the  same  time  the  eyeball  will  be  rendered 
very  hard  by  tension,  the  sight  will  be  greatly  affected  by  the  compres- 
sion of  the  retina,  and  a  good  deal  of  dull  stretching  pain  is  usually  ex- 
perienced. The  first  thing  to  be  done  in  such  a  case  is  to  diminish  ten- 
sion, by  repeated  ])aracentesis  if  the  case  is  seen  early  and  can  be  closely 
watched,  by  iridectomy  under  the  opposite  conditions.  As  soon  as  the 
fluid  is  evacuated  the  pupil  will  respond  reapily  to  atropine,  and  uninter- 
rupted recovery  will  usuall}'  take  place. 

Iridochoroiditis. — When  plastic  iritis,  either  in  the  first  or  in  any  subse- 
quent attack,  extends  to  the  choroid,  the  severity  and  the  danger  of  the 
case  are  much  increased,  and  the  inflammation  frequently  terminates  in 
wasting  of  the  globe  and  loss  of  sight.  The  chief  evidence  of  extension 
to  the  choroid  would  be  furnished  by  tenderness  of  the  ciliary  region 
under  gentle  pressure,  by  an  impairment  of  vision  in  excess  of  that  for 
which  the  iritis  would  account,  and  b}'  immobility  of  the  pui)il  under 
atropine  ;  often,  if  tlie  cornea  and  aqueous  humor  retain  sufficient  trans- 
parency, liy  the  iippearance  of  visible  bloodvessels  in  the  iris  itself  The 
treatment  under  such  circumstances  must  be  mainl}'  mercurial,  combined 
with  careful  attention  to  the  diet  and  general  condition  of  the  patient. 
Pain  sliould  be  subdued  by  anodynes,  paracentesis  of  the  anterior  cham- 
ber should  be  performed,  and  the  acpieous  humor  evacuated  twice  daily. 
Under  the  most  favorable  circumstances  nothing  better  than  partial  re- 
covery can  be  expected,  with  a  closed  pujjil  and  often  with  an  oi)aque 
lens.  A  large  iridectomy  should  be  i)erformed  as  soon  as  the  inflamma- 
tion lias  subsided,  and  the  lens,  if  opaque,  should  be  extracted.  In  most 
cas(,'S  this  (Operation  will  be  followed  by  some  degree  of  fresh  inflamma- 
tion, which  will  usually  close  the  i)upil  left  l)y  the  iridectomy,  and  will 
leave  in  the  axis  of  vision  a  tough  membrane  consisting  of  iris  and  lens 
capsule,  united  by  effused  lymph.     When  a  sufficient  time  has  elapsed, 


CATARACT.  717 

and  the  eye  is  again  quiet,  some  degree  of  vision  may  often  be  restored 
by  cutting  out  a  large  portion  of  tliis  tougli  membrane  and  removing  it 
entirely,  so  as  to  leave  a  good  centi'al  pupil.  For  this  jjurpose  a  large 
incision  should  be  made  into  the  anterior  chamber  witli  an  iridectomy 
knife,  and  through  this  incision  an  appropriate  pair  of  scissors  may  lie 
introduced  and  made  to  pierce  the  membrane  with  one  blade,  so  that 
they  may  cut  out  a  piece  of  such  size  as  may  be  desired. 

Cataract. — The  structure  next  to  the  iris  in  point  of  anatomical  posi- 
tion is  the  crystalline  lens,  which  is  naturally  of  bi'illiant  trans|)arencv, 
but  which  is  liable  to  undergo  perversions  of  nutrition  which  render  it 
more  or  less  turbid  or  opaque,  and  which  constitute  the  various  foi-ms  of 
cataract.  Of  these  forms  the  most  noticeable  are  the  congenital,  the 
laminar,  and  the  senile. 

Congenital. — In  the  obviously  congenital  forms  of  cataract  it  l)ecomes 
apparent,  soon  after  birth,  that  the  pupils  of  the  infant's  eyes  are  not  of 
their  usual  blackness,  but  of  a  bluish-white  or  milky  appearance  ;  and 
dilatation  by  atropine  shows  that  this  appearance  extends  over  the  whole 
of  the  surface  of  the  lens.  When  the  infant  is  old  enough  it  will  be 
found  to  follow  a  lighted  candle  with  its  eyes,  but  to  have  no  vision  of 
conspicuous  objects  ;  and  in  this  condition  it  is  very  important  that  an 
opei'ation  should  be  performed  early,  because  otherwise  the  external  mus- 
cles of  the  eyes,  not  being  guided  in  their  movements  by  the  sense  of 
sight,  will  never  acquire  the  power  of  definite  fixation,  and  the  globes  will 
permanently^  oscillate  in  the  curious  rhythmical  fashion  which  has  re- 
ceived the  name  of  nystagmus.  The  operation  should  not  be  delayed 
beyond  the  third  or  fourth  month,  and  at  this  age  the  best  method  of 
proceeding  is  by  solution  ;  that  is  to  say,  l)y  breaking  up  the  lens  a  little 
at  a  time,  and  leaving  it  to  be  dissolved  or  absorbed  by  the  action  of  the 
aqueous  humor.  For  this  purpose,  the  pupil  being  first  fully  dilated  by 
atropine,  a  very  fine  cataract  needle  should  be  passed  through  the  cornea 
to  the  centre  of  the  pupil,  where  it  should  make  a  small  puncture  or  slit 
in  the  anterior  capsule  of  the  lens,  and  should  be  immediately  withdrawn. 
No  force  should  be  employed,  lest  the  lens  should  be  dislocated,  and  the 
needle-point  should  be  used  very  sparingly,  lest  too  much  lens-tissue 
should  be  disturbed,  and  the  eye  oppressed  l\y  more  tiian  it  can  readily 
absorb.  The  dilatation  of  the  pupil  should  be  maintained,  and  on  the 
second  or  third  day  a  fragment  of  lens-matter  may  be  seen  protruding 
through  the  wound  in  the  capsule.  As  the  fragment  is  ai>sorbed  more 
will  come  forward  in  a  similar  manner,  and  as  long  as  this  process  con- 
tinues, and  there  is  no  iritis,  there  is  no  cause  for  furthei-  interference. 
But  in  most  cases  the  first  wound  in  the  cai)sule  will  close,  or  at  all  events 
the  progressive  absorption  of  the  lens  will  lie  arrested,  and  then  it  will 
be  necessary  to  use  the  needle  again,  somewhat  more  freely  than  on  the 
first  occasion.  A  third  or  even  a  fourth  operation  may  be  required;  but 
eventually  the  lens  will  undergo  com[)lete  absorption  ;  and,  if  the  punc- 
tures have  been  made  in  the  centre  of  the  capsule,  this  structure  will  un- 
dergo retraction,  and  will  leave  a  central  clear  space  behind  the  pnpil, 
through  which  good  vision  may  be  obtained. 

Iritis  during  Solution. — The  eyes  of  infants  are  extremely  tolerant  of 
this  procedure,  provided  that  it  is  executed  with  due  care  ;  but  if  too 
much  of  the  lens  is  broken  up  on  any  one  occasion,  or  if  dilatation  of  the 
pupil  is  neglected,  so  that  its  margin  comes  into  contact  with  the 
lens-matter,  iritis  is  apt  to  be  excited,  in  which  case  the  whole  of  the 
lens  should  be  evacuated  as  speedily  as  possible,  by  suction,  in  the  man- 
ner presently  to  be  mentioned.     In  order  to  avoid  such  a  necessity  the 


718  DISEASES    OP    THE    EYE. 

surgeon  should  always  be  sure,  before  treatment  is  commenced,  that  the 
mother  or  nurse  understands  the  use  of  the  atropine  solution,  and  can  be 
trusted  to  apply  it  effectually. 

Pyramidal. — A  form  of  cataract  which  is  not  congenital,  and  which 
consists  essentially  of  a  deposit  of  lymph  on  the  anterior  capsule,  is 
sometimes  called  "pyramidal"  or  "punctated,"  according  to  its  appear- 
ance. It  is  produced  1)\-  the  purulent  ophthalmia  of  infanc}^,  during  which, 
if  the  cornea  is  perforated,  the  lens  falls  forward  into  contact  with  Des- 
cemet's  membrane,  and  is  pushed  back  again,  carrying  with  it  a  dot  of 
lymph,  as  the  aqueous  chamber  is  restored.  If  the  lymph  deposit  is  very 
small  it  remains  flat ;  but  if  it  is  abundant  it  is  apt  to  be  stretched  out 
before  the  cornea  and  lens  separate,  and  to  remain  attached  to  the  latter 
as  a  little  pyramid,  the  apex  of  which  projects  through  the  pupil.  Upon 
the  lym})h  thus  deposited  some  saline  matter  from  the  aqueous  humor  is 
thrown  down,  giving  a  chalky  whiteness  to  the  ultimate  formation  ;  and 
then,  as  the  cornea  recovers  its  transparency,  either  a  minute  white  dot 
or  a  small  white  pyramid  will  be  seen  in  the  centre  of  the  pupillary  space. 
Such  cataracts  are  so  small  that  the  patient  would  usually  be  able  to  see 
round  them  without  dilatation  of  the  pupil ;  and  any  impairment  of  sight 
with  which  they  may  be  associated  is  usually  due  rather  to  haziness  of 
the  cornea  than  to  opacity  in  the  lens.  In  consequence  of  the  former, 
such  cataracts  are  often  complicated  with  nystagmus.  In  any  case  in 
which  such  a  proceeding  seemed  advisable,  the  lenses  could  be  removed 
by  suction  or  solution  ;  but  improvement  of  sight  would  rarely  follow. 

Laminar. — In  "laminar"  cataract,  the  opacity,  although  sufficiently 
dense  to  interfere  with  even  the  beginning  of  lessons,  is  seldom  dense 
enough  to  be  conspicuous  through  undilated  pupils,  or  to  cause  anything 
approaching  to  actual  blindness  ;  and  hence,  although  probably  a  con- 
genital affection,  it  is  seldom  discovered  until  early  childhood  is  passed, 
and  frequently  not  until  the  patient  has  been  unjustly  punished  for  sup- 
posed obstinacy  or  stupidity,  which  in  reality  would  be  nothing  but  want 
of  sight.  Whenever  a  child's  first  teachers  complain  of  it  in  this  manner 
the  surgeon  should  dilate  the  pupils  and  carefully  examine  the  eyes.  The 
color  of  laminar  cataract  is  rather  gray  or  nebulous  than  white,  and  the 
turbidit}'  is  limited  to  a  stratum  of  lens-matter  which  surrounds  a  trans- 
parent nucleus,  and  is  itself  surrounded  by  transparent  cortical  substance, 
so  that  it  occupies  tlie  position  of  the  dark  line  A  in  the  annexed  diagram. 
The  size  and  thickness  of  the  cloudy  stratum 
^'"^''  ^-^-  are  variable,  so  that  some  laminar  cataracts  are 

muchlessthan  others  in  superficial  extent.  They 
differ  also  in  this,  that  in  some  the  transparent 
l)eriplieral  portion  of  the  lens  is  absolutely 
transparent,  while  in  others  it  is  broken  by 
opaque  dots  or  striae.  In  the  former  cases  the 
periphery  may  be  expected  to  retain  its  trans- 
parency, in  the  latter  it  will  in  time  become  tur- 
V)id  throughout.  On  these  physical  differences 
depend  great  difterences  in  the  treatment  that 
Diagram  to  illustrate  the  position  slioiild  lie  pursued  ;  for,  if  the  periphery  around 
of  laminar  cataract.  tlie  opaquc   lamina    is  broad    and  transparent, 

it  is  obvious  that  good  vision  through  this  por- 
tion of  the  lens  may  be  f)btained  by  dilatation  of  the  pupil,  or  by  making 
an  artificial  pupil  in  front  of  the  transparent  portion;  while,  if  the  trans- 
parent annulus  is  very  narrow,  or  if  it  is  itself  threatened  with  opacity, 
the  vision  obtained  by  the  above  methods  will  either  be  imperfect  in  its 
degree  or  only  temporary  in  its  duration,  and  removal  of  the  lens,  which 


CATARACT. 


719 


Fig.  32G. 


will  eventually  be  necessary,  may  properly  be  undertaken  in  the  first 
instance.  For  the  determination  of  these  questions  the  suroeon  should 
examine  the  lenses  with  the  ophthalmoscopic  mirror  and  witli  focal  illu- 
mination in  a  way  which  will  be  described  when  the  diagnosis  of  senile 
cataract  is  being  considered. 

Removal  hij  Hurfion. — The  removal  of  laminar  cataract  may  often  be 
successfully  accomplished  by  solution  ;  but, 
as  the  patients  are  mostly  children,  whom  it 
is  more  or  less  ditlicult  to  restrain,  the  risks 
of  inflammation  or  of  injury  during  the  often- 
times lengthy  process  are  much  greater  in 
them  than  in  infants,  and  a  less  protracted 
treatment  is  exceedingly  desirable.  This  is 
aflbrded  by  the  old  Persian  method  of  suc- 
tion, which,  with  improved  appliances,  has 
been  introduced  into  modern  practice  by 
Mr.  Pridgin  Teale,  of  Leeds.  The  principle 
of  suction  is  that  the  whole  of  the  lens  should 
be  thoroughly  broken  up  and  cut  to  pieces 
with  needles  at  a  single  sitting;  and  that 
after  the  lapse  of  a  few  days,  when  the  dis- 
organized mass  has  been  rendered  pulpy  by 
the  aqueous  humor,  and  before  its  presence 
has  excited  irritation,  it  should  be  sucked 
out  of  the  eye  through  an  appropiiate  tube 
introduced  through  a  small  corneal  opening. 
When  this  is  successfully  accomplished  a 
cataract  which  would  have  required  months 
for  complete  absorption  may  be  entirely  re- 
moved in  the  course  of  a  single  week. 

For  the  successful  performance  of  suction 
it  is  necessary  that  the  original  cutting  up, 
or  "  discission  "  of  the  lens,  should  be  com- 
plete, and  it  is  highly  desirable  that  the  vit- 
reous body  should  not  be  penetrated  in  the 
process.  The  plan  which  I  pursue  is  to  ob- 
tain the  widest  possible  dilatation  of  the 
pupil,  and  then  to  introduce  two  needles  at 
once,  one  on  the  nasal,  the  other  on  the  tem- 
poral side  of  the  cornea;  each  needle  being 
used  for  the  half  of  the  lens  which  is  farthest 
from  its  wound  of  entrance.  Each  needle  is 
made  to  cut  through  its  portion  of  lens  by  a 
succession  of  regular,  closely  set,  parallel 
strokes,  reaching  from  margin  to  margin, 
and  carried  to  a  depth  corresponding  with 
the  thickness  of  the  lens-tissue  in  each  place. 
Nothing  but  practice  can  enable  the  operator 
to  accomplish  this  as  completely  as  he  would 
desire.  Dilatation  of  the  pupil  must  be  main- 
tained, and  in  the  course  of  a  day  or  two  the 
broken  lens-matter  will  fill  the  anterior  cham- 
ber, in  a  condition  much  resembling  a  white 
flocculent  precipitate.  It  may  then  be  evac- 
uated by  suction,  an  operation  which  is  per- 


il 


Curette  and   mouthpiece  for  the  re- 
moval of  cataract  by  suction. 


720  DISEASES    OF    THE     EYE. 

formed  by  means  of  a  small  slightly  curved  tubidar  curette,  semicircular  in 
section,  smooth  and  rounded  at  its  free  extremity,  and  provided  with  a 
small  round  or  oval  opening,  near  this  extremity,  in  its  flat  or  concave 
surface.  The  curette  has  been  attached  to  more  tlian  one  form  of  ex- 
hausting syringe,  but  its  action  is  most  eflectual  and  most  delicate  when 
it  is  fixed  to  a  glass  tube  which  serves  as  a  handle,  and  which  is  connected 
h^-an  india-rubber  tube  with  a  glass  monthjjiece,  thus  forming  the  instru- 
ment of  which  the  extremities,  the  intervening  piece  of  tube  being  omitted, 
are  shown  in  the  preceding  figure.  The  curette  itself  may  be  of  various 
sizes,  and  its  opening  may  be  large  enough  to  admit  quite  large  fragments, 
and  should  be  notched  transversely,  as  shown  in  the  small  figure,  to  pre- 
vent it  from  being  closed  by  contact  with  the  cornea.  It  should  be  intro- 
duced into  the  eye  through  a  small  incision  in  the  cornea,  near  its  margin, 
with  its  flat  or  perforated  side  towards  the  inner  suiface  of  the  cornea; 
and  it  should  be  made  to  dip  down  into  the  lenticular  space.  When  thus 
placed,  gentle  mouth-suction  will  draw  all  the  lens-matter  through  the 
aperture  and  into  the  glass  tube;  and  any  stray  fragment  may  be  followed 
until  the  aperture  is  beneath  it,  when  it  must  needs  fall  into  the  stream. 
If  the  tube  appears  to  be  obstructed  it  may  be  withdrawn  from  the  eye, 
blown  clear  and  reintroduced  ;  and  throughout  the  operation  the  course 
of  the  fragments  should  be  carefully  watched,  and  the  suction  regulated 
with  a  nicety  which  no  mechanical  substitute  for  the  mouth  can  imitate. 
When  all  turbid  matter  is  removed  the  eye  should  be  closed  by  a  com- 
pressive bandage,  and  atropine  should  be  applied  daily  until  recovery  is 
complete. 

Complicationi<. — If  the  preliminary  discission  of  the  lens  has  been  in 
any  wa}^  faultily  performed,  the  course  of  events  will  be  less  smooth.  If 
the  posterior  portion  of  the  lens  has  been  left  untouched  by  the  needles 
it  may  remain  transparent,  and  hence  invisible,  until  after  the  anterior  or 
broken  portion  has  been  removed.  In  such  a  case  the  suction  may  ap- 
pear to  be  complete,  and  the  pupil  may  look  clear  and  black  at  the  time 
of  operation  ;  but  yet,  a  day  or  two  later,  fresh  portions  of  turbid  lens- 
matter  may  present  themselves,  and  may  not  only  interfere  with  vision, 
but  may  even  produce  irritation.  If  the  quantity  thus  left  in  the  eye  is 
insignificant,  and  if  no  inflammatory  symptoms  appear,  it  will  be  suflH- 
cient  to  keep  the  pupil  dilated  and  to  wait  for  absorption  ;  but  if  the 
quantity  is  large,  or  if  there  should  be  any  evidence  of  threatening  or 
commencing  iritis,  suction  should  be  repeated  without  delay.  If  the 
needles  have  passed  through  the  lens,  so  as  to  pierce  the  hyaloid  mem- 
brane and  to  permit  vitreous  humor  to  mingle  with  the  fragments,  the 
latter  will  be  less  readily  softened  than  by  the  aqueous  alone,  and  some 
amount  of  vitreous  will  be  removed  by  the  suction  curette,  and  may  after- 
wards escape  through  the  corneal  wound.  In  early  operations  it  is  better 
to  do  too  little  than  too  much,  and  a  second  recourse  to  suction  is  prefer- 
able to  an  admixture  of  vitreous  with  the  lens  fragments. 

JilsLs. — Under  ordinary  circumstances  the  removal  of  laminar  cataract 
by  suction  is  a  very  safe  operation  ;  but  in  a  few  instances  it  is  followed 
by  severe  plastic  iritis,  and  it  may  even  lead  to  suppuration  of  the  eye- 
ball. The  dangers  attending  it  may  be  looked  upon  as  arising  from  the 
circumstance  tliat  eyes  which  are  the  subjects  of  laminar  cataract  are 
often  in  other  respects  feeble  and  im[)erfectly  developed  organs,  prone  to 
destructive  changes  under  slight  provocation  ;  and  the  operation  must  be 
very  cautiously  undertaken  where  other  evidences  of  imperfection  are 
manifest.  If  there  is  congenital  displacement  of  the  lenses,  or  nystag- 
mus, or  strabismus,  or  if  the  eyeballs  are  small  and  generally  malformed, 


CATARACT.  721 

the  treatment  of  Laminar  cataract  must  be  undertaken  with  some  hesita- 
tion, and  must  be  made  the  subject  of  a  very  guarded  prognosis.  After 
discission  or  suction  has  been  practiced,  if  any  symptoms  of  acute  in- 
flammation should  show  themselves,  an  iridectomy  sliould  be  performed 
without  delay  ;  all  remaining  lens-matter  and  all  inflammatory  products 
should,  as  far  as  possible,  be  evacuated  ;  a  leech  or  two  should  be  applied 
near  the  margin  of  the  orbit,  and  cold  comi)resses  over  the  lids ;  rest  in 
bed  should  be  enforced,  and  pain  should  be  subdued  by  anodynes.  Under 
such  treatment  it  will  often  happen  that  a  favorable  or  partially  favor- 
able issue  may  be  obtained  ;  but,  if  suppuration  of  the  eyeball  should 
be  plainly  impending,  it  is  generally  advisable  to  save  pain  by  the  early 
performance  of  enucleation.  It  is  obvious,  supposing  laminar  cataract  to 
affect  both  eyes,  tliat  the}^  should  never  be  operated  upon  together. 

Senile  Cataract. — By  senile  cataract  is  meant  an  impairment  of  the 
transparency  of  the  crystalline  lens,  which  commences  in  persons  past 
the  middle  period  of  life  (or,  in  rare  instances,  in  those  who  are  com- 
paratively young),  and  which  appears  to  depend  upon  a  local  failure  of 
nutrition.  The  central  parts  of  the  healthy  lens  are  of  somewhat  firmer 
texture  than  the  superficial;  and  the  gradual  hardening  of  the  whole 
structure  which  occurs  as  life  advances  is  more  marked  in  the  former 
than  in  the  latter.  In  the  lens  of  any  aged  person,  whether  it  is  trans- 
parent or  opaque,  a  variable  depth  of  the  outer  laminie  will  be  soft,  and 
readily  removed  by  the  fingers ;  while  a  variable  bulk  of  the  central 
laminae  will  retain  a  marked  degree  of  firmness  and  coherence.  The 
former  portion  is  termed  the  cortex,  or  tiie  cortical  substance,  the  latter 
the  nucleus  ;  and  they  are  readily  to  be  distinguished  from  each  other, 
although  no  exact  line  of  demarcation  can  be  drawn  between  them.  Senile 
cataract  appears  in  two  principal  forms,  the  nuclear  or  hard  cataract,  in 
which  the  natural  hardening  or  drying  process  is  exaggerated,  and  in 
which  there  is  a  large,  hard,  or  almost  horny  nucleus,  surrounded  by  a 
thin  la3'er  of  transparent  cortex ;  and  the  cortical  or  soft  cataract,  in 
which  the  nucleus  may  remain  transparent  long  after  the  cortex  is  in- 
vaded by  opaque  strise,  which  appear  to  be  lines  of  fatty  degeneration, 
and  which,  as  they  increase  and  coalesce,  tend  to  envelop  the  hard  nu- 
cleus in  a  layer  of  softened  and  degenerated  cortical  substance,  which 
may  even  break  down  into  complete  liquefaction,  and  may  become  the 
seat  of  calcareous  deposits.  But  both  the  forms  of  senile  cataract  diff'er 
from  those  which  are  congenital,  or  which  occur  in  early  life,  in  this,  that 
both,  whatever  may  be  the  state  of  their  outer  layers,  contain  a  hard 
nucleus  which  does  not  undergo  softening,  which  cannot  be  broken  up 
with  needles,  and  which  cannot  be  absorbed  within  the  eye  ;  so  that,  for 
tlie  restoration  of  vision,  the  nucleus  must  be  removed,  or  "extracted" 
entire,  through  an  opening  sutticiently  large  to  aflTord  it  a  free  passage. 

Diagnosis. — In  childhood  and  early  life,  when  the  pupil  is  naturally  of 
a  clear,  bright  black,  any  milkiness  or  turbidity  of  the  crystalline  lens  can 
be  ascertained  by  simple  inspection,  and  cataract  can  hardly  be* over- 
looked if  there  is  any  complaint  of  defective  vision.  There  is  only  one 
condition  at  all  liable  to  be  mistaken  for  it,  and  that  is  the  growth  of  a 
malignant  tumor  in  the  vitreous  chamber,  when,  although  the  pupil  may  be 
of  a  whitish  or  yellowish  color,  the  diagnosis  would  generally  be  rendered 
eas}'  by  the  hardness  of  the  eyeball  produced  by  the  increase  in  the 
quantity  of  its  contents,  and  by  the  presence  of  a  greater  degree  of  blind- 
ness than  cataract  would  explain.  But  in  elderly  people,  in  whom  there 
is  alwa^^s  a  certain  degree  of  yellow  coloration  of  the  lens,  and  in  whom, 
from  various   conditions,  more  light  is  often  reflected  from   tlie  fundus 

46 


722  DISEASES    OF    THE    EYE. 

than  in  3'Oiing  people,  the  pupils  are  seldom  or  never  of  a  bright  black, 
and  they  often  present  a  most  deceptive  resemblance  to  the  color  of  com- 
mencing cataract.  At  the  same  time,  persons  in  the  decline  of  life  are 
subject  to  other  affections,  such  as  nerve  atrophy  and  chronic  glaucoma, 
whicli  may  in  some  degree  imitate  cataractous  blindness ;  and  hence  the 
diagnosis,  while  it  is  of  the  highest  importance,  is  not  altogetlier  free 
from  difhcult}'.  In  former  times,  indeed,  it  was  ver}'  difficult,  and  there 
can  be  little  doubt  that  even  highly  skilled  persons  were  often  led  to 
erroneous  conclusions  with  regard  to  it.  Of  late  years  the  difficulties 
have  been  in  great  measure  removed  by  the  employment  of  the  ophthal- 
moscope. 

By  the  Ophthalmoscope. — For  this  purpose  it  is  not  necessary  to  use 
the  instrument  in  such  a  manner  as  to  obtain  a  view  of  the  details  of  the 
background  of  the  eye,  but  onl^'  so  as  to  illuminate  the  area  of  the  pupil. 
The  observer  takes  the  mirror  alone,  places  its  edge  in  contact  with  the 
margin  of  his  orbit,  so  that  he  can  look  through  the  sight-hole,  and  then 
directs  the  light  from  a  suitably  placed  lamp  fully  into  the  eye  of  the 
patient,  which,  if  the  pupil  is  not  artificially  dilated,  should  be  directed 
somewhat  inwards  towards  the  nose.  Under  such  circumstances,  if  the 
media  of  the  patient's  eye  are  transparent,  the  circular  area  of  tlie  pupil 
will  appear  as  a  field  of  uniform  and  unbroken  illumination,  the  brighter 
the  larger  it  is,  and  more  or  less  whitish,  reddish,  or  yellowish  in  color, 
according  to  the  part  of  the  fundus  which  is  opposite  to  the  observer,  and 
to  the  degree  of  pigmentation  of  the  fundus.  If,  on  the  contrary,  the 
media  are  anywhere  opaque,  the  opacities  will  intercept  the  return  of  the 
light,  and  will  appear  as  black  lines  or  patches  in  the  illuminated  field. 
They  may  be  situated  in  the  cornea,  in  the  crystalline  lens,  or  in  the 
vitreous  body,  but*  in  the  cornea  they  will  be  readily  discoverable  by 
superficial  examination,  and  in  the  vitreous  they  will  in  almost  ever}^ 
instance  be  movable,  whisking  about  in  response  to  quick  movements  of 
the  eye  itself,  and  slowly  sinking  by  gravitation  when  it  is  at  rest.  In 
the  lens  they  are  of  two  chief  classes,  which  may  be  found  either  singly 
or  in  combination,  namel}^,  the  wedge-shaped  stride  of  cortical  cataract, 
which  have  their  bases  towards  the  periphery  and  their  points  directed 
towards  the  centre  of  the  pupil ;  and  the  central  irregular  cloud  of  nuclear 
cataract. 

By  Focal  Illumination. — When  opacities  in  the  lens  are  discovered  by 
the  ophthalmoscopic  mirror  they  should  next  be  studied  by  focal  illumi- 
nation, that  is  to  sa}',  by  concentrating  the  light  of  a  lamp  upon  the  pupil 
with  a  lens,  while  the  illuminated  surface  is  magnified  for  examinatic^n  by 
another.  The  annexed  figure  shows  the  relations  of  the  lamp  and  lenses 
to  the  eya.  of  the  patient;  and  by  focal  illumination  the  ojiacities  will  no 
longer  appear  as  dark  objects,  but  will  be  shown  in  their  proper  colors. 
The  opacity  of  nuclear  cataract  will  generally  be  of  a  dark  yellowish- 
brown  or  London  fog  color;  and  the  stride  of  cortical  cataract  will  be 
lines 'of  yellowish-white.  At  the  same  time  the  depth  of  the  opacities 
ma}'  be  discovered,  so  that  it  becomes  easy  to  say  about  what  thickness 
of  transparent  cortex  covers  a  cloudy  nucleus,  and  whether  cortical  striae 
are  chiefly  in  tlie  anterior  or  in  the  posterior  portion  of  the  lens. 

Extraction  of  senile  cataract,  which  is  practically  the  only  i-emedy  for 
the  blindness  which  it  produces,  must  be  deferred,  whenever  possible, 
until  the  cataract  is  mature;  that  is  to  say,  until  the  degeneration  has  so 
far  involved  the  cortical  layers  that  they  have  lost  their  natural  adlicsion 
to  the  capsule  of  the  lens,  and  will  slip  out  easily  wlien  that  structure  is 
divided.     If  extraction  is  prematurely  practiced  the  nucleus  may  leave 


CATARACT. 


723 


behind  a  qnantit}'  of  cortical  substance,  invisible  by  reason  of  its  trans- 
parency at  tlie  actual  time  of  operation,  but  whicli  on  tlie  following  day 
will  be  seen  lying  in  the  pupil  as  an  opaque  and  swollen  mass,  which  not 
seldom  excites  dangerous  or  destructive  inflammation.  A  mature  cortical 
cataract  is  either  uniformly  whitish  or  has  a  striated  appearance,  like  that 


Fig.  327. 


Pocal  illumination  for  detection  of  cataract. 


of  spermaceti ;  and  a  mature  nuclear  cataract  may  retain  its  pea-soup  tint ; 
but  the  best  test  of  maturity  is  that  the  iris,  under  lateral  illumination, 
casts  no  crescentic  shadow,  or  only  a  very  narrow  one,  upon  the  opaque 
surface  on  the  side  fi'om  which  the  light  comes.  The  presence  of  the 
shadow  evidently  implies  the  existence  of  a  space  filled  with  transparent 
matter  between  the  margin  of  the  pupil  and  the  opaque  surface  behind  it. 
If  the  opacity  appears  to  touch  the  pupillary  margin,  so  that  there  is  no 
room  for  a  shadow  between  them,  then  maturity  is  complete,  and  nothing 
can  be  gained  by  delaying  the  operation.  Under  some  circumstances, 
and  especially  when  the  fear  of  blindness  or  the  actual  impairment  of 
vision  is  either  a  source  of  great  mental  depression  or  a  cause  of  physical 
privation  by  producing  iucapacit}'  to  labor,  it  may  be  advisable  to  operate 
before  cataract  is  mature,  even  although  the  risk  of  failure  is  thereby 
somewhat  increased. 

Operation. — The  operation  of  extraction  is  one  of  great  delicacy,  which, 
after  having  been  performed  in  the  same  way,  almost  without  variation, 
for  about  a  century,  has  of  late  years  been  "  modified"  in  so  many  ways, 
and  by  so  many  different  o|)erators,  that  it  would  be  impossible,  within 
the  limits  here  available,  even  to  enumerate  the  changes  which  have  been 
suggested.  In  the  old  method,  which  is  now  usually  called  ''flap  extrac- 
tion," the  surgeon  cut  through  about  half  the  circumference  of  tiie  cornea, 
immediately  in  front  of  its  attachment  to  the  sclerotic,  thus  forming  a 
semicircular  "flap."  Through  the  wound  thus  made,  and  through  the 
pupil,  the  anterior  capsule  of  the  lens  was  freely  lacerated  by  an  appro- 
priate needle,  the  lens  itself  was  expelled  by  well-directed  pressure,  and 
the  lids  were  closed  and  secured.  This  method,  when  it  was  successful, 
left  nothing  to  be  desired;  but  it  was  followed,  in  about  20  per  cent,  of 


724 


DISEASES    OF    THE    EYE. 


Fig.  328. 


the  eyes  operated  upon,  by  destructive  changes,  which  commenced,  in 
about  equal  proportions,  in  iritis  due  to  the  stretching  of  the  pupil,  and 
in  slougliing  of  the  cornea  due  to  its  extensive  severance  from  the  sources 
of  its  nutrition.  Yon  Graefe  was  the  first  to  suggest  that  the  excision  of 
a  segment  of  the  iris  would  prevent  the  stretching  of  the  pupil  by  the 
lens,  and  would  diminish  the  tendency  to  iritis,  and  when  this  suggestion 
was  carried  into  effect  it  was  found  that  the  iridectomy  rendered  it  pos- 
sible to  extract  through  a  smaller  external  wound 
than  had  formerly  been  required,  and  thus  to  dimin- 
ish the  risks  of  corneal  sloughing.  Von  Graefe 
worked  very  sedulously  during  several  years  at  the 
endeavor  to  exclude,  one  by  one,  the  chief  sources 
of  danger  by  which  extraction  was  beset ;  and  he 
arrived  at  last  at  the  point  of  losing  only  four  eyes 
out  of  a  hundred  operations.  Since  his  death  a  few 
improvements  of  detail  have  been  introduced,  but 
as  far  as  principles  and  broad  outlines  are  concerned 
he  had  covered  the  ground  ;  and  the  operations  of 
a  few  surgeons  who  have  since  departed  from  his 
methods,  either  returning  to  a  modification  of  flap 
extraction  or  making  some  form  of  transverse  sec- 
tion of  the  cornea,  do  not  appear  likely  to  find  favor 
with  an3^  but  those  who  have  introduced  them. 

Modified  Linear  Extraction. — The  general  idea 
of  modified  linear  extraction  is  that  the  preliminary 
incision  should  be  no  longer  than  is  required  for  the 
exit  of  the  lens,  that  it  should  lie  entirely  in  a  por- 
tion of  a  larger  circle  than  that  of  the  cornea,  that 
it  should  be  in  a  tissue  which  will  heal  readily,  and 
that  the  escape  of  the  lens  should  be  facilitated  l)y 
the  excision  of  a  portion  of  the  iris.  At  the  same 
time  the  surgeon  must  be  careful  to  avoid  the  ciliary 
region,  a  wound  of  which  would  be  likel}'^  to  produce 
sympathetic  ophthalmia. 

For  the  fulfilment  of  these  indications  the  extremi- 
ties of  the  section  should  be  just  behind  the  true 
corneal  tissue,  in  a  line  parallel  to,  and  two  millime- 
tres below,  a  horizontal  line  touching  the  upper 
margin  of  the  cornea.  The  patient  being  recuml)ent, 
and  fully  etherized,  the  surgeon  separates  the  lids 
by  a  spring  speculum.  A  linear  knife  (Fig.  328), 
whicli  should  have  a  blade  thirt}'  millimetres  long, 
two  broad,  and  as  thin  as  is  compatible  with  the 
necessary'  rigidity,  is  lield  in  the  right  hand  for  the 
right  eye,  and  in  the  left  hand  for  the  left,  the  ope- 
rator standing  behind  the  head  of  the  patient.  Tlie 
eyeball  is  secured  by  fixation  forceps,  and  the  point 
of  the  knife  is  then  entered,  its  cutting  edge  up- 
wards, just  behind  the  margin  of  the  cornea,  as  at 
A,  in  the  diagram  (Fig.  329).  The  direction  of  the 
tlirust  is  towards  the  centre  of  the  eyeball,  until  the 
anterior  chaniber  is  penetrated,  when  the  point  is 
turned  so  as  to  descend,  in  a  direction  parallel  with 
the  plane  of  the  iris,  to  about  the  position  n.  Wlu!n  this  is  reached  the 
handle  is  depressed,  turning  on   the  back  of  the  blade  in  the  incision, 


Linear  knife  for  extraction 
of  cataract. 


EXTRACTION  OF  CATARACT. 


725 


Fig.  329. 


until  the  point  is  brought  to  c  on  the  same  horizontal  line  as  the  puncture. 
When  this  is  reached  the  liandle  must  be  inclined  somewhat  backwards, 
and  the  point  pushed  on  with  a  quick  movement, 
so  that  it  may  transfix  both  sclerotic  and  con- 
junctiva at  its  place  of  first  impact.  The  flat 
surfaces  of  the  blade  should  now  be  parallel  with 
the  plane  of  the  iris.  The  fixation  instrument 
should  bo  laid  aside,  the  edo;e  of  the  knife  turned 
very  slightly  forwards,  and  the  incision  completed 
by  a  succession  of  gentle  drawing  cuts,  which 
should  bring  its  centre  to  coincide  with  the  junc- 
tion of  the  cornea  and  sclerotic,  and  the  last  of 
which  should  be  made  with  especial  care. 

The  Iridectomy. — The  next  step  is  the  iridectomy,  which  has  not  for 
its  object  the  formation  of  a  large  coloboma,  but  only  to  destroy  the 
resistance  of  the  sphincter  of  the  pupil  to  the  passage  of  the  lens.  A 
pair  of  delicate  forceps,  shown  open  in  Fig.  331,  and 
with  their  minute  teeth,  both  open  and  closed,  at  a,  b, 
and  c,  are  introduced  closed  through  the  incision,  and 
suffered  to  expand  a  little  when  they  approach  the 
pupillary  margin  of  the  iris,  which  will  then  rise  be- 
tween them,  and  may  be  seized,  gently  drawn  out, 
and  cut  oft  close  to  the  forceps  blades  by  one  stroke 
of  a  pair  of  scissors.  If  this  is  properly  done  the 
angles  formed  between  the  terminations  of  the  incision 
and  the  margin  of  the  pupil  should  be  visible  within 
the  anterior  chamber,  as  at  a  and  b,  in  the  annexed 
diagram  ;  but  if  the  iris  is  dragged  out  and  cut  close 
to  the  angles  of  the  external  wound,  the  appearance 
shown  in  the  next  figure  will  be  presented,  and  por- 
tions of  iris   will  often  be   left   incarcerated  at  the 


Diagram   showing   the   incision 
for  linear  extraction. 


Fig.  331. 


Diagram  of  tlie  correct  and  faulty  sections  of  the  iris. 

angles,  where  they  may  excite  great  subsequent  irri- 
tation. The  iridectomy  completed,  the  operator  lace- 
rates or  freely  divides  the  capsule  of  the  lens,  using 
for  this  purpose  a  needle  slightly  curved  at  its  ex- 
tremity, or  the  "  fleam-shaped  "  cystitome  of  Von 
Graefe,  or  the  forceps  cystitome  of  De  Wecker,  by 
which  a  piece  of  capsule  may  be  brought  out  of  the  iridectomy  forceps. 
eye.  In  lacerating  the  capsule  it  is  essential  to  divide 
it  very  freely,  and  to  use  tlie  selected  instrument  very  gently,  as  other- 
wise the  lens  itself  might  be  dislocated  into  the  vitreous.  The  last  pro- 
ceeding is  to  expel  the  lens  from  the  eye  by  gentle  and  well-directed 
pressure.  For  this  purpose  the  conjunctiva  may  be  seized  with  forceps, 
and  the  back  of  a  small  vulcanite  spoon  applied  just  below  the  cornea, 
where  its  pressure  should  first  be  directed  backwards,  so  as  to  turn  the 
upper  border  of  the  lens  forwards  towards  the  incision,  then  upwards,  so 


726  DISEASES    OF    THE    EYE. 

as  gradnall_y  to  force  it  out  through  the  opening.  As  soon  as  the  nucleus 
has  escaped  the  speculum  may  be  removed,  and  gentle  friction  exercised 
througli  the  closed  lid,  by  wliich  any  remaining  cortical  fragments  will 
be  gathered  together  in  the  pupillary  space,  from  whence  they  may  be 
extruded  by  carefully  regulated  pressure.  As  soon  as  everything  is  re- 
moved the  eye  may  be  finally  closed  and  bandaged. 

Loss  of  Vitreous. — If  vitreous  hnmor  should  escape  before  the  lens  the 
latter  must  be  at  once  removed  from  the  eye  by  a  scoop  or  hook  ;  and  if 
vitreous  should  follow  the  lens  the  eye  must  be  closed  as  quickly  as  pos- 
sible, even  though  a  certain  amount  of  cortex  may  be  left  behind.  Yery 
rarely,  the  exit  of  the  lens  is  followed  by  intraocular  luiemorrliage,  due  to 
the  rupture  of  a  choroidal  vessel  suddenly  deprived  of  support.  When 
this  happens  there  is  no  hope  of  preserving  sight,  and  the  distended 
eyeball  usually  becomes  the  seat  of  painful  and  tedious  suppuration.  It 
is  better  to  prevent  this,  whenever  blood  or  coagulum  is  seen  issuing 
from  the  wound,  b}'  performing  enucleation  while  the  patient  is  still 
under  the  influence  of  an  angesthetic.  Of  course  the  trivial  bleeding 
which  ma}^  arise  from  the  cut  iris  must  not  be  confounded  with  that  from 
a  deeper  source. 

Natural  Healing. — If  the  whole  of  the  cataract  has  been  removed 
without  mishap,  and  if  the  reparative  powers  of  the  patient  are  even  mod- 
erately good,  the  external  wound  will  heal  quickly.  The  patient  may 
usually  rise  from  bed  on  the  second  or  third  day,  and  may  lay  aside  the 
bandage  in  the  daytime  after  the  fourth  or  fifth  day,  wearing-a  shade, 
and  replacing  the  bandage  before  assuming  a  recumbent  posture.  As 
irritation  subsides  the  light  may  be  gradually  admitted;  but  the  eye 
should  not  be  brought  into  use  for  a  few  weeks,  so  that  the  cicatrix  may 
become  firmly  consolidated  before  it  is  exposed  to  the  traction  of  the 
recti  muscles. 

Suppurative  Inflammation. — In  cases  which  proceed  less  favorably 
there  are  two  chief  dangers  to  be  dreaded.  In  some  patients  the  injury 
is  followed  by  acute  iritis,  with  a  tendency  to  suppuration,  or  by  slough- 
ing of  the  cornea,  and  either  of  these  conditions  commonly  leads  to  com- 
plete suppuration  of  the  eyeball.  They  are  ushered  in,  usually  on  the 
second  da}^,  by  redness  and  swelling  of  the  upper  lid,  with  swelling  of 
the  conjunctiva  and  slight  puriform  discharge  ;  and  these  conditions  call 
for  the  administration  of  quinine,  ammonia,  and  alcohol,  for  the  applica- 
tion of  firm  pressure,  alternated  with  hot  fomentations,  and  for  the  use 
of  a  lotion  containing  five  grains  of  hydrochlorate  of  quinine  to  the 
ounce  of  distilled  water,  to  be  applied  to  the  conjunctiva  of  the  lower  lid 
by  a  quill.  By  such  treatment  it  is  sometimes  possible  to  save  an  only 
partially  damaged  eye;  but  if  the  suppuration  and  swelling  increase,  and 
the  whole  cornea  becomes  opaque,  all  hope  must  be  given  up,  and  free 
incisions  should  be  made  tlirough  the  sclerotic  between  the  recti  muscles, 
to  diminisli  pain  and  tension,  and  to  permit  tlie  escape  of  pus  and  sloughs. 
Such  instances  are  fortunatel}'^  much  less  common  tlian  they  were  when 
flap  extraction  was  practiced  ;  but  a  moderatel}'  large  proportion  of  pa- 
tients still  suffer  from  a  chronic  iritis  of  plastic  character,  which  is  often 
excited  by  the  remains  of  cortical  substance  left  witliin  the  eye,  and 
which  in  severe  cases  may  produce  a  good  deal  of  very  obstinate  neural- 
gia, terminating  in  wasting  of  tlie  globe  and  loss  of  sight.  In  mild  cases 
it  may  do  no  further  mischief  than  to  leave  the  i)u[jillary  space  obstructed 
liy  bands  or  menibranes  of  blended  capsule  and  lymph,  wliich  may  re- 
quire to  be  torn  b\'-  cataract-needles,  or  even  cut  out  and  removed  by 
scissors  and  forceps,  in  order  to  afford  useful  vision.     The  treatment  of 


CATARACT-GLASSES. 


727 


this  chronic  iritis  must  be  hy  atropine,  an  occasional  leech  at  the  margin 
of  the  temple,  the  seclusion  of  the  eye  from  all  irritants,  the  control  of 
pain  by  morphia  or  other  anodynes,  and  the  use  of  such  constitutional 
remedies  as  circumstances  may  require. 

Gataracl-Olaases. — An  eye  from  which  a  cataract  has  been  extracted, 
unless  it  was  originally  very  highl^^  myopic,  will  have  no  defined  vision 
until  the  optical  power  of  the  natural  lens  is  supplied  by  an  artificial  one. 
Moreover,  as  it  is  the  elasticity  of  the  natural  lens  which  allows  the  eye 
to  be  adjusted  for  different  distances,  and  as  this  quality  is  wanting  in 
the  artificial  one,  it  must  lie  supplied  by  the  use  of  diflferent  powers.  As 
a  general  rule,  an  eye  whicli  has  been  operated  upon  for  cataract  will  re- 
quire a  convex  lens  of  about  2  or  2^  inches  focal  length  for  reading,  and 
of  about  3  or  '6\  inches  focal  length  for  distance. 

Excepting  large  hoemorrhages  into  tlie  vitreous  body,  and  the  growth 
of  intraocular  tumors,  both  of  which  may  produce  a  deepseated  change 
of  color  discernible  by  focal  illumination,  the  diseases  of  the  parts  of  the 
eye  behind  the  crystalline  lens  were  formerly  concealed  from  observation ; 
and,  until  many  of  them  were  revealed  by  the  invention  of  the  ophthal- 
moscope, they  were  all  included,  when  they  produced  impairment  of  sight, 
under  the  general  term  "  amblyopia  ; "  and  when  they  produced  blindness 
under  the  general  terra  "  amaurosis."  The  impossibility  of  seeing  into 
the  deeper  chambers  of  the  eye  without  optical  assistance  depends  upon 
the  fact  that  the  rays  of  light  can  only  return  from  an  eye  by  the  same 
track  along  which  they  enter  it ;  and  hence  the  eye  of  an  observer  cannot 
be  so  placed  as  to  receive  tlie  returning  rays  without  his  head  at  the  same 
time  intercepting  the  entering  rays,  and  throwing  what  he  wishes  to  see 
into  darkness.  The  ophtlialmoscope  is  a  mirror  with  a  central  perfora- 
tion, and  it  acts  by  reflecting  the  light  of  a  lamp,  which  is  placed  at  the 
side  of  and  a  little  behind  the  head  of  the  patient,  into  the  eye  under  ex- 
amination. The  returning  light  then  comes  back  to  the  mirror,  and  some 
of  it  passes  through  the  central  perforation  into  tlie  eye  of  the  observer, 
which  is  so  placed  as  to  receive  it. 

There  are  two  methods  of  using  the  ophthalmoscope — the  direct  and  the 
indirect.  The  latter  affords  the  best  general  view  of  the  interior  of  the  eye; 
the  former  is  more  especially  adapted  for  the  minute  examination  of  details. 

Direct  Method.— In  the  direct  method  the  eye  of  the  observer  is  brought 
close  to  that  of  the  patient,  the  mirror  only  intervening,  and  the  ob- 
server looks  into  the  eye,  and  sees  the  structures 
within  in  their  natural  positions,  as  real  objects, 
magnified  by  their  own  crystalline  lens.  The 
position  is  shown  in  Fig.  332,  which  is  a  dia- 
grammatic section  of  the  two  heads  and  the 
mirror.  The  heads  are  inclined  a  little  ob- 
liquely, and  the  left  eye  should  be  used  for  the 
examination  of  the  left,  and  nice  versd^  to  avoid 
contact  between  the  faces  or  annoyance  from 
the  breathing.     In  the  diagram  the  observer, 

A,  receives  the  light  from  the  flame  upon  his 
mirror,  directs  it  into  the  left  eye  of  the  patient 

B,  and  sees  the  fundus  of  b's  left  eye  through 
the  perforation  in  the  mirror.  The  statement 
that  only  the  mirror  is  interposed  is  only  true 
wlien  both  eyes  are  normal-sighted.  If  either 
of  them  is   shortsio-hted  the   defect  must  be     „.  f,-     f    wi  i       „  •„ 

»  Diagram  of  direct  ophthalmoscopic 

corrected  by  a  concave  lens  of  proper  strength,  examination. 


728 


DISEASES    OF    THE    EYE. 


Fig.  333. 


and  if  either  of  them  is  flat  or  hypermetropic  the  defect  must  be  corrected 
by  a  convex  lens  of  proper  strength  before  a  perfect  picture  will  be  ob- 
tained. In  either  case  the  correcting  lens  is  most  conveniently  placed 
in  a  clip  behind  the  mirror,  or  in  a  revolving  disk  carr3'ing  several  lenses, 
so  that  different  ones  maj^  be  brought  over  the  sight-hole  by  simple  rota- 
tion. 

Indirect  Method. — In  the  indirect  method  the  observer  remains  at  some 
distance  from  the  patient,  and  holds  up  near  the  C3'e  of  the  latter,  and  in 
the  track  of  the  light,  a  strong  convex  lens,  which  produces,  between  itself 
and  tlie  observer,  an  inverted,  aerial,  brightly  illuminated  image  of  the 
fundus  of  the  eye  looked  at.  This  image,  and  not  the  fundus  itself,  be- 
comes the  object  of  vision.  By  placing  another  convex  lens  behind  the 
mirror  the  image  may  he.  magnified  and  rendered  more  distinct ;  but  it 
can  only  be  seen  so  long  as  the  observer  handles  the  mirror  properly, 
so  as  to  maintain  the  illumination,  and  so  long  as  he  keeps  in  a  straight 
line  with  the  eye  examined,  so  as  to  be  in  the  track  of  the  returning  rays. 
The  diagram  shows  the  position  of  things.  A  is  the  head  of  the  observer, 
B  of  the  patient,  whose  left  eye  is  under  examination.    The  rays  of  light 

from  the  flame,  received  on  the  mirror 
and  directed  into  the  eye  of  b,  are 
united  on  their  return  by  the  convex 
lens  into  the  image  i,  and  this  image 
is  seen  by  a,  through  the  mirror  per- 
foration, as  soon  as  he  is  at  the  proper 
visual  distance  from  it,  and  as  long 
as  he  keeps  strictly  on  the  line  l  b, 
along  which  he  must  move  to  and  fro 
until  the  proper  distance  is  obtained. 
If  he  moves  laterally  to  a'  or  a"  he 
loses  the  image  entirel}^  The  whole 
art  of  using  the  ophthalmoscope  is 
comprised  in  keeping  the  eye  of  the  ob- 
server in  a  line  with  that  of  tlie  patient, 
in  maintaining  a  steady  illumination, 
and  in  finding  the  correct  distance. 
The  instrument  is  extremely  simple 
both  in  construction  and  application, 
and  any  intelligent  person  may  acquire 
the  knack  of  seeing  with  it  in  half  an 
hour,  although  the  art  of  interpreting 
the  appearances  exhibited  can  only 
be  gained  b}^  practice  and  reflection. 
The  opportunities  for  learning  to  han- 
dle the  ophthalmoscope  are  now  so 
abundant  that  it  is  nnnecessar}'^  to 
devote  space,  in  a  manual  of  this  kind,  to  any  more  detailed  description 
of  the  way  in  which  it  should  be  managed. 

Glaucoma. — Among  tlie  diseases  wliich  involve  the  deeper  parts  of  the 
eye  the  most  important  is  glaucoma,  and  it  owes  its  importance  mainly 
to  these  circumstances — first,  that  its  nature  is  often  overlooked  until 
irreparable  mi.schief  has  been  done  ;  secondly,  tliat  if  it  is  recognized  in 
time  it  may  in  most  cases  be  arrested  or  cured  by  the  operation  of  iri- 
dectomy. Tlie  word  glaucoma  was  originally  ai)plied,  in  a  very  vague 
manner,  to  nearly  all  cases  in  which  the  blackness  of  the  pupil  liad 
changed  to  a  greenish  hue ;  but  of  late  years  it  has  come  to  have  a  per- 


& 


Diagram  of  indirect  oplitlialiuoscopic  exami- 
nation. 


GLAUCOMA.  729 

fectly  definite  meaning  wliich  stands  in  no  sort  of  relation  to  its  etymol- 
ogy. It  used  to  denote  all  the  morbid  conditions  which  arise  from  in- 
creased hardness  or  heightened  tension  within  the  eyeball ;  and  it  is 
coupled  with  adjectives  which  denote  different  periods  of  duration — such 
as  "•chronic,"  ^'subacute,"  "acute,"  and  "•fulminating." 

Its  Nature  and  Degrees. — Concerning  the  essential  nature  of  the  pro- 
cesses by  which  the  fulness  or  tension  of  the  eyeball  may  be  increased 
there  is  nothing  certainly  known  ;  but  they  are  conjectured  to  be  in- 
creased secretion,  as  an  effect  of  some  perversion  of  nervous  action,  and 
diminished  exhalation  or  transudation,  as  an  effect  of  some  change — ■ 
probabl}' senile  hardening — of  the  tissues  of  the  eye;  these  conditions 
l)ossibly  existing  either  singly  or  in  combination.  When  a  state  of  over- 
fulness  of  the  eyeball  is  once  produced  it  tends  to  maintain  and  to  in- 
crease itself,  chiefly  because  the  vente  vorticosae,  which  convey  blood 
from  the  choroid,  pierce  the  sclerotic  so  obliquely  that  their  channels  are 
compressed  and  partially  closed  by  any  increment  of  fluid  within  the 
globe.  Hence  a  certain  degree  of  venous  congestion  or  blood-stasis  is 
produced,  and  may  lead  to  transudation  of  liquor  sanguinis  and  conse- 
quent redema.  Notwithstanding  the  retarded  outflow  of  blood  the  arterial 
inflow  continues,  even  if  in  diminished  quantity,  and  in  this  way  a  steadily 
increasing  degree  of  pressure  may  be  brought  about.  The  natural  or 
physiological  tension  of  the  eye  varies,  in  different  people,  within  rather 
wide  limits,  and  the  instruments  which  have  been  devised  for  measuring 
it  with  exactness  are  of  no  great  practical  value.  The  best  estimate  of 
tension  for  clinical  purposes  ma>'  be  made  by  careful  palpation,  but  care- 
less palpation  may  lead  to  very  erroneous  conclusions.  The  patient  should 
be  directed  to  look  downwards,  closing  the  lids  gently,  and  the  surgeon 
should  i)lace  the  tips  of  the  two  forefingers  on  the  upper  part  of  the  eye- 
ball, close  under  the  orbital  margin,  as  far  back  as  the  closed  lid  will 
allow.  One  forefinger  should  be  used  to  steady  and  support  the  eye,  the 
other  to  feel  its  degree  of  hardness  by  gentle  and  intermittent  pressure. 
A  healthy  eye  will  dimple  somewhat  under  the  finger,  with  a  peculiar 
slight  elastic  resistance ;  and  a  diseased  one  may  be  either  too  hard  or 
too  soft.  Mr.  Bowman  proposes  to  recognize  nine  degrees  of  tension — 
the  normal,  four  of  increase,  and  four  of  diminution.  He  distinguishes 
the  normal  tension  as  T.  n.,  and  the  four  varieties  by  a  T  with  a  /^/ws 
(  4-  ),  or  minus  (  —  )  sign,  and  with  either  a  note  of  interrogation  or  a 
numeral.  T  4-  ?  is  doubtful  increase;  T  -f  1,  distinct  increase;  T  -f  2, 
considerable  increase  ;  T  -f-  3,  great  increase  ;  while  the  minus  sign  indi- 
cates diminution  of  tension  in  the  same  manner.  Tiiis  method  of  stating 
tension  is  now  in  general  use,  although  it  has  the  obvious  defect  of 
affording  no  standard  for  anj'  of  the  degrees  which  it  records. 

Its  Effects. — The  manifest  effects  of  heightened  tension  are  produced, 
first,  upon  the  circulation  of  the  eye  ;  next,  upon  its  nerves  ;  lastly,  upon 
its  tunics;  and  they  diflfer  in  their  more  marked  characters  in  accordance 
with  the  rate  at  which  tension  increases.  If  the  increase  is  very  slow 
the  tunics  accommodate  themselves  to  it,  and,  for  a  time  at  least,  yield 
painlessly,  while  the  sensibility  of  the  retina  is  slowly  destroyed  by  com- 
pression and  by  arrested  circulation.  If  the  increase  is  rapid  the  sti'etch- 
ing  of  the  tunics  is  acutely  painful,  and,  together  with  the  sudden  dis- 
turbance of  the  circulation,  produces  inflammatory  reaction.  Hence 
chronic  glaucoma  is  liable  to  be  mistaken  for  atrophy  of  the  optic  nerve, 
and  acute  glaucoma  is  liable  to  be  mistaken  for  inflammation.  In  con- 
sequence of  the  attendant  pain  it  has  often  been  mistaken  for  gouty  or 


730  DISEASES    OP    THE    EYE. 

rheumatic  inflammation,  and  lias  been  suffered  to  go  on  to  blindness 
before  its  true  nature  was  discovered. 

On  the  Circulation. — As  soon  as  the  free  exit  of  blood  through  the  venae 
voi'ticos;i3  is  impeded,  q,n  endeavor  is  made  to  obtain  the  necessary  outlet 
through  other  channels,  and  chiefly  through  a  series  of  veins  which  pass 
out  from  the  eyeball  through  the  sclerotic  not  far  from  the  corneal  margin, 
and  course  backwards  under  the  conjunctiva.  In  health  these  veins  are 
scarcely  visible,  but  lieightened  tension  renders  them  distended  and  toi'- 
tuous,  carrying  dark-colored  blood.  They  are  very  visible  under  the  con- 
junctiva, and  can  hardly  be  mistaken  for  the  A'eins  proper  to  that  mem- 
brane. At  the  same  time  a  remarkable  phenomenon  is  produced  in  the 
vessels  of  the  retina,  which  constitute  a  closed  circuit  of  their  own, 
almost  independent  of  that  of  the  rest  of  the  eye.  Of  course,  when  there 
is  increased  tension,  the  entrance  of  blood  through  the  central  artery  of 
the  retina  and  its  exit  through  the  central  vein  are  both  impeded,  and  the 
result  is  the  production  of  a  visible  pulse  in  the  larger  portions  of  these 
vessels  where  they  lie  upon  the  surface  of  the  optic  disk,  first  in  the  veins, 
secondly  in  the  arteries.  The  observer,  looking  at  the  optic  disk  with 
the  ophthalmoscope,  sees  it  alternately  more  and  less  pallid,  the  variations 
occurring  synchronously  with  the  radial  pulse.  What  first  happens  is 
that  the  blood  in  the  veins  is  driven  a  little  back  towards  the  capillaries, 
so  as  to  make  I'oom  for  the  entering  arterial  wave,  the  walls  of  the  veins 
collapsing,  and  the  disk  losing  color,  until  as  the  pulse-wave  flags  the 
blood  in  the  veins  flows  back  again,  and  is  thus  constantly  driven  to  and 
fro.  The  venous  pulse,  therefore,  consists  of  an  emptying  of  the  veins 
from  the  centre  of  the  nerve-disk  to  its  margin,  alternately  with  a  reflux 
of  blood  from  the  margin  of  the  disk  to  the  centre.  A  venous  pulse  may 
be  readily  produced  in  most  eyes  by  pressure  upon  the  globe  with  the  tip 
of  a  finger,  and  it  is  an  early  symptom  in  glaucoma,  occurring  either 
spontaneously  or  under  very  light  pressure  indeed.  As  tension  increases 
tlie  arterial  blood  can  no  longer  enter  in  a  continuous  flow,  but  only 
during  the  acme  of  the  pulse-wave,  so  that  the  arteries  collapse  during 
the  cardiac  diastole,  producing  a  visible  arterial  pulse,  the  reverse  of  that 
in  the  veins,  the  arteries  emptying  themselves  from  the  margin  of  the 
disk  to  the  centre,  and  refilling  from  the  centre,  to  the  margin.  It  must 
be  observed  that  these  pulses,  arterial  and  venous,  are  neither  peculiar 
to  glaucoma  nor  pathognomonic  of  it.  They  indicate  increased  resistance 
to  the  entrance  of  blood,  or  diminished  propelling  force;  and  they  only 
point  to  glaucoma  when  there  is  a  distinct  increase  of  tension.  In  some 
eyes  a  venous  pulse  is  a  physiological  phenomenon,  and  it  can  be  pro- 
duced in  all  by  pressure.  An  arterial  pulse  may  be  due  to  defective 
power  of  the  heart,  or  to  aortic  regurgitation,  or  to  heightened  tension 
and  increased  resistance  of  the  bloodvessels. 

On  the  Nerves. — The  effect  of  heightened  tension  upon  the  nerves  of  the 
eye  is  to  impairtlieir  function,  and  sometimes  to  alter  their  physical  struc- 
ture by  direct  compression. 

The  motor,  vaso-motor,  and  common  sensory  nerves  are  the  long  and 
short  ciliary,  which  receive  twigs  from  the  third  and  liftli  cranial  nerves 
and  from  tlie  sympathetic.  The}^  course  between  the  choroid  and  the 
sclerotic,  and  during  the  progress  of  glaucoma  they  are  squeezed  against 
the  latter  tunic.  If  the  compression  to  which  they  are  subjected  is  slight 
it  produces  numbness  or  imperfect  function  ;  if  greater,  it  may  excite  the 
sensory  nerves  to  pain.  On  the  retina,  the  effect  is  to  render  it  torpid  to 
the  impressions  produced  l)y  light,  and  ultimately  insensible  to  them; 
and  the  optic  nerve,  the  surface  of  wliicli  is  mechanically  the  least  resist- 


GLAUCOMA.  731 

ing  part  of  the  eyeball,  is  often  forced  back  in  such  a  manner  that  it  be- 
comes an  excavation  or  pit,  instead  of  being  slightly  prominent  as  in  the 
natural  state.  The  nerve-fibres,  bending  round  the  edge  of  this  pit  almost 
at  a  right  angle,  are  squeezed  against  the  margin  of  the  sclerotic  opening 
and  undergo  wasting,  by  which  this  margin  itself  is  rendered  conspicuous  ; 
while  the  bloodvessels,  following  the  same  course,  may  be  seen  to  bend 
in  a  similar  manner,  and  the  portions  on  the  floor  of  the  cup  may  even 
appear  to  be  disconnected  from  their  continuations  on  the  retina. 

Couri<e  and  Symptomi^. — In  extremel}'  chronic  cases  the  progress  of 
glaucoma  may  be  almost  uniform,  and  may  be  quite  painless.  The  symp- 
toms are  gradual  failure  of  vision,  attended  by  gradual  hardening  of  the 
eyeball.  The  peripheral  parts  of  the  retina  are  not  only  compressed,  but 
by  reason  of  their  distance  from  the  centre  of  circulation  their  blood- 
supply  is  checked  sooner  than  that  of  the  central  portions;  and  hence  it 
happens  that  they  are  the  first  to  show  failure  of  siglit,  and  that  the 
blindness  of  glaucoma  afli'ects  the  outer  part  of  the  field  of  vision,  and 
contracts  or  diminishes  its  extent,  even  while  central  vision  may  be  but 
little  impaired.  At  the  same  time  there  will  be  some  diminution  of  the 
natural  sensitiveness  of  the  cornea,  and  the  ophthalmoscope  will  show  a 
slight  depression  of  the  surface  of  the  optic  nerve,  generally  with  pul- 
sation in  the  veins.  In  the  subacute  form  the  pressure  does  not  increase 
regular]}',  but  at  uncertain  periods,  which  are  separated  by  remissions  ; 
and  the  symptoms  may  Ije  divided  into  the  premonitory  and  the  actual. 
The  premonitory  symptoms  are  some  diminution  of  the  acuteness  or  some 
contraction  of  the  field  of  vision,  together  with  failure  of  the  power  to 
adjust  the  eye  for  near  objects;  so  that  the  patient,  who  is  usually  past 
middle  age,  requires  stronger  spectacles  than  would  be  suited  to  his  3'ears, 
and  may  require  to  strengthen  them  once  and  agaiu  at  short  intervals. 
Very  often  there  will  be  some  irregular  dispersion  of  light  by  the  media 
of  the  eye,  so  that  a  candle-flame  appears  to  be  surrounded  by  a  halo  of 
prismatic  colors.  After  a  longer  or  shorter  duration  of  such  symptoms 
as  these  the  patient  experiences  a  sudden  attack  of  pain,  attended  by  ob- 
scuration of  sight,  which  may  be  either  complete  or  comparable  to  a  fog 
or  mist,  and  which  may  pass  away  in  a  few  minutes  or  not  for  some 
hours,  but  which  seldom  leaves  vision  as  good  as  it  was  before.  It  also 
leaves  a  very  decided  increase  of  tension,  and  sometimes  a  deep  excava- 
tion of  the  disk.  Such  attacks  occur  again  and  again,  and  presently  they 
establish  a  permanently  glaucomatous  state,  in  which  the  iris  and  lens 
are  pushed  forward  towards  the  cornea,  so  that  the  depth  of  the  anterior 
chamber  is  diminished,  in  which  the  pupil  is  somewhat  dilated,  and  often 
elliptical,  with  the  major  axis  horizontal,  and  in  wliich  the  anterior  veins 
which  perforate  the  sclerotic  near  the  cornea  are  dilated  and  tortuous. 
At  this  stage  the  cornea  is  often  steamy,  and  the  vitreous  hazy,  so  that 
no  good  view  of  the  fundus  can  be  obtained,  and  there  is  often  an 
amount  of  pain  and  of  conjunctival  congestion  which  may  lead  unskilled 
persons  to  apply  remedies  for  the  cure  of  an  imaginary  "ophthalmia."  In 
the  acute  form  tlie  paroxysms  are  nearer  together,  the  remissions  less  de- 
cided, and  the  course  is  more  rapid  ;  while  in  the  fulminating  form  sight 
may  be  hopelessly  destro3'ed  in  the  course  of  a  few  hours.  In  all  forms, 
unless  they  are  arrested,  total  blindness  is  the  inevitable  ultimate  result. 

Treatment. — The  only  treatment  which  is  of  any  avail  against  glau- 
coma is  the  operation  of  iridectomy,  which  should  be  performed  in  every 
case  as  soon  as  the  nature  of  the  disease  is  recognized,  so  long  as  any 
vision  remains.  The  eflTect  of  the  iridectomy  is  to  diminish  tension,  and 
to  restore,  more  or  less  completely,  the  natural  elasticity  of  the  eyeball, 


732 


DISEASES    OF    THE    EYE. 


r\. 


so  that  circulation  can  be  re-established,  and  the  nerves  ma_y  recover 
from  the  compression  to  which  they  have  been  subjected.  As  a  general 
rule,  iridectomy  may  be  expected  to  arrest  chronic  glaucoma  and  to  pre- 
serve the  sight  which  remains,  but  not  to  produce  more  than  a  slight  de- 
gree of  improvement,  gradually  developed  during  the  two  or  three  months 
after  the  operation.  In  subacute  and  acute  cases  it  is  useful  almost  in 
proportion  to  the  acuteness,  and  may  even  restore  sight  to  its  natural 
standard.  Occasionally  it  only  temporarily  reduces  tension,  and  in  some 
(chiefly  chronic)  cases  the  reduction  of  tension  fails 
Fig.  334.  to  arrest  atrophy  of  the  nerve,  which  leads  to  blind- 

ness. Still  the  operation  always  affords  the  only  pros- 
pect of  doing  good,  and  it  should  never  be  delayed 
in  the  hope  of  amendment  under  any  other  practice. 
Notwithstanding  all  that  has  been  said  and  written 
on  this  subject  during  the  last  few  years,  the  profes- 
sion generally  is  hardly  yet  aware  of  the  great  im- 
portance of  earh'  iridectomy  in  all  cases  of  glaucoma. 
The  precise  way  in  which  the  operation  reduces  ten- 
sion is  hardly  determined,  but  it  is  probably  partly 
by  the  actual  removal  of  a  large  piece  of  iris,  which 
is  also  a  secreting  surface,  and  parth'  by  the  for- 
mation of  a  comparatively  permeable  cicatrix  in  the 
ocular  tunics. 

hndectomy. — In  order  to  perform  iridectomy  for  the 
relief  of  tension  it  is  necessary  to  remove  a  large  piece 
of  iris,  and  to  remove  its  entire  width  quite  up  to  the 
ciliary    attachment.      The    portion    selected    should 
[  usually  be  the  middle  third,  or  more  than  the  middle 

third,  of  the  upper  half,  so  that  the  gap,  unless  the 
eye  is  very  prominent,  may  be  partly  or  entirely  con- 
cealed by  the  upper  lid,  and  ma^'  neither  be  unsightly 
nor  disturbing  to  vision.  If  the  anterior  chamber  is 
tolerably  deep  a  lance-knife  (Fig.  334)  may  be  used, 
and  the  incision  made  by  a  single  thrust ;  but  if  the 
chamber  is  shallow,  so  that  the  lens  would  be  exposed 
to  risk,  it  is  better  to  use  a  linear  knife  b}^  puncture 
and  counter-puncture,  as  for  the  extraction  of  cataract. 
The  patient  being  recumbent  and  fully  etherized,  and 
the  lids  separated,  the  operator  seizes  the  conjunctiva 
with  fixing  forceps  at  a  point  opposite  the  centre  of 
his  intended  incision.  If  the  lance-knife  is  used  its 
point  is  placed  on  the  centre  of  the  intended  incision, 
about  half  a  line  behind  the  corneal  margin,  and  is 
thrust  gently  through  until  it  can  be  seen  in  the  an- 
terior chamber.  It  is  then  directed  somewhat  for- 
ward, and  thrust  steadil3'on  over  the  opposite  margin 
of  the  pupil  until  nearly  the  whole  width  of  the  lilade 
has  entered  the  eye.  It  is  then  gently  but  quickly 
withdrawn.  The  operator  next  introduces  a  pair  of 
iris  forceps,  seizes  the  iris  near  the  pupillary  margin, 
draws  it  out,  cuts  it  through  with  scissors  quite  up  to 
Lance-knifc  for  iridcc-  ^^^^'  ^ihary  margin  at  one  end  of  the  wound,  tears  it 
tomy.  from  its  attachments  up  to  the  other  end,  and  cuts  it 

through  tiiere  in  the  same  manner.     If  a  portion  of 
iris  remains  entangled  at  either  end  of  the  wound  it  must  be  cut  out  if 


DISEASES    OF    DEEPER    PARTS    OF    EYE.  733 

possible,  or  it  may  be  made  to  return  into  tlie  chamber,  by  light  friction 
through  the  closed  lid,  or  it  may  be  replaced  by  the  end  of  a  fine  probe. 
Any  coagula  should  then  be  removed  from  the  sac  of  the  conjunctiva, 
the  eyelids  closed,  and  secui-ed  as  usual  by  a  bandage. 

For  Artificial  Pupil. — When  iridectomy  is  not  required  for  the  relief 
of  tension,  but  onl}'  for  an  artificial  pupil  to  afford  vision  through  some 
clear  part  of  the  media,  the  method  of  performance  is  essentiall}'  the 
same,  but  with  the  ditlerence  that  only  a  small  piece  of  iris  need  be  re- 
moved, and  that  the  place  selected  must  be  that  where  the  best  sight 
will  be  obtained,  that  is  to  sa}',  generally  speaking,  wherever  there  is  the 
best  piece  of  clear  cornea.  The  puncture  may  be  made  with  a  lance- 
knife  of  small  size,  and  the  piece  of  iris  which  is  drawn  out,  instead  of 
being  cut  and  torn,  may  l)e  simply  cut  off  close  to  the  forceps,  and  the 
rest  suffered  or  coaxed  to  return  into  the  eye. 

Diseases  of  the  Deejwr  Parts  of  the  Eye. — The  ophthalmoscope  reveals 
a  great  number  of  changes  in  the  deeper  parts  of  the  eye,  changes  which 
for  the  most  part  belong  rather  to  the  domain  of  medicine  than  of  sur- 
gery. Thus,  in  Bright's  disease  the  retina  l)ecoines  the  seat  of  patches 
or  flecks  of  white  or  glistening  fatty  degeneration,  usuall}'  intersi)ersed 
with  hfiemorrhages  ;  and  haemorrhages  ma}^  also  take  place  from  the  retinal 
arterioles  in  hj'pertrophj^  of  the  heart,  or  in  atheroma  of  the  vessels,  or 
as  an  accidental  result  of  the  plugging  of  a  considerable  branch  by  an 
embolus.  Venous  retinal  haemorrhage  occurs  in  several  forms  of  venous 
obstruction  or  passive  congestion,  in  many  cases  of  disordered  or  inter- 
rupted menstruation,  and  in  some  blood-diseases,  such  as  purpura.  The 
optic  nerves  are  liable  to  become  swollen  and  prominent  in  some  forms 
of  intracranial  disease,  and  notably  in  intracranial  tumors,  and  this  con- 
dition is  often  called  "optic  neuritis."  It  is  probably  essentially  an 
cedema,  attended  by  more  or  less  inflammatory  reaction.  It  may  be  en- 
tirely confined  to  the  connective  tissue  which  unites  the  fibres,  and  ma}'' 
thus  be  present  in  a  very  pronounced  degree  without  affecting  vision, 
although  even  then  it  ma\'  lead  to  secondary  atrophy  of  the  nerve,  by 
which  ultimatel}'  vision  may  be  totally  destroyed.  Whenever  there  is  a 
syphilitic  history  and  headache,  the  swelling  of  the  optic  disks  would 
point  to  the  probable  presence  of  a  gummatous  tumor  in  the  brain,  and 
would  demand  the  prompt  administration  of  full  doses  of  iodide  of  potas- 
sium. The  retina  is  not  unfrequently  studded  with  patches  of  syphilitic 
deposit,  around  which  some  inflammator}'  action  may  take  place;  and 
retinal  inflammation  may  also  be  excited  by  the  tissue  disturbance  inci- 
dental to  haemorrhage.  Perhaps  the  only  primar}'  inflammation  of  the 
retina  is  the  very  chronic  disease  which  is  known  as  "pigmentary  reti- 
nitis," in  which,  over  a  broad  zone  the  inner  margin  of  which  is  at  some 
little  distance  from  the  optic  nerve,  the  fundus  of  the  eye  is  strewn  with 
irregular  stripes  and  patches  of  black  pigment,  the  nerve  itself  being 
pallid  and  its  arteries  dwindled.  The  symptoms  of  pigmentary  retinitis 
are  comparative  blindness  at  night  and  contraction  of  the  field  of  vision, 
and  it  is  due  to  a  chronic  inflammation  which  involves  the  perceptive 
layer  of  the  retina  and  the  subjacent  choroid,  and  disorganizes  both.  The 
disease  is  very  slowly  progessive,  and  eventually  destroj's  sight;  but 
there  is  some  reason  to  believe  that  its  rate  of  progress  may  be  retarded 
by  the  persevering  administration  of  preparations  of  iron..  Besides  the 
presence  of  adventitious  deposits  and  the  occurrence  of  inflammation,  the 
retina  is  liable  to  be  absolutely  detached  from  the  subjacent  choroid  and 
elevated  like  a  blister  by  efiused  fluid  beneath.     Such  an  eLevation  is  seen. 


734  DISEASES    OF    THE    EYE. 

b}'  the  ophthalmoscope  as  an  irregular,  mobile,  whitish  prominence, 
crossed  b}'  the  retinal  vessels,  and  thrown  into  tremulous  vibrations  by 
the  movements  of  the  e_ye.  Attempts  have  been  made  to  procure  the 
subsidence  of  the  elevation  b^'  lacerating  it  with  needles,  so  as  to  permit 
the  fluid  beneath  to  escape  and  mingle  with  the  Vitreous;  but  none  of 
these  attempts  have  been  attended  by  an}^  great  measure  of  success. 

Diseases  of  the  Glioroid. — The  choroid,  besides  the  acute  inflammation 
which  may  extend  to  it  from  the  iris,  is  liable  to  chronic  inflammation, 
which  is  only  discoverable  by  the  ophthalmoscope,  and  which  ma,y  be 
either  disseminated  in  scattered  patches  or  diffused  generally  over  the 
surface.  Tlie  pathology  of  choroiditis  is  by  no  means  completel}^  under- 
stood, but  it  is  probably  due  to  syphilis  in  a  great  majority  of  the  in- 
stances in  which  it  occurs  ;  and  in  the  cases  which  are  not  syphilitic  it  is 
often  associated  with  a  high  degree  of  m3^opia,  which  appears  to  be  an 
exciting  cause  on  account  of  the  mechanical  strain  thrown  on  the  pos- 
terior hemisphere  of  the  eyeball  by  excessive  convergence.  Choroiditis 
is  often  more  immediately  and  more  permanently  injurious  to  the  sight 
than  any  of  the  forms  of  so-called  retinitis  ;  for  the  latter  may  affect  the 
connective  tissue  of  the  fibre  layer,  scarcely  at  all  interfering  with  the 
perceptive  elements  beneath,  while  the  former  necessarily  involves  the 
inner  or  capillary  layer  of  the  choroid,  from  which  the  perceptive  ele- 
ments of  the  retina  derive  the  materials  of  their  nutrition.  In  its  earlier 
stage  choroiditis  is  attended  by  effusion,  and  this  is  succeeded  by  atrophy 
of  the  aff'ected  part  of  the  membrane,  which  wastes  and  disappears  en- 
tirel}',  so  as  to  uncover  the  white  surface  of  the  sclerotic.  At  the  same 
time  the  aff"ected  patches  usually  become  bordered  bj'  black  pigment. 
All  these  changes  are  often  present  together,  with  the  effect  that  a  case 
of  choroiditis,  when  examined  by  the  ophthalmoscope,  presents  a  gen- 
eral effect  of  variegation  or  "marbling"  of  the  fundus  of  the  eye,  the 
natural  orange-red  or  brownish-red  surface  being  variegated  by  patches 
of  effusion,  patches  of  progressing  or  of  completed  atrophj-,  and  black 
deposits  of  every  variety  of  outline. 

Treatment. — A  case  of  choroiditis  sometimes  comes  under  observation 
only  when  the  storm  has  spent  its  force  and  when  atrophy  has  made  con- 
siderable progress.  For  such  no  treatment  is  required;  but  whenever  a 
careful  examination  discovers  patches  of  recent  or  still  existing  etfusion 
the  disease  is  continuing.  It  is  then  necessary  to  consider  the  question 
of  syphilis,  and  to  treat  it  if  it  exists,  or  if  on  any  good  ground  it  is 
strongly  suspected.  Apart  from  this,  rest  of  the  eyes  must  be  enforced, 
t'hey  niust  be  sheltered  from  strong  light  by  shaded  rooms  and  dark-blue 
spectacles;  blood  may  be  taken  from  the  temples  1)}'^  cupping  or  by  Heur- 
teloup's  artificial  leecli,  and  iodide  of  potassium  may  generally  be  admin- 
istered, together  with  such  other  constitutional  remedies  as  circumstances 
ma}'  require. 

Diseases  of  the  Vitreous -It  is  an  open  question  whether  the  vitreous 

body  is  itself  suscei)tible  of  inflammation.  Cases  have  been  recorded  in 
whicli  de[)osits  of  pus  were  found  in  its  very  centre;  but  ex[)erimeuts  on 
tlie  lower  animals,  so  far  as  tliey  may  be  accepted  as  conclusive,  tend  to 
show  that  apparent  inflammation  of  the  vitreous  is  a  condition  propagated 
from  its  containing  mcml)r;incs.  However  this  may  be,  the  vitreous  is 
often  turbid  in  retinitis  or  ciioroiditis;  and  it  may  Ije  so  turbid  as  com- 
pletely to  conceal  tiiese  conditions.  It  is  often  discolored  by  hlood  in 
cases  of  intraocuhir  iuemorrhage,  and  is  sometimes  beset  by  membranous 


MORBID    GROWTH?.  735 

flocculi,  which  float  about  in  sucli  a  manner  as  to  show  that  the  humor 
has  lost  its  natural  gelatinous  consistence  and  has  become  fluid.  All 
these  conditions  are  evidences  of  profound  nutritive  disturbance,  and 
justify  a  grave  prognosis.  Unless  other  indications  are  i)rcsent,  turbidity 
of  tlie  vitreous  generally  calls  for  counter-irritation  on  the  temple,  and 
for  the  administration  of  perchloride  of  mercury  or  of  iodide  of  potassium, 
under  which  treatment,  in  a  certain  number  of  cases,  very  considerable 
restoration  of  transparency  may  be  brought  about.  Von  Graefe  has 
recorded  a  single  instance  in  which  a  membranous  film  occupied  tli« 
vitreous  chamber  and  stretched  across  it  behind  the  lens  in  such  a  way 
as  almost  entirely'  to  destroy  vision.  Having  satisfied  himself  of  tlie 
depth  of  the  film,  he  lacerated  it  by  two  needles  introduced  beliind  tlie 
ciliary  region,  and  succeeded  in  making  a  central  aperture  througii  which 
excellent  sight  was  ultimately  obtained. 

Morbid  Growths  ivithin  the  Eye. — Tlie  vitreous  chamber  of  the  eye  is 
liable  to  be  the  seat  of  malignant  growths  of  two  distinct  classes — sar- 
comata, which  commence  in  the  choroid  or  iris  ;  and  gliomata,  which  com- 
mence in  the  connective  tissue  of  the  retina.  Both  alike  destroy  vision 
at  an  early  period  of  their  progress,  both  produce  enormous  enlargement 
and  projection  of  the  eyeball,  and  both,  when  its  coats  give  way,  protrude 
as  'fungous  and  bleeding  masses.  The  sarcomata  prove  fatal  mainly  in 
this  way :  wearing  out  the  patient  by  pain  and  exhaustion  ;  but  the  gli- 
omata still  more  speedily,  by  spreading  backwards  along  the  optic  nerve 
and  optic  tract,  and  occasioning  the  formation  of  secondary  tumors  in 
the  brain.  Sarcomata  are  extremely  rare ;  and  Knapp,  in  his  treatise  on 
intraocular  tumors,  records  only  eight  cases  originating  in  the  choroid, 
and  two  originating  in  the  iris,  in  one  of  which,  as  the  growth  was  not 
removed,  the  diagnosis  was  not  absolutel}'  certain.  I  have  myself  pub- 
lished a  case  of  multiple  round-celled  sarcomata  of  both  irides,'  which 
has  now  been  two  years  under  observation  with  only  slight  increase  of 
the  growths.  Gliomata  are  more  frequently  met  with,  and  usuall}'  occur 
in  young  children.  The  presence  of  a  tumor  within  the  eye  is  made 
known  by  impairment  or  loss  of  vision,  by  projection  forward  of  the  lens 
and  iris  towards  the  cornea,  by  increased  hardness  of  the  globe,  by  ten- 
sive pain  and  inflammatory  reaction  of  a  degree  proportionate  to  the 
rapidity  of  increase  of  the  growth,  and  by  the  visibility  of  the  tumor 
itself.  The  gliomata  are  white  or  primrose-^yellovv  in  color,  and  soon  be- 
come conspicuous  through  the  pui)il ;  but  the  sarcomata  are  yellowish  or 
reddish,  often  contain  melanotic  pigment,  and  are  less  easily  discoverable. 
Still,  by  dilatation  of  the  pupil  and  by  focal  and  ophthalmoscopic  illumi- 
nation, a  new  growth  can  generally  be  seen  if  carefully  looked  for;  and 
no  absolute  certainty  about  the  nature  of  any  intraocular  growth  can  be 
obtained  prior  to  its  removal.  In  a  few  instances  an  intraocular  tumor 
has  proved  to  be  no  more  than  a  mass  of  tubercle  ;  and  I  have  seen  one 
case  in  which  the  appearance  of  a  tumor  was  precisel}'  imitated  by  a  de- 
posit of  yellow  gelatinous  lymph  on  the  posterior  surtlace  of  the  lens.  A 
far  more  dangerous  error  has  been  occasioned  by  the  white  color  of  a 
glioma,  which,  seen  througii  the  still  transparent  lens,  has  been  mistaken 
for  cataract.  The  unnatural  hardness  of  the  globe,  the  projection  for- 
ward of  the  iris,  and  the  total  loss  of  sight,  should  render  such  an  error 
impossible. 

Whatever  ma}'  be  the  nature  of  an  intraocular  growth,  enucleation  of 
the  eye  should  be  performed  without  delay  ;  and,  in  a  case  of  glioma,  the 

'  Trans,  of  Clinioid  Society,  vol.  vii. 


736  INJURIES    OF     THE    EYE. 

oi)tie  nerve  should  be  severed  at  the  apex  of  the  orbit,  instead  of  imme- 
diately behind  the  globe.  For  this  purpose  the  best  instrument  is  a 
probe-pointed  bistour}-,  curved  on  the  flat,  which  may  be  guided  along 
the  nerve-trunk  as  far  as  possible  before  being  made  to  divide  it.  The 
results  of  early  removal  of  the  eye  in  sarcoma  are  fairly  good,  half  of 
Knapp's  cases  having  undergone  no  relapse,  while  the  other  half  died  of 
secondary  growths  in  internal  organs.  In  glioma  the  prognosis  is  much 
less  favorable;  and  Hirsehberg  has  been  able  to  collect  only  five  cases 
in  which  the  diagnosis  was  established  beyond  doubt  by  microscopic  in- 
vestigation, and  in  which  the  patient  remained  under  observation  for  a 
suHk'iently  long  time  to  render  it  certain  that  a  permanent  cure  had  been 
effected.  In  one  of  these  cases  I  was  the  operator,  and  the  patient  is 
still  in  good  health,  after  the  lapse  of  thirteen  years.  In  two  other  cases 
of  mine  there  has  been  no  recurrence  for  some  months,  and  the  children 
have  then  been  lost  sight  of,  their  parents  having  promised  to  bring  tliem 
without  delay  if  any  symptoms  of  a  return  of  the  growth  appeared.  On 
the  whole,  I  think  the  evidence  is  in  favor  of  a  belief  that  recurrence 
may  be  prevented  by  sufficiently  early  enucleation,  while  the  glioma  is 
still  wholly  included  within  the  e^'e  ;  and  that  the  unfavorable  cases  are 
those  in  which  the  disease  has  already  made  its  v/a}'  along  the  optic 
nerve  to  beyond  the  point  of  section.  I  read  before  the  Clinical  Society^ 
a  very  instructive  case  of  congenital  glioma  of  both  retinte.  The  right 
e3'e  was  removed  during  the  third  month,  and  the  character  of  the  patches 
on  the  retina  was  determined  by  microscopic  examination.  The  parents 
refused  to  permit  removal  of  tlie  left  eye  until,  when  the  child  w^as  three 
years  old,  it  had  become  greatly  enlarged  and  acutely  painful.  Removal 
was  then  performed,  and,  in  a  forlorn  hope  that  the  Ijrain  might  have  es- 
caped, the  wliole  contents  of  the  orbit  were  cleared  out  by  the  galvanic 
cautery,  and  the  cavity  was  lined  with  chloride  of  zinc  paste.  The  child 
died  a  few  days  afterwards,  and  a  large  mass  of  intracranial  cancer  was 
found  on  the  left  side ;  but  the  right  side  was  free  from  disease,  and  the 
right  optic  nerve  had  dwindled  to  a  fibrous  cord  quite  up  to  the  chiasma. 
There  can  be  little  doubt  that  if  both  eyes  had  been  removed  in  infancy'' 
the  child's  life  would  have  been  saved. 

Wlien  a  malignant  growth  has  already  occasioned  enlargement  of  the 
ej-eball,  or  has  perforated  its  coats,  the  expectation  of  preserving  life  is 
scarcely  to  be  entertained  ;  and  an  operation  can  only  be  undertaken  with 
a  view  to  the  relief  of  suffering  V)y  the  removal  of  the  acutely  sensitive 
textures  of  the  eyeball  and  its  appendages.  For  such  a  purpose  the  re- 
moval should  be  as  complete  as  p(jssible,  and  should  include  all  the 
tissues  witliin  the  orbit.  I'he  enlarged  ophthalmic  artery  will  generally 
bleed  freely  ;  and  it  may  be  necessary  to  apply  the  actual  cautery,  or  to 
plug  with  compresses  moistened  with  solution  of  perchloride  of  iron,  and 
secured  b}'  firm  pressure  with  a  bandage. 

In  the  few  cases  in  which  a  tumor  within  the  eye  is  found,  after  enu- 
cleation, to  be  of  a  benign  character,  there  can  yet  be  no  doubt  of  the 
propriety  of  the  operation.  A  mass  of  tubercle  or  lymph  would  destroy 
the  eye  as  an  organ  of  vision  ;  and  in  course  of  time  might  undergo 
osseous  or  calcareous  change  which  would  irritate  the  ciliary  nerves  and 
occasion  sympathetic  ophthalmia. 

Injuries  of  the  Eye. — Like  all  otliei-  i)arts  of  the  body,  the  eye  is  ex- 
posed to  various  kinds  of  accidental  injury  ;  and,  although  it  is  much 

'   Trans.,  op.  cit. 


REMOVAL    OF    FOREIGN    BODIES.  737 

sheltered  from  direct  violence  by  the  prominence  of  the  margin  of  the 
orbit,  and  from  small  projectiles  by  the  eyelashes,  by  the  rapid  and  in- 
stinctive closure  of  the  lids,  and  by  the  rotation  of  the  cornea  nijwards, 
which  occur  at  the  slightest  intimation  of  danger,  yet  tlie  peculiar  vul- 
nerability^ of  the  organ  causes  it  to  suffer  severely  from  casualties  which 
would  be  unfelt  or  unnoticed  elsewhere.  The  intense  irritation  occa- 
sioned by  the  jiresence  of  minute  foreign  bodies  is  familiar  to  most  per- 
sons, and  is  perhaps  experienced  in  the  greatest  degree  when  the  intruder 
is  lodged  in  a  very  common  position,  beneath  the  upper  lid  and  just 
within  its  margin,  so  that  it  scrapes  the  sensitive  epithelium  of  the  cornea 
at  every  movement.  It  is  necessary  to  remember  that  a  patient  is  often 
unconscious  of  the  ijnpactof  a  foreign  body,  and  totally  unsuspicious  of 
its  presence  ;  and  that  while,  if  under  the  ujiper  lid,  it  is  concealed  from 
view,  it  may  also,  if  itself  of  dark  color,  easily  escape  the  notice  of  a 
careless  observer  when  it  is  imbedded  in  the  cornea  over  the  region  of 
the  i)U})il,  or  even  when  it  has  a  background  of  dark  iris.  In  every  case 
of  suddenly  occurring  inflammator}'  irritation  of  the  eye  it  is  proper  to 
evert  the  lid  and  to  inspect  its  under  surface,  and  also  to  scrutinize  the 
surface  of  the  cornea  closel}^,  and  by  the  aid  of  light  falling  upon  it  at 
different  angles,  so  that  no  foreign  suljstance  ma}'  be  overlooked.  In  the 
out-patient  departments  of  hospitals  it  is  not  uncommon  to  see  persons 
who  have  been  severely  treated  for  ophthalmia,  and  who  are  cured  at  once 
by  the  removal  of  a  morsel  of  iron  or  cinder,  which  had  not  been  observed 
by  the  practitioner  to  whom  they  first  made  application. 

RemoxKil  of  Foreign  Bodies. — When  a  foreign  substance  is  lodged  be- 
neath the  upper  lid  it  may  be  removed  in  an  instant,  as  soon  as  the  lid  is 
everted,  by  the  point  of  a  pen  or  of  a  penknife,  or  by  the  finger-nail ;  and 
the  case  will  seldom  require  any  further  treatment.  But  when  a  similar 
substance  is  imbedded  in  the  cornea  its  removal  may  be  much  more  diffi- 
cult, chiefly  on  account  of  the  great  sensitiveness  of  the  surface.  In  the 
country  the  wing-case  of  a  minute  beetle  is  a  foreign  body  frequently  met 
with,  and  this  ma^^  be  dislodged  by  a  touch,  as  it  is  held  against  the 
cornea  only  by  atmospheric  pressure.  In  towns  we  have  more  frequently 
to  deal  with  splinters  of  wood,  or  iron,  or  glass,  or  with  fragments  of 
cinders — these  being  especially  common  among  railway  travellers  who 
look  out  of  windows — and  all  such  things,  when  they  are  really  im- 
bedded, require  circumspection.  They  should  seldom  be  touched  with 
any  sharp  instrument,  which  would  scratch  the  cornea  as  often  as  it  failed 
to  dislodge  them  ;  but  they  should  be  tilted  out  by  means  of  a  minute 
spatula,  set  in  an  appropriate  handle.  If  the  surgeon  is  nnpracticed  at 
operations  of  this  kind,  and  if  the  eye  is  irritable,  it  is  better  at  once  to 
place  the  patient  in  a  recumbent  posture,  to  keep  the  lids  apart  by  a  wire 
speculum,  and  to  fix  the  eye  by  pinching  up  a  fold  of  the  conjunctiva 
with  appropriate  forceps,  so  that  the  removal  may  be  done  deliberately. 
If  the  patient  is  a  child  it  is  better  to  give  an  anaesthetic.  When  the 
foreign  body  is  very  small,  or  when  it  is  inconspicuous  b}'  reason  of  its 
color,  an  assistant  should  concentrate  lami)light  or  daylight  upon  it  by  a 
lens,  as  in  focal  illumination  ;  and  when  it  has  nearly  penetrated  the 
cornea  it  may  be  supported  from  within  during  removal  by  a  smooth 
blunt  spatula,  introduced  into  the  anterior  chamber  through  a  preliminary 
puncture  with  a  narrow  knife  or  broad  needle.  Complete  removal  should 
be  effected  whenever  it  is  possible,  but  it  must  be  borne  in  mind  that 
fragments  of  iron  stain  the  tissues  with  which  they  have  been  in  contact, 
and  leave  a  discoloration  when  the  whole  of  the  metal  is  gone.  This  dis- 
coloration may  be  readily  distinguished  from   the  remains  of  a  foreign 

47 


738  INJURIES    OF    THE    EYE. 

body,  because  it  is  {vlwa3's  an  anmilns  with  a  transparent  or  colorless 
centre,  a  character  which  may  be  seen  at  once  with  a  magnifying  glass. 
After  the  removal  of  an}^  imbedded  substance  the  exposed  corneal  tissue 
is  often  higldy  sensitive:  but  it  may  usually  be  effectually  sheltered  from 
air  and  from  the  friction  of  the  lid  by  the  occasional  application  of  a  drop 
of  castor  oil  to  the  surface  until  healing  is  complete.  Tlie  oil  appears  to 
act  only  mechanically  ;  but  where  a  foreign  body  has  been  long  imbedded, 
and  there  is  much  irritation,  sulphate  of  atropia  may  be  dissolved  in  the 
oil  by  the  aid  of  heat,  in  the  proportion  of  two  grains  to  the  ounce,  so  as 
to  obtain  also  the  action  of  a  medicinal  sedative. 

Severe  Injuries. —  Wlien  a  more  severe  injury  has  been  inflicted,  such 
as  a  violent  blow  or  contusion,  a  punctured  or  in-cised  wound,  or  the 
lodgment  of  a  foreign  body  within  the  globe,  the  first  care  of  the  surgeon 
must  be  to  consider  whether  the  safet}'  of  the  other  eye  is  imperilled.  It 
is  now  well  establislied  that  injuries  of  a  certain  class  are  liable  to  pro- 
duce what  is  called  sympathetic  ophthalmia  ;  that  is  to  saj^,  an  affection 
of  tlie  other  eye,  which  commences  as  an  apparently  sligiit  and  very  in- 
sidious plastic  iritis,  and  which  leads  in  nearly  all  cases,  under  whatever 
treatment,  to  ultimate  wasting  of  the  globe  and  destruction  of  sight. 
Tliere  is  much  reason  to  believe  that  the  initial  phenomenon  of  S3'mpa- 
thetic  oiihthalmia  is  irritation  of  one  of  the  ciliary  nerves  of  the  injured 
eye  ;  and  many  instances  are  now  on  record  in  which  such  irritation  has 
been  conspicuously  present,  a  ciliary  nerve  liaving  been  found  imbedded 
in,  and  compressed  by,  the  cicatrix,  or  even  in  a  state  of  actual  inflam- 
mation. Nothing  is  known  with  regard  to  the  time  during  which  such 
conditions  may  remain  limited  to  the  affected  e3^e ;  but  wlien  once  this 
time  lias  passed,  when  the  irritation  has  reached  some  central  ganglion, 
and  has  been  so  reflected  as  to  influence  the  nutrition  of  the  sound  eye, 
remedial  measures  are  generally  of  little  or  no  avail.  As  a  general  rule, 
it  is  almost  always  possible  to  prevent  the  occurrence  of  sympathetic 
ophthalmia  by  the  timely  removal  of  an  eye  which  is  in  a  state  likely  to 
produce  it;  but  it  is  seldom  possible  to  arrest  sympathetic  ophtlialmia 
when  it  is  once  produced.  In  every  case  of  severe  injury,  therefore,  the 
propriet}'  of  removing  the  injured  eye  must  be  a  matter  for  serious  con- 
sideration. 

Sj/mpathetic  ophthalmia  is  produced,  most  quickly  and  certainly,  by 
injuries  which  implicate  the  region  of  the  ciliary  bod}'.  Next  in  order 
come  wounds  which  produce  dragging  upon  the  tunics  of  the  eye  by  the 
contraction  of  cicatrices ;  next,  cases  in  wluch  chronic  inflammation, 
whether  produced  or  not  by  the  lodgment  of  a  foreign  substance,  spreads 
from  the  iris  to  the  ciliar}'  body  ;  lastly,  cases  in  which  the  effusion  of 
plastic  choroiditis  becomes  in  time  converted  into  bone.  Whenever  the 
ciliary  region  is  at  all  severely  hurt  it  is  generally  advisable  to  perform 
enucleation  without  dela}' ;  and  in  all  extensive  wounds  it  should  be  men- 
tioned as  a  proceeding  which  events  may  render  necessary.  It  should 
also  be  performed  whenever,  at  any  period  after  injury,  the  ciliary  region 
Ijeconies  very  tender  to  the  touch,  especially  if  palpation  discovers  bony 
hardness  in  the  deeper  j)arts  of  the  globe.  Whenever  an  injury  is  so  se- 
vere that  the  eye  is  manifestly  destroyed  as  an  organ  of  vision  it  is  best 
to  perform  enucleation  at  once,  as  in  primary  amputation  after  injury 
before  local  inflammation  is  set  up;  but  in  less  severe  cases  it  is  proper 
to  wait  and  watch,  since  sympathetic  oj)hthalmia  seldom  or  never  occurs 
prior  to  the  time  of  cicatrization,  or  of  conti'action  of  inflammatory 
effusions. 

Sympathetic  Irritation. — A  few  cases  are  on  record  in  which  an  injury 


CONTUSIONS,  739 

^vliich  would  ordinarily  produce  syinpatlietic  ophthalmia  has  produced 
instead  a  state  which  has  been  called  sj'mpathetic  irrritation  ;  in  which, 
witliont  an}'  manifest  morbid  change,  the  secondarily  affected  eye  has 
been  rendered  useless  by  h^'perresthesia,  disi)layed  by  intolerance  of  light, 
lachryniation,  and  total  want  of  power  to  exercise  tlie  visual  function. 
Such  cases  have  continued  without  improvement  for  long  periods,  and 
have  been  cured  immediatel}'  b}'  removal  of  the  e_ye  primarily  injured, 
the  patients,  on  recovering  from  the  an.iesthetic  administered  for  the 
operation,  having  been  ready  to  resume  their  duties  in  life.  In  one  pa- 
tient of  my  own,  a  wasted  and  irritable  eye,  containing  a  shell  of  bone, 
failed  to  affect  its  fellow,  but  produced  a  succession  of  attacks  of  general 
tetanic  spasm,  some  of  wliich  were  of  great  severity.  After  the  removal 
of  the  eye  the  attacks  abated  in  frecpienc}-,  and  soon  entirely  ceased. 

Enucleation. — The  operation  of  enucleation,  when  the  tunics  of  the  eye 
are  unbroken,  is  very  easy  of  performance.  The  object  is  to  remove  tlie 
globe  alone,  leaving  the  wliole  of  the  muscles  to  coalesce  and  form  a 
stump,  on  which  an  artificial  eye  may  be  supported  in  such  a  manner  as 
to  be  freel}'  movable.  Besides  the  ordinary  speculum,  the  only  instru- 
ments recpiired  are  a  strabismus  hook,  a  pair  of  strong  fixation  forceps, 
and  a  pair  of  strabismus  scissors,  curved  on  the  flat,  and  witli  smooth 
and  rounded  points.  The  lids  being  widely  separated,  the  operator 
pinches  up  the  conjunctiva  over  the  insertion  of  the  external  rectus  mus- 
cle and  divides  it,  with  its  subjacent  tissue,  down  to  the  surface  of  the 
tendon.  The  tendon  is  then  lifted  on  the  hook,  and  cut  through  in  such 
manner  as  to  leave  not  more  than  a  line  of  its  length  attached  to  the 
sclerotic.  Seizing  tliis  remaining  portion  with  the  forceps,  the  operator 
rotates  the  eye  strongly  towards  the  nose,  then  introduces  the  scissors  at 
the  wound  and  carries  tliem  round  tlie  posterior  hemisphere  of  tlie  eye- 
liall,  so  tliat  their  blades  may  include  the  optic  nerve  and  may  divide  it 
close  to  the  sclerotic.  Retaining  his  hold,  he  pushes  one  blade  of  the 
scissors  under  the  tendon  of  the  inferior  rectus  and  divides  it,  and  the 
conjunctiva  covei'ing  it,  at  one  stroke;  and  then  divides  the  tendon  of 
the  superior  rectus  in  the  same  vvay,  in  both  cases  cutting  close  to  the 
eyeball,  wliich  can  then  be  lifted  out  of  the  orbit,  jirior  to  the  division  of 
any  remaining  attachments  of  the  oblique  muscles,  and  of  the  internal 
rectus  and  conjunctiva.  When  the  tunics  of  the  eye  are  broken  the 
operation  is  less  easy,  and  resolves  itself  into  a  careful  dissection  with 
scissors,  the  points  of  which  must  be  kept  close  to  the  slerotic.  As  soon 
as  an  eye  is  removed,  the  cavity  must  be  plugged  witii  sufficient  sponge 
to  afford  a  basis  for  firm  pressure  with  a  bandage.  The  sponge  may  be 
removed  in  three  of  four  hours,  when  all  tendency  to  bleeding  has  ceased  ; 
but  if  it  is  not  efficiently  applied,  or  if  it  is  removed  too  soon,  blood  will 
find  its  way  into  the  connective  tissue,  and  will  produce  extensive  ecchy- 
inosis  of  the  lids  and  cheek,  which  may  not  disapj)ear  for  weeks.  When 
the  sponge  is  removed  no  other  dressing  than  a  simple  covering  will  be 
required  ;  and  in  about  ten  days  the  patient  should  begin  to  wear  a  glass 
scale,  as  a  step  towards  a  properly  fitted  artificial  eye. 

Conlusions  of  the  eye,  if  they  do  not  rupture  the  cornea  or  the  sclerotic, 
are  generally  recovered  from  with  comparatively  little  injury,  unless  they 
produce  veiy  large  haemorrhage  from  the  sclerotic,  or  detachment  of  the 
retina,  both  rare  occurrences.  Haemorrhage  into  the  interior  chamber, 
even  if  considerable  in  amount,  is  usually  quickly  absorbed  without  doing 
mischief;  and  detachment  of  some  portion  of  the  iris  from  its  ciliaiy 
margin,  although  it  forms  a  second  pupil  and  alters  the  shape  of  the  nat- 
ural one,  is  seldom  followed  by  any  serious  consequences.     If  the  cap- 


740  INJURIES    OF    THE    EYE. 

siile  of  the  lens  is  ruptured,  so  as  to  admit  the  aqueous  humor  to  the 
cortex,  traumatic  cataract  will  be  produced ;  but  if  the  pupil  is  kept  well 
dilated  absorption  will  usually  go  on  quietl}-,  without  inflammation  or 
distress.  In  all  such  cases,  besides  the  use  of  atropine,  the  treatment 
should  consist  of  spirit-lotion,  anodynes  if  there  should  be  pain,  a  leech 
or  two  if  there  should  be  any  appearance  of  inflammation,  and  careful 
watchfulness  of  the  course  of  events.  Sometimes  the  nucleus  of  the  lens 
may  resist  absorption  by  reason  of  its  hardness,  and  maj'  ultimately  re- 
quire extraction.  Sometimes  the  lens,  possibly  in  its  unbroken  capsule, 
may  be  dislocated  into  such  a  position  that  it  troubles  the  iris  or  ciliary 
region  b^'  pressure.  In  all  cases  the  principle  is  the  same,  to  wait  and 
watch,  and  only  to  interfere  surgically  if  interference  is  manifestl}^  re- 
quired. The  same  may  be  said  of  cases  in  which  the  sclerotic  is  rup- 
tured but  the  conjunctiva  remains  unbroken.  Under  such  circumstances 
the  lens  is  sometimes  driven  out  of  the  e^'e,  and  appears  as  a  prominence 
under  the  conjunctiva.  It  must  be  treated  like  a  false  cartilage  which 
has  been  pressed  out  of  the  knee-joint  into  the  subcutaneous  tissue  :  not 
removed,  that  is,  until  the  wound  in  the  deeper  tunics  has  had  time  to 
unite  and  consolidate.  The  conjunctiva  maj^  then  be  divided  with  scissors, 
and  the  lens  tilted  out  of  its  new  bed. 

Contusions  icith  Rujiture. — When  the  tunics  are  completel}'^  ruptured 
by  a  contusion,  and  the  fracture,  so  to  speak,  is  originally  compound, 
the  results  are  generally  disastrous.  There  is  usually  a  free  escape  of 
vitreous  humor  and  a  good  deal  of  bleeding;  and  only  an  imperfect 
restoration  of  sight  can  be  hoped  for.  The  treatment  is  practical!}-  the 
same  as  for  more  simple  injuries. 

Incised  or  punctured  ivoimds  occur  most  frequently  in  the  cornea, 
the  former  often  from  breakages  of  glass,  especially  from  the  bursting 
of  bottles  containing  elfervescent  liquids,  the  latter  often  from  the 
endeavors  of  children  to  unfasten  knots  or  bootlaces  with  a  fork.  In- 
cised wounds  are  sometimes  met  with  in  the  sclerotic,  where  they  give 
little  trouble,  and  where  they  may  be  united,  if  large,  by  a  single 
point  of  fine  suture.  Incised  wounds  of  the  cornea  alone,  if  cleanly  cut, 
will  often  unite  with  no  worse  consequence  than  an  opaque  linear  cicatrix, 
which  possil)ly  ma^'  produce  some  cbange  in  the  corneal  curvatnre.  The 
only  treatment  necessary  is  to  apply  a  compressive  bandage  and  to 
endeavor  to  keep  the  iris  awa}'  from  the  injury,  so  that  it  may  not  be- 
come adherent  to  it.  This  is  best  accomplished,  if  the  injury  is  central, 
by  atropine  dilatation  ;  and  if  it  is  marginal,  by  using  in  the  same  man- 
ner a  solution  of  sulphate  of  eserine  (gr.  j  ad  f3iu)  to  produce  complete 
contraction  of  the  pupil. 

Of  the  Iris  and  Lens. — It  will  happen  most  usually  in  incised  wounds, 
and  almost  alwaj's  in  punctured  wounds  of  the  cornea,  that  the  iris  or 
the  lens,  or  both,  will  participate  in  the  injury;  and  a  punctured  wound, 
if  inflicted  by  a  blunt  fork  or  by  a  shot  corn,  will  have  mucli  the  char- 
acter of  a  contusion.  In  all  such  cases,  if  any  foreign  body  remains 
witliin  tlie  eye,  it  should  be  extracted  if  possil)le  ;  and  if  it  should  be 
lodged  in  the  iris  it  should  be  extracted  by  excision  of  the  piece  in  wiiich 
it  is  so  lodged.  It  is  not  always  possil)le  to  be  sure  whether  a  foreign 
body,  such  as  a  shot-corn,  has  lodged  or  escaped  ;  but  where  there  is 
good  reason  to  suspect  lodgment,  and  tlie  injury  is  severe,  it  is  better  to 
perform  enucleation  without  delay.  If  the  injury  is  not  manifestly  severe 
it  is  right  to  wait  for  a  time,  and  to  be  guided  by  the  course  of  events. 
When  traumatic  cataract  is  produced  it  should  generally  be  removed  by 
suction  or  extraction  ;  and  when  iris  is  incarcerated  in  a  corneal  wound 


INJURIES    FROM     CORROSIVE    SUBSTANCES.  741 

the  hernia  shouhl  either  be  reduced  or  excised.  In  all  cases  inflamma- 
tion should  be  combated  by  coolinj^  applications  and  by  the  control  of 
pain,  as  well  as  by  suitable  general  management  of  the  case;  and  the 
issue  will  depend  upon  the  success  with  which  tliis  is  done.  In  many 
cases  severe  injuries  lead  to  wasting  of  the  eyeball ;  in  some  they  are 
recovered  from  with  no  worse  injury  than  some  impairment  of  vision,  due 
to  distortion  or  partial  opacity  of  the  cornea,  or  to  loss  of  the  crystalline 
lens. 

ItijuriPH  from  Corrosive  Substances. — A  class  of  injuries  of  a  differer)t 
character  from  any  of  tlie  foregoing  may  be  produced  by  burning,  or  by 
the  introduction  of  corrosive  substances  into  the  sac  of  the  conjunctiva. 
Lime  is  perhaps  the  agent  of  this  kind  which  is  most  commonly  intro- 
duced by  accident,  and  corrosive  acids  are  sometimes  thrown  over  the 
face  with  criminal  intent.  The  first  thing  to  be  done  in  such  cases  is 
to  evert  the  lids,  to  remove  all  solid  substances,  such  as  fragments  of 
lime  or  mortar,  grains  of  unburnt  gunpowder,  and  so  forth,  and  then  to 
wash  the  exposed  surfaces  thoroughly  with  a  syringe  and  warm  water,  so 
as  to  remove  finer  particles  or  chemically  irritant  liquids.  Atropinized 
castor  oil  should  then  be  applied  to  the  conjunctiva,  and  evaporating 
lotion  or  other  suitable  dressing  to  the  closed  lids.  Sometimes  the  cornea 
is  destroyed  or  disorganized,  and  rendered  opaque,  and  vision  is  wholly 
lost ;  but  in  many  cases  the  upper  half  of  the  cornea  has  been  sheltered 
by  the  upper  lid,  and  has  escaped  either  entirely  or  without  serious  in- 
jury. Very  often,  however,  the  lower  portion  of  the  cornea  is  denuded 
of  epithelium,  and  the  lower  portion  of  the  conjunctiva,  both  ocular  and 
palpebral,  is  extensively  destroyed  ;  and  when  this  is  the  case  the  op- 
posed raw  surfaces  unite  during  the  healing  process,  and  produce  that 
adhesion  of  the  lid  to  the  eyeball  which  is  called  symblepharon.  This 
state  is  not  only  exceedingly  disti'essing  by  its  interference  with  the 
movements  of  the  eye,  but  it  also  feeds  the  corneal  cicatrix  by  the  con- 
junctival vessels,  and  renders  it  fleshy  and  opaque.  Symblepharon  was 
practically  incurable  until  Mr.  Teale  of  Leeds  devised  a  very  ingenious 
operation  for  its  relief.  After  separating  the  united  surfaces  by  dissec- 
tion, he  brings  down  a  bridge,  or  two  flaps,  of  conjunctiva,  from  above 
the  cornea,  and  transplants  them  to  fill  the  gap  belovv  it.  In  this  way 
raw  surfaces  are  no  longer  in  contact,  and  it  is  found  that  very  extensive 
union  may  thus  be  treated  with  entire  success  ;  and,  generally  speaking, 
with  excellent  eventual  results  as  regards  vision.  It  would  probably  be 
advisable  to  appl}'  M.  Reverdin's  method  of  grafting  to  the  prevention 
of  symblepharon,  by  placing  grafts  of  conjunctiva  below  the  cornea  be- 
fore the  original  union  had  taken  place,  and  as  soon  as  the  raw  surface 
was  granulating. 

The  affections  of  the  external  ocular  muscles  require  the  careful  con- 
sideration of  the  surgeon.  It  is  the  function  of  these  muscles,  in  their 
healthy  condition,  to  keep  the  two  eyes  constantly  directed  to  the  same 
object,  or  the  same  point  of  an  object,  so  that  the  images  formed  by  the 
refracting  media  may  fall  upon  corresponding  points  of  the  two  retime, 
and  may  be  combined  so  as  to  produce  a  single  effect  upon  the  conscious- 
ness, and  to  aflTord  the  benefits  of  binocular  or  stereoscopic  vision. 
When  the  muscles  generally  are  out  of  harmony,  or  when  an}-  one  of 
them,  or  any  pair  of  them,  are  suffering  from  paralysis,  from  spasm,  or 
from  excessive  tonic  contraction,  the  two  images  no  longer  fall  on  cor- 
responding points  of  the  two  retinae,  and  diplopia  or  double  vision  is 
produced.    If  one  eye  is  normally  and  the  other  abnormally  directed,  the 


742 


AFFECTIONS    OF    THE    EYE. 


iniaoe  seen  by  the  former  is  described  as  the  true,  thjit  seen  by  the  latter 
as  the  false  image;  and  diplopia  is  further  described  as  "homonymous" 
— when  the  rio;ht-hand  image  belongs  to  the  right  eye,  and  the  left-hand 
image  to  the  left;  or  as  "crossed,"  when  these  conditions  are  reversed. 
Homonymous  diplopia  is  produced  by  convergent  deviation  ;  crossed 
diplopia  by  divergent  deviation;  the  apparent  position  of  the  false  image, 
in  every  case,  being  in  the  opposite  direction  to  that  of  the  actual  devia- 
tion of  the  centre  of  the  cornea.  In  order  to  determine  with  certainty 
the  eye  to  which  each  image  belongs,  we  give  the  patient  a  lamp  or  candle 
flame,  eight  or  ten  feet  distant,  as  an  object  of  vision,  and  place  a  slip  of 
red  glass  before  one  of  his  eyes.  The  image  of  that  eye  will  appear  to  be 
of  a  red  color,  and  its  position  with  regard  to  that  of  the  other  can  be 
immediately  identified.  The  reason  of  the  apparent  deviation  of  the 
image  will  perhaps  be  rendered  more  intelligible  b_v  Fig.  335,  in  which  a 

represents  a  right  e3^e,  naturally 
^i"-  335.  directed  in  order  to  look  at  an 

object,  B,  placed  in  front  of  it, 
and  receiving  the  rays  of  light 
from  B  on  the  yellow  spot,  just 
external  to  the  optic  nerve. 
There  is  also  another  object, 
lying  far  to  the  right,  at  c,  and 
the  rays  from  this  object  fall 
upon  the  retina  on  the  inner 
side  of  the  optic  nerve.  At  a' 
we  have  the  same  eye,  no  longer 
directed  forwards,  but  twisted 
inwards,  as  if  l)^^  spasm  of  the 
internal  rectus  muscle.  As  the 
eye  rotates  about  a  centre,  the 
outward  excursion  of  the  pos- 
terior hemisphere  is  equal  to  the  inward  excursion  of  the  anterior  hem- 
isphere, with  the  result  that  the  rays  of  light  from  an  object  in  the 
position  b'  are  no  longer  received  upon  the  yellow  spot,  but  upon  a  point 
of  the  retina  on  the  inner  side  of  the  optic  nerve,  which  in  the  natural 
state  receives  rays  from  the  far  right  only.  Hence  the  consciousness 
misinterprets  the  impression  which  it  receives,  and  refers  the  ray  coming 
from  b'  to  an  object  situated  at  c' ;  or,  as  it  is  said,  projects  the  image  in 
that  direction.  The  same  principle  applies  to  every  deviation  of  the 
cornea,  whether  it  be  vertical,  horizontal,  or  in  some  intermediate  direc- 
tion. The  intensity  of  the  false  image  will  be  greater  the  nearer  it  falls 
to  the  yellow  spot,  and  the  smaller,  consequently,  is  its  apparent  depar- 
ture from  its  proper  position.  A  very  slight  deviation  of  one  eye,  so 
slight  as  to  be  scarcely  perceptible,  may  leave  the  patient  constantly  in 
doubt  between  the  false  image  and  tlie  true — unable  to  distinguish  tliem 
apart  with  certainty  or  to  direct  his  steps  with  confidence — and  suffering, 
often  severely,  from  vertigo;  while  a  large  deviation  suffers  the  false 
image  to  fall  upon  a  peripheral  part  of  the  retina,  where  it  is  neglected 
by  the  consciousness,  so  that  the  patient,  although  he  suffers  little  mani- 
fest inconvenience,  is  practically  rendered  one-eyed. 

Hquinl. — The  most  conspicuous  form  of  loss  of  harmony  between  the 
ocular  muscles  is  that  which  is  seen  in  common  convergent  strabismus, 
or  squint.  Tliis  affection  commences  in  early  childhood,  usually  between 
two  and  six  years  of  age.  At  first,  when  the  child  is  looking  intently  at 
any  near  object,  the  two  eyes  are  seen  to  be  equall}'  convergent,  but 


'A  A 

Diagram  to  illustrate  the  formation  of  double  images 


SQUINT. 


743 


directed  to  a  point  still  nearer  than  the  object;  and,  after  a  while,  the 
eyes  l)ecorne  slightly  and  equally  convergent  when  they  are  at  rest ;  that 
is  to  say,  when  they  are  not  directed  to  an  object  at  all.  The  next  step 
is  that  the  e^'cs,  when  looking  at  a  near  object,  are  no  longer  equally 
convergent;  one  being  directed  to  the  object,  the  other  deviating  in- 
wards ;  and  after  a  time  this  relative  position  becomes  habitual,  witli  the 
difference  that  the  squint  may  be  fixed — the  right  eye  always  looking 
forwards,  and  the  left  inwards,  or  vice  versa,  or  alternating,  sometimes 
one  eye  deviating  and  sometimes  the  other.  It  is  convenient  to  distin- 
guish the  eye  which  is  directed  forwards  as  the  working  eye,  and  that 
which  deviates  as  the  squinting  eye. 

Pafhologi/. — The  pathology  of  squint  is  very  simple.  The  children  in 
whom  it  occurs  are,  as  a  rule,  hypermetropic,  or  flat-eyed  ;  that  is  to  sa^', 
their  retinre  are  situated  within  the  focal  length  of  their  crystalline  lenses. 
In  order  to  obtain  clear  vision  they  are  compelled  to  neutralize  their 
defect  by  i-endering  their  crystalline  lenses  more  convex  ;  a  change  which 
is  only  required  by  normal  eyes  when  they  are  directed  to  objects  very 
near  to  them,  and  which  also  require  a  great  degree  of  convergence  of 
the  two  optic  axes.  The  ciliary  muscles,  or  muscles  of  accommodation, 
which  render  the  lenses  more  convex,  derive  their  nerves  from  the  same 
source  as  the  internal  recti  muscles,  which  govern  convergence;  and  the 
two  functions  are  intimately  connected  together  through  the  nervous 
centres.  The  flatness  of  the  eyeball,  a  mere  accidental  malformation  of 
an  external  organ,  does  not  interfere  with  this  intimate  nervous  connec- 
tion ;  and  hence  the  constant  action  of  the  muscles  of  accommodation,  in 
a  hypermetropic  child,  involves  an  equally  constant  action  of  the  muscles 
of  convergence,  which  become  abnormally  strong,  and  habitually  over- 
power their  antagonists,  so  that  the  resting  position  of  the  eyes,  or  their 
position  during  sleep,  is  one  of  equal  convergence  instead  of  api)roximate 
parallelism.  At  the  age  when  the  child  begins  to  look  attentively  at  near 
objects  he  requires  a  still  greater  effort  of  accommodation  in  order  to  see 
them  clearly,  and  in  making  this  effort  he  makes  a  corresponding  effovt 
of  convergence,  with  the  result  that,  as  his  ej'es  start  from  a  position  of 
acquired  convergence  instead  of  from  one  of  parallelism,  their  convergence 
becomes  greater  than  is  necessary, 

and  they  are  both  directed  to  a  point  Fig.  336. 

nearer  than  the  object,  so  that  double 
vision  is  produced.  In  order  to  see 
cleaily,  and  to  avoid  the  double  im- 
ages, the  child  renders  one  eye  more 
divergent,  so  that  it  may  be  directed 
to  the  object ;  and,  as  the  two  axes 
have  become  combined  in  a  relation 
of  convergence,  instead  of  in  their 
original  relation  of  parallelism,  it 
follows  that,  when  one  of  them  turns 
outward  to  fix  the  object,  the  other 
turns  inward  in  a  greater  degree 
than  before.  In  Fig.  336  a  and  b 
represent  a  pair  of  hypermetropic 
eyes,  which,  by  the  constant  action 
of  their  internal  recti,  have  departed 

from  their  original  state  of  parallel-        Diagram  to  elucidate  the  mechanism  of  squint. 

ism  when  at  rest,  and  are  actually 

combined  in  a  state  of  convergence,  their  axes,  A  c,  b  c,  subtending  equal 


744  AFFECTIONS    OF    THE    EYE. 

angles  with  the  imaginary  line  D  c,  drawn  from  the  root  of  the  nose  into 
space.  If  the  attention  is  directed  to  an  object  at  E,  a  nerve  stimulus  is 
applied  which  would  have  brought  the  optic  axes  from  parallelism  to  the 
positions  a  e,  b  e,  but  which,  as  they  start  from  a  state  of  convergence, 
actually  brings  them  to  the  positions  A  F,  B  F.  The  child  then  receives 
two  images,  neither  of  thenj  on  the  yellow  spot,  and  neither  of  them  in 
the  highest  degree  distinct.  He  is  unable,  by  the  action  of  both  ex- 
ternal recti,  to  overpower  the  stronger  internal  recti,  and  to  direct  both 
liis  eyes  to  the  proper  point,  without  at  the  same  time  relaxing  his  ac- 
commodation, which  he  is  bound  to  maintain.  But  he  is  able,  by  the 
action  of  one  external  and  the  other  internal  rectus,  to  turn  both  eyes 
together,  as  if  they  were  structurally  united.  If  he  fixes  the  eye  a  upon 
the  point  e,  the  eye  b  moves  together  with  a,  turning  inwards  as  a  turns 
outwards,  and  directing  its  axis  along  the  course  B  G.  If  he  fixes  the 
eye  b  upon  the  point  E,  the  e^'e  A  moves  together  with  B,  turning  in- 
wards as  B  turns  outwards,  and  directing  its  axis  along  the  course  A  G. 
It  follows  that  one  eye  looks  at  the  point  e,  and  sees  it  clearly,  while 
the  other  looks  at  the  point  G,  or  towards  the  nose,  and  squints.  It 
receives  a  false  image  of  the  point  e,  but  upon  so  peripheral  a  }iortion 
of  its  retina  that  the  double  vision  produces  no  inconvenience.,  and  is 
neglected  by  the  attention  until  it  ceases  to  be  an  object  of  consciousness. 
If  the  acuteness  of  vision  and  the  degree  of  flatness  are  alike  in  both  eyes, 
and  the  external  recti  are  of  equal  strength,  it  is  a  matter  of  accident 
which  eye  will  be  directed  to  the  object  and  which  towards  the  nose,  and 
the  squint  will  be  alternating.  But  such  equality  of  sight  and  of  muscular 
power  is  not  common,  and  the  majority  of  children  can  direct  one  eye 
more  readil}-  than  the  other,  or  can  see  with  it  more  clearly.  When  this 
is  the  case  the  employment  of  the  best  eye  becomes  instinctive — it  is 
always  directed  to  the  object,  and  the  squint  becomes  fixed.  Under  sucli 
circumstances  the  vision  of  the  squinting  eye  often  undergoes  steadily 
progressive  deterioration. 

Secondary  Squint. — In  a  case  of  fixed  squint,  after  a  certain  time,  it  is 
conceivable  that  the  internal  rectus  of  the  squinting  eye  might  undergo 
shortening,  or  that  its  external  rectus  might  become  atrophied,  so  that 
the  faulty  position  would  be  rendered  permanent.  Practically^,  this  sel- 
dom occurs,  and  it  is  probable  that  the  two  eyes  return  to  equal  converg- 
ence during  sleep,  as  they  mostl}'  do  under  the  influence  of  an  angesthetic. 
In  nearly  all  cases,  if  the  working  eye  is  closed  or  covered,  the  squinting 
eye  can  be  made  to  fix  an  object  correctly,  just  as  if  the  squint  were  still 
alternating,  and  with  the  result  that  the  working  eye  will  deviate  inwards, 
behind  its  covering,  to  the  same  extent  that  tlie  squinting  eye  deviated 
before.  The  deviation  of  the  working  eye  is  called  the  secondary  squint, 
and  it  is  observed  by  screening  the  object  from  this  eye  by  the  hand,  or 
some  other  opaque  sul)stance  over  which  the  surgeon  may  look  to  observe 
the  relative  positions  of  the  two. 

When  the  secondary  deviation  of  the  working  eye  is  equal  to  the 
ordinary  deviation  of  tlie  squinting  eye  we  have  proof  that  the  squint  is 
not  caused  by  abnormal  muscular  weakness.  A  fixed  convergent  squint 
of  the  right  e3'e  miglit  be  produced  by  paralysis  of  its  external  rectus 
muscle,  so  that  the  internal  rectus  had  no  antagonist,  and  rolled  the  cor- 
nea inwards.  If  the  i)aralysis  were  complete,  the  squinting  eye  would 
make  no  eflfbrt  to  fix  the  object  when  the  working  eye  was  covered,  be- 
cause the  former  would  have  no  power  of  abduction  or  outward  rotation 
at  all.  If  the  external  rectus  were  only  weakened  the  squinting  eye 
would,  indeed,  turn  outwards   when  the  working  eye  was  covered,  but 


SQUINT.  7-15 

Avith  an  effort  more  or  less  feeble,  and  the  working  eye  would  deviate 
inwards  in  a  greater  degree.  The  reason  is  that  the  central  nerve-ganglia 
of  the  external  rectus  of  one  eye  and  of  the  internal  rectus  of  the  other 
are  in  intimate  relation,  for  the  purpose  of  turning  both  eyes  right  or 
left  l)y  a  consentaneous  movement;  and  hence,  in  the  case  supposed,  the 
external  muscle  of  the  scpiinting  eye  and  the.  internal  muscle  of  the  work- 
ing eye  would  receive  equal  motor  im})ulses  at  the  same  moment.  The 
weakened  muscle  of  the  squinting  eye  would  respond  feebly,  the  healthy 
muscle  of  the  working  eye  wouhl  respond  naturally  ;  and  the  eye  which 
was  moved  by  the  latter  would  make  a  larger  excursion  than  that  which 
was  moved  by  the  former.  Hence  it  is  oidy  when  the  secondary  devia- 
tion of  the  working  eye  is  equal  to  the  primary  deviation  of  the  squint- 
ing eye  that  we  have  to  deal  with  uncomplicated  strabismus  ;  and  when- 
ever the  squinting  eye  has  lost  its  power  of  fixation,  or  when  its  move- 
ment for  that  purpose  is  attended  by  a  still  larger  movement  of  its 
covered  fellow,  the  squint  is  either  caused  or  complicated  by  paralysis, 
in  the  former  case  complete,  in  the  latter  incomplete,  of  the  physiological 
antagonist  of  the  muscle  by  which  the  deviation  is  produced. 

Treatment. — The  effort  of  accommodation  on  which  squint  is  primarily 
dependent  could  be  theoretically  rendered  unnecessary  by  convex  spec- 
tacles. But  the  effect  upon  the  convergence  muscles  is  usually  produced 
at  so  earl}'  an  age  that  spectacles  could  not  be  worn  in  time  to  be  useful. 
When  squint  is  fairly  established,  spectacles,  although  they  may  diminish, 
will  fail  to  cure  it;  and  a  variety  of  ingenious  endeavors  to  restore  paral- 
lelism of  the  eyes  by  stereoscopic  exercises,  exercises  with  prisms,  and 
other  like  contrivances,  have  not  been  attended  with  such  a  measure  of 
success  as  to  encourage  their  adoption  in  any  bnt  exceptional  instances. 
When  the  sight  of  both  eyes  is  good,  and  the  squint  is  uncomplicated  by 
paralysis,  it  is  always  curable,  not  only  coarsely,  and  so  as  to  correct  a 
manifest  deformity, "but  perfectly,  so  as  to  restore  harmony  of  position 
and  movement  under  all  circumstances,  by  a  well-planned  and  skilfully 
performed  operation  or  operations.  As  long  as  the  squint  is  alternating 
the  operation  may  be  postponed  without  injury;  but  as  soon  as  the  squint 
is  fixed  it  should  be  performed  without  delay,  in  order  to  prevent  impair- 
ment of  the  vision  of  the  squinting  eye.  In  very  young  children,  under 
such  circumstances,  it  is  often  best  to  be  content  with  a  somewhat  coarse 
correction,  and  to  leave  the  final  operation  to  a  later  period.  The  sur- 
geon may  always  say  that  the  result  is  absolutely  under  his  control,  but 
that  in  order  to  obtain  perfection  he  must  be  permitted  to  operate  twice, 
or  even  thrice  if  necessary. 

Objects  of  the  Operation. — The  immediate  object  of  each  squint  oper- 
ation is  to  separate  the  tendon  of  the  internal  rectus  muscle  from  the 
sclerotic,  with  the  least  possible  disturbance  of  surrounding  parts,  so  that 
the  muscle  may  form  a  new  attachment  posterior  to  its  original  one,  and 
may  produce  by  the  same  effort  of  contraction  a  smaller  degree  of  con- 
vergence than  previously.  The  final  object  of  all  the  operations  which 
may  be  necessary  is  to  place  the  optic  axes  in  a  position  of  approximate 
parallelism,  with  only  the  normal  slight  inclination  to  convergence  when 
the  eyes  are  at  rest,  and  to  do  this  without  any  impairment  of  the  power 
of  volitional  convergence,  which  should  be  left  available  for  directing 
both  eyes  equally  to  any  near  object,  and  for  maintaining  this  direction 
as  long  as  it  may  be  required. 

Considering  that  squint  is  always  a  binocular  affection,  it  is  obvious 
that  a  perfect  result  can  seldom  be  expected  from  an  operation  on  one 


'46 


AFFECTIO>;S    OF    THE    EYE. 


Fig.  337 


Diagram  to  illustrate  the  operation  for 
strabismus. 


e3"e  onl3^  If  the  degree  of  deviation  is  not  large,  such  an  operation  may 
produee  parallelism  when  the  eyes  are  at  rest,  and  may  correct  a  conspic- 
uous deformity,  but  it  can  only  do  so  at  the  cost  of  producing  a  perma- 
nent ditlerence  of  convergence  power  between  the  two,  so  that  a  common 

motor  impulse  would  aifect  them  dif- 
ferently, and  the  eye  operated  upon 
would  lag  behind  the  other  during 
every  eflbrt  to  direct  both  to  some 
near  point.  Fig.  337  represents  a 
pair  of  eyes,  A,  b,  in  the  ordinary  po- 
sition of  fixed  squint.  At  rest,  that 
is,  during  sleep,  the}^  would  be  equall}' 
convergent,  but  the  working  eye,  A,  is 
habitually  directed  forward,  for  visual 
purposes,  along  the  line  A  a',  and  the 
whole  convergence  is  manifested  by 
the  squinting  e3'e  b,  which  is  habitu- 
ally directed  inwards  along  the  line 
B  b',  these  two  lines  forming  always  an 
angle  of  the  same  magnitude.  The 
internal  recti  muscles  of  the  two  eyes 
are  inserted  into  the  sclerotic  at  the 
points  c  c'.  Let  it  be  supposed  that  an  operation  upon  the  eye  B,  which 
put  back  its  internal  rectus  to  a  new  attachment  at  D,  would  overcome 
the  habitual  convergence,  and  would  allow  the  line  of  direction  b  b'  to 
become  parallel  to  the  line  of  direction  a  a'.  When  the  eyes  were  di- 
rected forwards  the  squint  would  be  cured,  but  the  internal  rectus  of  the 
eye  a  would  be  left  in  a  position  of  advantage,  with  its  strength  undi- 
minished, while  the  internal  rectus  of  the  eye  B  would  be  weakened  by 
being  placed  in  a  position  of  great  disadvantage.  When  any  attempt 
was  made  to  fix  both  eyes  on  a  near  object  the  same  central  motor  im- 
pulse would  produce  different  results  upon  the  two,  and  the  eye  b  would 
either  lag  behind  its  fellow  and  appear  to  squint  divergently  in  relation 
to  it,  or  its  muscle  would  become  tired  and  strained  by  being  called 
upon  for  a  greater  exertion  than  its  fellow.  The  proper  operation  is  to 
divide  the  correction  equall}'  between  the  two  eyes  by  putting  back  the 
two  nuiscles  to  the  points  of  attachment  E  e'.  By  this  we  not  only  obtain 
parallelism  when  the  eyes  are  at  rest,  but  leave  them  with  equal  and  suffi- 
cient convergence  power,  and  replace  them  in  that  natural  condition  from 
which  they  had  been  caused  to  deviate  by  the 
acquired  hypertrophy  of  their  internal  recti 
muscles. 

Mcnpritnde  of  a  Hquint. — The  magnitude  of  a 
stpiint  is  commonly  expressed  by  the  distance 
between  two  vertical  lines,  one  of  which  bisects 
the  palpebral  oi)ening  of  the  scpiinting  eye,  while 
the  other  bisects  the  pupil  of  the  same  eye  when 
the  working  eye  is  directed  forwards,  as  shown 
at  A  and  b,  Fig.  338.  It  is  obvious,  as  tenot- 
omy of  the  internal  rectus  cannot  be  made  to 
of  csUmating  the  degree  of  producc  less  than  a  certain  minimum  of  effect, 
squint.  that  a  scjuint  may  be  so  small  as  only  to  admit 

of  a  single  operation,  which  should  then  be  per- 
formed upon  the  squinting  eye;  and  it  is  also  obvious  that  a  squint  may 


DiaKrarn  to  sliow  the  inctlio<l 


OPERATION     FOR    SQUINT. 


747 


be  so  large  that  no  single  operation  can  correct  it.  In  former  times, 
when  neither  the  etiology  nor  the  hinocnlar  character  of  the  affection  was 
nnderstood,  it  was  cnstomary  in  such  cases  to  perform  the  second  opera- 
tion on  the  same  or  squinting  eye,  and  some  very  hideous  deformities 
were  occasionally  thus  produced,  the  displaced  muscle  ultimately  losing 
all  power  over  tlie  globe,  and  permitting  its  inner  side  to  project  in  an 
unsightly  manner,  while  the  cornea  was  directed  outwards.  It  is  now 
understood  that  if  a  first  operation  upon  the  squinting  eye  produces  only 
partial  correction,  the  second  operation  must  be  performed  upon  the 
working  eye,  even  ajthough  it  is  the  other  which  still  squints.  The  affec- 
tion remains  a  hinocnlar  one,  although  it  fsiUs  upon  the  eye  which  has 
the  least  useful  vision,  and  parallelism  will  be  restored  by  operating  upon 
the  other.  When  a  squint  is  very  large  it  is  admissible  to  operate  upon 
both  eyes  at  once ;  but  when  it  is  only  of  moderate  dimensions  it  is  more 
prudent  to  defer  the  second  operation  for  two  or  three  months,  until  the 
muscle  first  divided  has  entirely  regained  its  power. 

Detaih  of  O'peratio)). — For  the  performance  of  the  operation  the  pa- 
tient should  be  recumbent  upon  a  narrow  couch  and  fully  etherized.  The 
surgeon  stands  on  the  right  hand  side  of  the  patient,  and,  having  sepa- 
rated the  lids  by  a  speculum,  pinches  up  with  forceps  a  vertical  fold  of 
conjunctiva  and  subconjunctival  tissue  at  a  point  where  the  inner  vertical 
and  the  lower  horizontal  tangents  to  the  cornea  would  intersect  each 
other.  With  a  pair  of  fine  scissors,  pointed  and  curved  on  the  flat,  he 
divides  this  fold  to  its  base  immediately  below  the  forceps,  and  gives  an 
additional  snip,  to  be  certain  that  he  has  cut  quite  down  to  the  sclerotic, 
making  a  horizontal  wound.  Retaining  his  hold  with  the  forceps,  he 
places  the  extremity  of  a  strabismus  hook  (Fig.  339)  on  the  exposed  scle- 
rotic, runs  it  a  little  down,  to  be  sure  of  getting  beneath  the  tendon,  well 
back,  to  be  sure  of  getting  behind  it,  and  then  upwards  and  forwards  in 
a  bold  curve,  the  extremity  of  the  hook  never 
losing  touch  of  the  surface  of  the  eyeball.     When  fig.3:!9. 

this  manoeuvre  is  properly  executed  the  extremity 
of  the  hook  shows  under  the  conjunctiva  above  the 
upper  margin  of  the  tendon,  and  the  curved  part 
is  completely  concealed  from  view  by  the  body  of 
the  tendon,  and  is  checked  by  it  from  advancing  to 
the  corneal  margin.  If  the  whole  of  the  hook  can 
be  seen  through  tiie  conjunctiva,  or  if  it  can  be 
pulled  up  to  the  corneal  margin,  it  is  not  under  the 
tendon  at  all,  and  another  sweep  must  be  made. 
When  the  hook  is  rightly  placed  the  operator  shifts 
it  into  his  left  hand,  and  takes  the  scissors  in  his 
right.  He  makes  steady  traction  with  the  hook 
towards  the  outer  canthns,  holds  the  scissors  very 
slightly  open,  with  their  curve  corresponding  to  that 
of  the  hook,  introduces  them  into  the  wound,  and 
passes  the  lower  blade  under  the  tendon,  in  contact 
with  the  convexity  of  the  hook,  which  serves  as  a 
director,  while  the  point  of  the  upper  blade  is  insin- 
uated between  the  conjunctiva  and  the  tendon,  just 
making  its  own  track  through  the  subconjunctival 
connective  tissue.  When  the  scissor  blades  include 
a  third  or  a  fourth  of  the  width  of  the  tendon  they  The  strabismus  hook. 
may  be  closed,  then  opened  and  pushed  on  for 
another  snip,  and  so  on  until  the  whole  of  the  tendon  is  divided,  when 


748  AFFECTIONS    OF    THE    EYE. 

the  hook,  no  longer  held  back  against  the  traction  of  the  operator,  will 
at  once  break  through  the  connective  tissue  and  advance  to  the  corneal 
margin.     The  operation  is  then  completed. 

Si(tiirri<. — In  a  general  way  the  wound  requires  no  treatment,  except 
the  application  of  cold  or  iced  water  to  the  lids  if  there  is  sufficient  ten- 
dency to  bleeding  to  threaten  a  disfiguring  eccliymosis  which  would  be 
only  slowly  absorbed.  In  the  case  of  a  second  operation,  if  there  is  any 
fear  that  too  great  an  effect  has  been  produced,  the  retraction  of  the  mus- 
cle may  be  checked  b}'  the  insertion  of  a  deep  suture  to  draw  it  forwards 
towards  the  cornea.  If  the  original  wound  was  a  little  large,  or  if  any 
vertical  cut  has  been  accidentally  made  in  the  conjunctiva,  a  fine  suture 
should  be  passed  through  this  membrane  only.  A  suture  should  also  be 
applied  if  the  cut  edge  of  the  tendon  is  exposed  in  any  part  of  the  wound, 
as  otherwise  a  fleshy  prominence  is  apt  to  spring  up  in  such  a  place  and 
to  be  a  source  of  disfigurement.  If  such  a  prominence  should  form  it 
may  be  snipped  off  close  to  the  conjunctiva,  and  the  cut  surface  may  be 
touched  with  nitrate  of  silver,  after  which  all  trace  of  the  swelling  will 
disappear. 

Paralytic  Strabismus. — When  strabismus  is  not  produced  in  the  ordi- 
nary waj',  but  is  a  result  of  paralysis,  as  shown  by  the  secondary  squint 
being  larger  than  the  primary,  the  case  will  in  the  first  instance  require 
treatment  addressed  to  tlie  paralysis  itself.  But  if  this  should  prove 
ineffectual  a  perfect  cure  may  often  be  produced  by  tenotomy  of  the 
contracted  muscle,  followed  by  daily  localized  faradization  of  its  weakened 
antagonist.  The  electricity'  should  be  applied  by  a  pair  of  very  fine  con- 
ductors to  the  conjunctiva  covering  the  affected  muscle. 

Divergent  strabismus  is  comparatively  seldom  met  with,  although  it 
sometimes  occurs  as  a  result  of  over-correction  of  the  convergent  form, 
sometimes  as  the  result  of  the  mere  wandering  outwards  of  an  eye  which 
has  lost  vision,  and  occasionally  from  weakness  of  the  internal  recti 
muscles.  It  is  scarcely  ever  sufficient  to  perform  tenotomy  of  the  ex- 
ternal recti,  but  in  most  cases  trhe  internal  recti  must  be  shortened  or 
brought  forward  to  an  attachment  nearer  to  the  cornea.  For  this  pur- 
pose the  internal  rectus  of  the  affected  eye  must  be  separated  from  its 
attachments,  a  portion  of  its  tendon  cut  off,  and  the  rest  brought  forward 
b}'  two  sutures,  one  of  them  taking  in  a  broad  piece  of  the  upper  portion 
of  the  conjunctiva,  the  other  of  the  lower.  The  muscle  should  be  ex- 
posed, for  this  purpose,  by  a  horizontal  incision  from  the  margin  of  the 
cornea  to  the  caruncle,  but  no  conjunctiva  should  be  taken  away.  Division 
of  both  external  recti  will  generally  be  necessary.  Such  operations  are 
chiefly  perfoi-med  for  the  improvement  of  appearance,  and  they  require 
to  ])e  carefully  planned  and  skilfully  executed  in  order  that  they  may  not 
do  harm  rather  than  good.  It  is  better  that  they  should  not  be  under- 
taken by  any  surgeon  who  has  not  had  opportunities  of  gaining  experi- 
ence of  the  general  effect  of  displacements  of  the  ocular  muscles,  as  it  is 
ver}^  easy  to  do  either  too  little  or  too  much.  In  the  former  case  the 
patient  will  be  unconscious  of  benefit,  in  the  latter  he  will  often  have 
much  reason  to  complain. 

liacent  Paralysis  of  Ocular  Muscles. — In  cases  of  recent  paral^'sis  or 
weakening  of  one  or  more  of  the  ocular  muscles,  double  vision  is  alwa3'^s 
a  prominent  and  often  a  distressing  symptom  ;  although  the  degree  of 
deviation  of  the  eye  may  be  extremely  slight.  When  paralysis  attacks 
the  third  nerve,  which  supplies  the  levator  palpebme,  the  sphincter  of  the 
pupil  and  the  muscle  of  accommodation,  and  all  the  external  muscles  of 
the  eye,  except  the  external  rectus  and  the  superior  oblique,  the  effect 


CAUSES    OF    PARALYSIS.  749 

• 

produced  is  very  remarkable.  The  ui)per  lid  falls  completely,  and  cannot 
be  raised  by  any  effort  of  the  will.  When  it  is  raised  by  the  surgeon  it 
shows  the  pui)il  dilated,  the  eye  somewhat  abducted,  but  capable  of  being- 
carried  further  outwards  by  an  effort,  and  immovable  in  other  directions. 
When  paralysis  attacks  the  sixth  nerve,  only  the  external  rectus  muscle 
is  affected  ;  the  eye  is  adducted,  and  there  is  doulile  vision  of  all  objects 
towards  its  temporal  side,  but  not  of  objects  situated  on  its  nasal  side. 
In  some  cases  the  third  nerve  is  only  partially  affected,  the  muscles  sup- 
plied by  certain  twigs  entirely  escaping;  and  in  all  cases  the  position  of 
the  eye  and  of  the  false  image  are  not  the  direct  results  of  the  paralysis, 
but  the  final  results  of  the  rearrangement  of  a  group  of  forces  from  which 
certain  members  have  been  taken  away,  so  that  the  balance  of  the  whole 
group  is  disturbed. 

Determination  of  the  Deviating  Dye. — When  the  amount  of  deviation 
of  the  affected  eye  is  very  small,  it  is  not  always  easy  to  determine  which 
of  the  two  is  at  fault;  but  the  most  simple  test  for  this  purpose  is  to  de- 
sire the  patient  to  look  fixedly  at  an  object,  and  then  to  conceal  it,  first 
from  one  eye  and  then  from  the  other,  by  the  interposition  of  a  screen 
over  which  the  movements  of  the  eye  may  be  watched.  When  the  screen 
conceals  the  object  from  the  unaffected  eye  the  deviating  eye  vvill  in- 
stantly move  to  fix  it;  but  when  the  screen  is  placed  over  the  deviating 
eye  the  other  remains  motionless.  Again,  if  the  patient  keeps  his  head 
still,  and  follows  with  his  eyes  any  object  which  is  moved  to  and  fro,  up 
and  down,  and  laterally,  the  observer  can  hardly  fail  to  detect  a  loss  of 
mobility  in  some  direction.  Lastl}^,  the  test  with  red  glass  alread}'  men- 
tioned will  determine  to  which  eye  each  image  belongs. 

Causes  of  Paralysis. — Paralysis  of  a  single  cranial  nerve,  producing 
paralysis  of  one  or  more  of  the  muscles  of  the  eye,  may  be  due  to  various 
kinds  of  lesion,  but  in  probably  half  the  cases  in  which  it  occurs  it  is  due 
to  the  cropping  up  of  some  late  form  of  syphilis  ;  either  to  gummatous 
tumor  in  the  nervous  centres  or  to  pressure  on  a  nerve-trunk  from  perios- 
teal deposit.  The  mere  fact  of  paralysis  of  the  sixth  nerve,  or  of  the 
fourth,  throws  no  light  upon  its  cause;  but  paralysis  of  all  the  branches 
of  the  third  is  presumably  due  to  some  cause  of  pressure  acting  upon 
the  common  trunk  in  which  they  are  combined  prior  to  distribution, 
while  paralysis  of  single  branches  is  presumably  due  to  some  cause  act- 
ing upon  one  or  more  of  the  scattered  ganglia  of  origin.  On  the  same 
principle,  if  two  or  more  of  the  nerves  entering  the  orbit  are  affected, 
there  is  at  once  reason  to  suspect  pressure  from  periostitis  at  the  sphe- 
noidal fissure,  where  the  trunks  are  contiguous  to  one  another.  Besides 
gumma  and  periostitis,  paralysis  of  one  or  more  of  the  orbital  nerves 
may  be  produced  by  various  forms  of  disease  or  degeneration  of  the 
nervous  centres,  and  also  b3Mnjuries  of  the  head.  There  has  latel}'  been 
a  girl  in  St.  George's  Hospital  who  received  a  severe  blow  on  the  parietal 
region,  and  in  whom,  after  the  lapse  of  some  months  and  the  subsidence 
of  other  s3mptoms,  paralysis  of  the  superior  and  inferior  recti  on  the 
injured  side  remained,  although  the  other  muscles  supplied  by  the  third 
nerve  were  unaffected. 

Treatment. — In  any  case  of  paralysis  of  an  ocular  muscle  the  surgeon 
must  seek  any  guidance  as  to  the  cause  which  can  be  obtained  from  the 
histor}'  and  the  other  symptoms  of  the  patient;  and  must  especially-  en- 
deavor to  satisfy  himself  with  regard  to  the  presence  of  syphilis.  Unless 
the  results  of  his  examination  point  definitely  to  some  other  mode  of 
treatment  he  will  generally  do  well  to  give  iodide  of  potassium,  and  to 
give  it  in  doses  frequently  increased  to  the  fullest  extent  which  can  be 


750  AFP^ECTIONS    OF    THE    EYE. 

borne;  commencing  with  ten  grains  three  times  a  da_y,  and  proceeding 
to  double  or  treble  that  qnantity.  In  all  cases  of  disease  of  the  nervous 
centres  produced  by  late  forms  of  syphilis  the  iodide  will  alleviate  the 
existing  symptoms,  and  if  sufHciently  pnsiied  will  remove  them  in  a  very 
remarkable  manner;  but  it  seems  to  have  no  influence  in  preventing  the 
recurrence  of  syphilitic  mischief  in  some  other  form  or  in  some  other 
organ.  AVhenever,  therefore,  paralysis  of  a  cranial  nerve  has  yielded 
rapidly  to  the  iodide,  there  is  a  prima  facie  reason  for  a  course  of  per- 
chloride  of  mercury,  or  for  some  other  method  of  mercurial  treatment,  in 
the  hope  that  b}-  its  means  the  constitutional  taint  ma}-  be  removed.  In 
some  cases,  when  the  nervous  affection  has  been  relieved,  the  muscular 
paralysis  remains,  because  the  muscle,  weakened  and  wasted  by  a  period 
of  inaction,  is  no  longer  able  to  strive  against  its  physiological  an- 
tagonist. Under  such  circumstances  benefit  may  be  derived  from  local- 
ized faradization  of  the  weak  muscle,  and,  if  this  should  not  prove  suffi- 
cient, the  tendon  of  the  contracted  muscle  may  be  divided. 

Dii<eai-es  of  the  Lachrymal  A2oparatus. — The  lachrymal  apparatus  is  often 
the  seat  of  derangements  which  call  for  the  interference  of  the  surgeon. 
The  lachrymal  glands  may  become  hypertrophied  and  may  require  re- 
moval, or  they  may  be  removed  on  account  of  inveterate  obstruction  of 
the  nasal  ducts.  The  operation  is  easily  performed  through  an  incision 
immediately  below  the  outer  two-thirds  of  the  margin  of  the  orbit,  but 
care  should  be  taken  to  make  this  incision  sufficiently  long.  The  lachrymal 
gland  often  has  appendages  at  some  little  distance  from  its  main  body, 
and  any  of  these,  if  left  behind,  will  continue  to  discharge  its  secretion 
through  its  divided  duct  into  the  surrounding  tissue,  producing  trouble- 
some swelling  which  may  end  in  abscess.  Tiie  lachrymal  puncta  are  some- 
times occluded,  and  may  be  seen  by  a  magnifying-glass  as  little  promi- 
nences Avith  no  central  apertures.  Or  the  canaliculi  may  be  occluded 
between  the  eye  and  the  lachrymal  sac,  a  condition  which  can  only  be 
discovered  by  the  passage  of  a  very  fine  probe,  sufficiently  fine  to  pass 
through  the  punctum  itself  It  must  be  remembered  that  the  punctum 
constitutes  a  short  vertical  channel  placed  at  the  extremity  of  the  hori- 
zontal canaliculus,  which  joins  it  at  a  right  angle  ;  and  it  is  necessar}'  in 
any  attempt  to  pass  a  probe  to  remember  this  right  angle,  and  to  convert 
it  into  an  ol)tuse  one  by  drawing  the  e3'elid,  generall}'  the  lower  lid,  out- 
wards, and  fixing  it  by  tinger-pressure  while  the  probe  glides  round  the 
little  corner  and  straightens  out  the  channel.  Once  within  the  canalic- 
ulus, the  probe  should  pass  on  without  encountering  resistance  until  it 
crosses  tiie  lachrymal  sac  and  is  arrested  by  bone.  If  the  canaliculus  is 
obstructed  the  resistance  may  be  felt  by  the  fingers,  and  the  eyelid  may 
be  seen  to  be  moved  by  the  probe.  Obstructions  of  the  puncta  or  the 
canaliculi  are  scarcely  worth  treatment,  so  prone  are  they  to  reunite,  and 
so  trifling  is  the  inconvenience  which  they  occasion. 

Obstruction  of  the  nasal  duct  below  the  lachrymal  sac  is  a  much  more 
formidaltle  and  troul)lesome  affection.  It  may  commence  at  any  period  of 
life,  from  earl}'  childhood  to  old  age,  and  is  generally  attributed  to  some 
cause  with  which  it  has  no  intelligible  conneclion.  The  first  symptoms 
observed  are  that  tears  lodge  and  overflow,  and  that  a  small  colorless 
elastic  tumor  appears  at  the  inner  corner  of  the  lower  eyelid.  This  tumor 
is  the  distended  lachrymal  sac,  which  becomes  filled  with  tears  until  no 
more  can  enter.  \i\  pressure  witli  the  finger  it  can  be  emptied,  and  its 
contents,  which  consist  at  first  of  tears  more  or  less  ins[)issated,  can  be 
squeezed  back  into  the  conjunctival  sac  through  the  puncta.  After  a 
time  the  tear-bag  becomes  irritated  b}'  distension,  and  its  lining  mem- 


WEBER'S    CANALICULUS    KNIFE. 


751 


Fig.  340. 


brane  secretes  a  quantity  of  mucus,  which  mingles  with  the  tears  and 
can  be  pressed  out  with  them.  Either  by  the  mere  continuance  of  the 
irritation,  or  by  some  accidental  increase  of  it,  a  state  of  actual  inflam- 
mation is  produced,  and  the  secretion  becomes  purulent.  The  swelling  of 
the  lining  membrane  closes  the  only  outlet,  and  the  result  is  an  al)scess 
which  discharges  itself  ui)on  the  cheek  by  an  opening  which  is  prevented 
from  healing  by  the  continual  discharge  of  tears  tlirough  it,  and  which 
becomes  a  lachr3'mal  fistula.  When  the  listula  is  established  the  irritation 
often  subsides,  leaving  only  a  minute  hole,  through 
which  a  drop  of  clear  fluid  now  and  again  exudes, 
and  whicli  is  surrounded  by  a  more  or  less  reddened, 
incrusted,  or  unsightly  margin.  But  even  then  a 
small  matter  will  excite  fresh  mischief,  and  will 
render  the  secretion  of  the  sac  once  more  profuse 
and  purulent. 

Treatment. — Excepting,  perhaps,  in  a  few  per- 
sons of  more  than  ordinary  irritability,  the  train 
of  evils  above  described  is  only  produced  by  over- 
distension of  tile  tear-bag,  and  may  be  prevented 
l)y  keeping  it  emptied  by  pressure.  In  children 
it  is  never  desirable  to  oi)erate  unless  abscess  is 
imminent;  and  many  adults  live  in  perfect  com- 
fort by  the  simple  precaution  of  squeezing  out  the 
contents  of  the  little  tumor  ever}-  lialf-hour  or  so,  a 
habit  which  soon  becomes  a  second  nature.  If  this 
habit  has  not  been  acquired  or  has  been  broken 
through,  and  if  the  lining  membrane  of  the  sac  is 
becoming  irritable,  as  shown  by  a  little  tenderness 
on  pressure,  by  the  character  of  the  secretion,  and 
by  redness  or  swelling  of  the  conjunctiva  near  the 
puncta,  and  of  tlie  caruncle  and  plica  semilunaris, 
it  is  well  to  endeavor  to  cure  the  stricture  by  pass- 
ing through  it  a  full-sized  lachrymal  probe,  either  of 
Bowman's  or  Weber's  pattern.  Sucli  a  probe  is  too 
large  to  pass  through  the  punctum  or  the  canalic- 
ulus, and  the}'  must  be  slit  up  to  make  room  for 
it.  Tlie  best  instrument  for  this  purpose  is  Weber's 
canaliculus  knife  (Fig.  340),  a  keen  narrow  blade 
terminating  in  a  short,  smooth,  and  rounded  beak. 
Drawing  the  lower  lid  outwards,  and  rendering  it 
tense,  the  surgeon  passes  the  beak  through  the  punc- 
tum, carries  it  carefully  round  the  angle  into  the 
canaliculus  (with  the  cutting  edge  upwards),  and 
pushes  it  horizontall}'  onwards  until  its  beak  is  arrest- 
ed by  bone.  Still  keeping  the  lid  tense,  he  raises  the 
knife  to  a  vertical  position,  and  in  doing  so  lays  open 
the  punctum  and  the  canaliculus  quite  up  to  the 
lachrymal  sac.  Along  the  groove  thus  formed  he 
introduces  a  probe  in  a  horizontal  direction  until  it 
also  is  arrested  by  bone  and  then  keeping  touch  of 
tliis  bone,  as  far  as  possible — that  is,  not  withdraw- 
ing the  probe  in  the  least — he  raises  it  into  a  ver- 
tical position,  so  that  it  may  cross  the  supraorbital 
notch,  and  that  its  extremity  may  with  a  little  care  be  engaged  in  the 
upper  orifice  of  the  nasal  duct.     The  probe  is  then  pushed  down,  and 


Weber's  canaliculus  knife. 


'52 


AFFECTIONS    OF    THE    EYE. 


Fig.  3-11. 


tbrongli  the  stricture  (which  may  sometimes  offer  a  considerable,  though 
elastic,  resistance),  until  its  extremity  rests  upon  the  floor  of  the  nose, 
when  it  should  be  left  in  position  for  a  few  minutes  and  then  withdrawn. 
For  the  first  few  da3's  the  lips  of  the  incision  along  the  canaliculus  must 
be  separated  dail}-,  until  they  have  lost  their  original  disposition  to  unite, 
and  the  slit  is  rendered  a  permanent  one.  After  an  interval  of  from  three 
days  to  a  week,  according  to  the  pain  suffered  and  the  degree  of  local 
irritation,  the  probe  may  be  passed  through  the  stricture  again,  and  it 
should  encounter  much  less  resistance  than  before.  In  order  to  modify 
the  chronically  inflamed  state  of  the  mucous  membrane  of  the  sac,  an 
astringent  lotion,  say  of  five  grains  of  acetate  of  lead  to  an  ounce  of 
water,  should  be  dropped  into  the  inner  canthus  every  three  or  four 
hours,  the  sac  having  first  been  thoroughly  emptied 
by  pressure,  and  the  probe  should  be  passed  every 
few  days  for  three  or  four  weeks.  It  may  then  be 
laid  aside,  and  only  the  lotion  continued,  with  the 
result  that,  in  favoi'able  cases,  the  stricture  will  re- 
main pervious,  the  secretion  of  the  sac  will  return 
to  its  normal  character  and  quantity,  and  the  tears 
will  be  carried  into  the  nose  by  the  natural  channel. 
Relapsing  Cases. — A  result  so  favorable  as  this 
is  by  no  means  the  rule,  and  in  a  large  proportion 
of  instances  the  stricture  will  again  become  impass- 
able and  the  old  troubles  will  be  renewed.  The 
surgeon  may  then  have  recourse  to  division  of  the 
stricture,  for  which  purpose  he  first  passes  a  probe 
through  it  as  before,  and  then,  withdrawing  the 
probe,  replaces  it  with  Stilling's  knife  (Fig.  341), 
which  is  introduced  in  the  same  manner,  and  which 
is  made  to  divide  the  stricture  radially,  from  the 
centre  to  the  walls  of  the  nasal  duct,  in  three  or 
four  directions ;  until  the  blade  is  quite  free  and 
loose  in  the  duct,  and  blood  escapes  from  the  cor- 
responding nostril.  Nothing  more  need  be  done, 
and  a  complete  cure  will  sometimes  follow.  Too 
often,  however,  the  stricture  again  contracts,  and 
then  tlie  cases  fall  into  two  classes — those  in  which 
the  patient  can  keep  himself  tolerably  comfortable 
by  frequently  emptying  the  sac  and  by  the  use  of 
an  astringent  lotion,  and  those  in  which  the  sac  is 
often  inflamed  and  the  eye  constantly  irritable. 
Many  attempts  have  been  made  to  cure  cases  of 
the  latter  class  by  repeated  probing,  b}'  leaving 
short  probes  in  the  duct,  by  the  use  of  probes  of  a 
material  whicli  expands  by  the  absorption  of  moist- 
ure, when  introduced,  and  by  applying  lotions  di- 
rectly to  the  duct  with  a  syringe.  I  have  not  seen 
any  of  these  methods  produce  results  at  all  equiva- 
lent to  the  disadvantages  which  attend  upon  them, 
and  in  tlie  bad  cases  it  is  probably  the  best  practice 
either  to  remove  the  lachrymal  gland  or  to  destroy 
the  diseased  sac  with  caustic.  The  former  opera- 
stiiiing's  knife  for  dividing   ^^jf^,,  1,.^^^  already  been  referred  to;  the  latter  is  per- 

lachrvmal  fistula.  ,.  .    ,  ,•  .  ,.,...  ,,  i     .1 

tornied   i)y  making  a  vertical  incision   through  the 
cheek  into  the  sac,  so  as  to  open  its  whole  length.     Bleeding  having  been 


THE    USES    OF    SPECTACLES.  753 

arrested,  and  all  secretion  removed,  the  sac  may  be  filled  with  a  pellet  of 
cotton-wool  charged  with  chloride  of  zinc  paste,  and  the  wliole  sac  will 
in  dne  time  be  thrown  ofl"  as  a  slough.  Care  must  be  taken  to  protect 
the  cheek,  by  plaster  or  oil,  from  the  action  of  the  caustic  ;  and  it  will 
often  happen,  during  cicatrization,  that  the  tears  will  maintain  for  them- 
selves a  passage  tlirough  the  tissues  by  which  the  sac  is  replaced.  After 
extirpation  of  the  gland  the  conjunctiva  is  moistened  only  by  its  own 
secretion;  and  the  sac,  no  longer  irritated  by  tears,  returns  gradually  to 
a  healthy  condition. 

If  tlie  patient,  when  first  seen,  has  actual  abscess  of  the  lachrymal  sac, 
an  attempt  should  be  made  to  prevent  yielding  of  the  skin  by  opening 
the  abscess  through  the  canaliculus.  The  cavity  should  be  kept  empt}' 
by  frequent  gentle  pressure,  but  no  attempt  should  be  made  to  pass  a 
probe  through  the  stricture  until  all  acute  irritation  has  subsided.  If 
fistula  lacrymalis  has  actually  been  formed  the  stricture  must  be  treated 
in  the  manner  already  described,  and,  if  it  can  be  treated  successfully, 
the  fistulous  opening  will  close  so  far  as  to  be  imperceptible. 

The  Uses  of  Spectacles. — It  still  remains  to  speak  of  the  uses  of  spec- 
tacles, a  large  and  somewhat  complicated  subject,  which,  in  the  space 
available  in  this  volume,  can  only  be  treated  in  the  most  superficial 
manner.  It  may  be  laid  down  as  a  general  principle  that  spectacles  are 
required  in  almost  every  case  in  which  there  is  good  vision  under  some 
circumstances  but  not  under  others — good  vision  limited  by  some  con- 
ditions of  space  or  of  time.  The  only  notable  exception  is  in  cases  of 
night-blindness,  which  depends  either  upon  pigmentary  retinitis  or  upon 
exhaustion  of  the  retina  by  exposure  to  excessive  illumination.  But, 
roughly  s[)eaking,  if  vision  is  conditioned  bj^  space,  so  that  a  person 
can  see  clearly  only  within  a  certain  limit  of  distance,  or  onl^^  beyond  a 
certain  limit  of  distance,  or  if  it  is  conditioned  by  time,  so  that  a  person 
can  see  clearly  for  a  certain  period  of  effort,  but  no  longer  ;  or  if  it  is 
conditioned  by  the  shape  or  direction  of  objects,  as  when  horizontal  lines 
are  seen  more  or  less  plainly  than  vertical  ones,  in  all  such  instances 
spectacles  will  alleviate  or  remove  the  defect.  The  fact  that  there  is 
good  vision  at  any  time,  or  under  any  circumstances,  proves  that  the 
retina  is  healthy  and  the  sensorium  receptive ;  so  that  the  defective 
vision  under  other  circumstances  can  onl}'  be  due  to  some  imperfection 
of  the  muscular  apparatus  of  vision  by  which  the  eyes  are  adjusted  and 
directed  to  the  object.  Moreover,  the  occurrence  of  pain,  aching,  or 
straining,  which  is  not  constant,  but  which  is  brought  on  only  by  using 
the  eyes,  and  is  relieved  by  resting  them,  may  generally  be  taken  to 
indicate  that  nothing  but  the  muscular  system  is  in  fault,  that  there  is 
no  organic  disease  or  serious  defect,  and  that  optical  assistance  is  all  that 
is  required. 

Emmetropia. — The  eye  of  natural  shape  and  proportion  is  said  to  be 
"  emmetropic."  Emmetropia  signifies  that  the  eye,  when  in  a  state  of 
absolute  rest,  sees  distant  objects  clearly.  Its  vision  is  bounded  by  no 
far  point,  but  extends  theoretically  to  infinity,  and  practically  takes  in 
the  fixed  stars.  In  order  that  such  an  eye  may  see  near  objects  clearly 
the  convexit}'  of  its  crystalliiie  lens  must  be  increased  ;  and  the  nearer 
the  object  approaches  the  greater  the  convexity  must  become.  The 
change  is  brought  about  by  the  action  of  the  ciliary  muscle,  or  muscle  of 
accommodation  ;  and,  as  the  power  of  the  muscle  is  limited,  the  extent 
to  which  the  convexity  of  the  lens  can  be  increased  is  also  limited,  and 
clear  vision  is  limited  by  a  "  near  point,"  nearer  than  which  objects  cannot 

48 


754  AFFECTIONS    OF    THE    EYE. 

be  seen  distinctl}'.  The  state  of  the  eye  at  rest  is  called  its  "  refraction  ;" 
the  power  of  altering  the  refraction  to  see  near  objects  is  called  "  accom- 
modation." 

Freffbijopio. — While  the  muscular  power  available  for  accommodation 
is  always  about  the  same,  the  plasticity  or  elasticity  of  the  crystalline 
lens  diminishes  from  childhood  onwards,  and  it  becomes  every  3-ear 
harder  alter  tlie  age  of  about  eleven.  Consequently,  after  that  age,  the 
near  point  goes  farther  away  from  the  eye  every  year,  as  the  power  to 
mould  the  shape  of  the  lens  diminishes.  A  child  of  eleven  might  read 
small  print  at  four  or  five  inches,  but  the  same  person  at  the  age  of 
twenty  would  not  be  able  to  read  it  nearer  than  at  six  or  seven  inches.  ■ 
As  years  increase,  the  accommodation  diminishes  in  an  increasing  ratio, 
until,  at  forty-five  or  fift}'  years  of  age,  the  near  point  is  so  far  away  that 
a  book  or  newspaper  can  only  be  read  when  it  is  inconveniently  remote, 
so  that  the  eyes  hardh'  receive  sufficient  light  from  it.  This  state  is 
called  aged  sight,  or  presbyopia,  and  it  is  a  natural  and  physiological 
condition,  common  to  all  healthy  and  well-formed  eyes.  When  it  occurs 
prematurely  it  may  be  a  sign  of  premature  senile  decay  ;  and  when  it 
increases  verj-  rapidly  it  may  be  premonitory  of  glaucoma.  But  at  the 
average  time,  and  in  the  average  degree,  it  is  simply  the  common  lot  of 
humanity,  from  which  only  people  who  were  originally  shortsighted  are 
even  apparently  exempt. 

Glasxes  for  Presbyopia. —  Presbyopia  is  in  its  essential  natnre  incura- 
ble, l)ut  its  effects  are  entirely  obviated  by  convex  spectacles,  which  pro- 
duce outside  the  eye  the  same  optical  effect  which  the  wearer  is  no  longer 
able  to  produce  by  an  internal  effort.  Presbyopic  persons  should  use 
spectacles  as  soon  as  the  defect  makes  itself  felt,  and  should  not  be 
tempted  by  spectacle  sellers  to  begin  with  insufficient  power.  Tlie  use 
of  glasses  will  save  them  from  much  straining  and  effort,  and  will  restore 
them  to  juvenility  of  vision.  Comfort  in  use  is  the  best  test  of  efficiency, 
•and  no  glasses  that  are  comfortable  in  use  will  ever  do  mischief. 

Ametropia. — The  essential  condition  of  emmetropia  is  that  the  focal 
length  of  the  crystalline  lens  should  be  equal  to  its  distance  from  the 
■retina;  or,  supposing  the  lens  to  be  an  invariable  quantity,  tliat  the  eye- 
ball should  be  of  a  certain   depth  from  front  to 
Fig- 342.  back.     It  is  obvious  that  this  condition  may  be 

departed  from  in  two  opposite  directions — by  the 
eyeball  being  too  short  from  front  to  back,  or  by 
its  being  too  long.     An  eye  in  either  of  these 
conditions  is  distinguished  as  being  ametropic, 
and  ametropic  eyes  tall  naturally  into  two  classes 
— the   hyi)ermetropic,  which  are  too  short  from 
front  to  back ;  and  the  hypometropic,  or  myoi)ic, 
Diagram  of  <'niimtro|)ia,  iiiyo-   wliicli  ai'c  too  long.     In  the  annexed  diagram  the 
pia,  and  iiyiarnic'tropia.        dark  line  represents  emmetropia,  or  the  normal 
standard  ;  the  inner  dotted  line  resi)resents  hy- 
permetropia ;  the  outer  dotted  line  represents  myopia. 

IJij]ierrneb-opia.' — Hypermetropic  i)eople  have  conditioned  vision.  They 
do  not  see  anything  clearly  when  their  e^es  are  at  rest,  and  hence  they 
instinclively  exert  accommodation,  more  or  less,  according  to  the  degree 
of  their  defect,  even  for  distant  objects.  For  near  objects  they  require, 
of  course,  to  accommodate  still  more.  In  childhood  they  are  liable  to 
S(piint,  and  at  all  ages  they  are  apt  to  find  the  use  of  tiieir  eyes  exces- 
sively wearisome.  Employment  over  minute  objects  produces  intolerable 
aching.     The  intensity'  of  these   symptoms  is  determined   by  three  ele- 


MYOPIA.  755 

ments — the  degree  of  liypermetropia,  the  flexibility  of  the  lens,  and  the 
strength  of  the  muscle  of  accommodation.  When  the  degree  is  slight, 
and  other  circnmstances  are  favorable,  hypermetropia  may  appear  only 
as  early  presbyopia,  calling  for  glasses  at  thirty-five  or  forty  3'ears  of  age, 
independently  of  prematme  senility.  When  the  degree  is  high,  and  cir- 
cumstances are  unfavorable,  the  result  may  be  absolute  incapacity  to  use 
the  ej^es  for  sustained  looking  at  any  near  object. 

Glasses  for  Hypermetropia. — Hypermetropia  in  its  extreme  degrees, 
is  a  malformation  which  partakes  of  the  nature  of  an  arrest  of  develop- 
ment, and  which  is  often  associated  with  an  imperfect  sensitiveness  of 
the  retina.  Except  for  this  it  is  entirely  relieved  by  convex  spectacles; 
and  whatever  the  degree  of  sight,  all  pain  or  discomfort  may  be  removed 
by  resting  the  accommodation  by  their  employment.  The  spectacles 
should  be  worn  constantly,  from  morning  to  nig'iit,  so  that  the  eyes  are 
never  called  upon  for  abnormal  effort,  and  their  strength  should  be 
exactly  compensatory  of  the  defect.  How  to  ascertain  the  necessary 
strength  may  he  found  in  systematic  treatises  upon  the  subject.  For  the 
purposes  of  this  volume  it  is  sufficient  to  point  out  that  the  pains  of  hy- 
permetropia require  and  may  be  cured  by  spectacles,  and  that  they  do 
not  require  and  cannot  even  be  improved  by  the  energetic  medical  treat- 
ment which  they  sometimes  receive. 

lli/ojna. — The  opposite  condition,  myopia,  is  the  physical  cause  of  short 
sight,  in  which  vision  is  limited  b}- some  finite  "far  point."  The  far 
point  may  be  six  inches  from  the  eye,  or  twenty-four  inches,  or  six  feet, 
but  wherever  it  is  there  is  no  clear  vision  beyond  it.  The  evil  results  of 
myopia  are  two  in  number :  first,  that  it  i)revents  those  who  suffer  from  it 
from  seeing  the  world,  and  thus  greatly  curtails  the  unconscious  education 
which  the  world  imparts.  Next,  in  its  high  degiees,  by  requiring  the 
two  eyes  to  be  maintained  in  a  high  degree  of  convergence  in  order  to 
direct  them  both  to  a  near  object,  it  throws  a  mechanical  strain  upon  the 
posterior  part  of  the  hemisphere  which  leads  to  its  mechanical  elongation, 
with  consequent  increase  of  the  myopia,  and  which  leads  also,  in  many 
cases,  to  atrophy  and  even  to  chronic  inflammation  of  the  choroid,  and 
to  subsequent  clianges  which  are  destructive  to  sight.  Hence  it  is  im- 
portant that  myopic  children  should  constant!}^  wear  spectacles  which  will 
enable  them  to  see  the  world  in  which  they  move,  and  it  is  still  more 
important  that  they  should  wear  spectacles  which  will  keep  their  books 
and  their  work  away  from  them — whicli  will  not  indeed,  enable  them  to 
see  better,  but  will  compel  them  to  see  farther  off.  Such  spectacles  must 
be  concave,  and  whether  or  not  the  same  pair  will  fulfil  both  purposes 
will  depend  upon  the  degree  of  the  defect.  How  to  measure  this  degree, 
and  how  to  prescribe  for  it  when  it  is  ascertained,  are  points  on  which 
information  must  be  sought  elsewhere. 

Astigmatism. — There  is  also  a  complicated  form  of  ametropia  called 
astigmatism,  in  which  the  cornea,  like  the  bowl  of  a  spoon,  is  differently 
curved  in  two  directions  which  are  at  right  angles  to  each  other,  and 
sometimes,  but  not  aUvays,  vertical  and  horizontal.  The  possible  combi- 
nations of  astigmatism  are  very  numerous,  but  the  general  test  of  its 
presence  is  that  similar  lines  are  seen  more  or  less  clearly  according  10 
their  direction.  Even  more  than  hypermetropia  it  is  a  source  of  fatigue 
and  distress  which  disqualify  the  eyes  from  exertion  ;  but  it  admits  of 
being  greatly  relieved  by  glasses  with  cylindrical  surfaces,  which  i-e- 
fract  more  in  one  direction  than  in  another,  and  which  must  be  carefully 
calculated  to  meet  the  peculiarities  of  everj'  case. 


756  DISEASES    OF    THE    EAR. 


CHAPTEK  XXXVI. 

DISEASES  OF  THE  EAE. 

The  present  chapter  is  only  intended  as  an  indication  of  the  chief 
topics  in  aural  pathology  and  therapeutics  ;  as  an  auxiliary  to  the  under- 
standing of  a  very  difficult  and  complex  subject,  and  an  introduction  to 
the  study  of  special  treatises. 

The  most  intelligible,  and  I  think  for  practical  purposes  the  most  useful, 
division  of  the  diseases  of  the  ear  is  into  those  of  the  external  meatus,  the 
membrana  tj'mpani  and  tj^mpanum  (including  the  Eustachian  tube  and 
mastoid  cells),  and  the  lab^-rinth.  And  it  may  be  said,  I  think,  with  truth 
that  most  of  the  affections  of  the  external  parts  are  curable,  many  of  those 
of  the  tjanpanura  very  difficult  of  cure,  and  all  those  of  the  labyrinth  at 
present  inaccessible  to  treatment. 

Malformations^  such  as  imperfect  development  of  the  external  parts, 
absence  of  the  meatus  or  supernumerary  auricles,  are  every  now  and  then 
met  with.  They  are  interesting  in  a  scientific  or  morphological  point  of 
view,  but  of  little  surgical  importance.  Supernumerar}'  auricles  should 
be  removed  when  it  will  improve  the  patient's  appearance;  for  the  other 
malformations  no  treatment  can  be  recommended. 

Tumors  of  the  Auricle. — A  blood-tumor  (hematoma  auris)  is  often 
met  with  in  the  auricle  in  insane  persons.  It  is  not  usually  necessary  or 
desirable  to  meddle  with  it.  If  it  threatens  to  grow  large  it  should  be 
treated  by  setons.  Other  tumors  form  in  the  auricle,  the  most  familiar 
being  the  little  fibrous  or  keloid  tumor  which  sometimes  grows  around 
the  puncture  of  the  earring  in  ladies.  When  this  is  reall}^  increasing,  or 
when  it  has  attained  a  size  which  produces  disagreeable  deformity,  it 
should  be  removed ;  but  the  operation  is  rarely  necessary.  When  it  is 
so,  the  best  plan  is  to  cut  out  the  tumor  by  a  V-shaped  incision,  and 
bring  the  parts  together  at  once. 

Cysts,  gout}'  deposits,  and  fatty  or  other  innocent  tumors  are  found 
occasionally  in  the  auricle,  but  their  treatment  presents  no  peculiarity. 

Eruptions. — The  most  common  affections  of  the  auricle  are  the  pustular 
or  vesicular  skin  eruptions,  eczema,  herpes,  impetigo,  and  the  chronic 
inflainmation  which  occasionally  follows  on  erysipelas.  The  cliief  differ- 
ences in  t])e  patholog}'  and  treatment  of  such  affections  from  those  which 
occur  in  other  situations  depends  on  the  difficulty  of  keeping  the  eai's 
clean  and  dry,  and  on  the  liability  to  accumulation  of  secretion  in  the 
recess  of  tiie  meatus:  scrupulous  attention  to  these  points  will  generally 
render  these  diseases  much  more  tractable.  The  general  health  and  the 
state  of  the  secretions  must  be  carefully  attended  to,  and  the  diet  and 
medical  treatment  regulated  accordingly;  the  auricle  must  be  carefully 
cleansed  and  dried  twice  a  day,  and  the  meatus  well  .syringed  out  with 
w^arm  water  or  any  appropriate  lotion,  after  which  the  local  application 
which  is  indicated  in  each  skin  eruption  is  to  be  ap[)lied  (see  Diseases  of 
the  .Skin).  In  tiie  chronic  erysipelatous  infiammation  lotions  of  nitrate  of 
silver  will  be  most  serviceable. 


OTORRHCEA.  757 

Periostitis  and  Caries  of  External  Meatus. — The  periosteum  of  the 
external  meatus  is  sometimes  inflamed,  leading  to  an  acutely  painful 
swelling,  which  after  some  time  may  suppurate.  It  is  not  necessary, 
however,  to  wait  for  the  formation  of  matter  in  order  to  open  the  swell- 
ing. A  free  incision  will  relieve  the  patient's  sufferings  and  may  avert 
further  mischief.  Otherwise  the  bone  itself  may  become  carious ;  and 
although  this  disease  is  less  alarming  than  that  which  affects  the  parts 
of  the  bone  nearer  to  the  vessels  and  membranes  of  the  brain,  yet  it  is 
A'ery  tedious,  threatens  permanent  damage  to  the  hearing,  and  may 
spread  inwards. 

Examination  of  the  External  Meatus  and  Memhrana  Ti/mpani. — The 
examination  of  the  external  meatus  is  directed  to  ascertain  the  condition 
and  appearance  of  its  lining  membrane,  the  presence  or  absence  of  foreign 
bodies,  or  of  accumulations  of  wax,  and  the  condition  of  the  membrana 
tympani.  In  a  very  good  light  the  tympanic  membrane  can  sometimes 
be  seen  without  a  speculum  ;  but  nsuall}^  a  silver  tube,  either  solid  or 
cleft  and  dilatable,  is  necessary;  and  nnless  bright  daylight  is  available 
it  is  necessary  to  throw  the  light  of  a  lamp  with  a  reflector  behind  it 
down  the  tube.  The  best  light  is  bright  daylight  reflected  from  a  mirror 
with  8-inch  focus.  In  operative  procedures  a  similar  mirror  shonld  be 
worn  on  the  forehead  (as  in  laryngoscopy),  in  order  to  leave  both  hands 
free.  Mr.  Hinton  says  that  in  the  case  of  very  young  children  the  specu- 
lum is  to  be  used  with  caution,  on  account  of  the  shallowness  of  the 
meatus.  "  The  points  to  be  noted  in  the  examination  of  the  meatus  are 
the  size  and  calibre  of  the  canal,  whether  normal  or  infringed  upon  ;  the 
presence  or  absence  of  extraneous  bodies  and  cerumen,  and  the  condition 
of  the  lining  membrane." 

Accumulation  of  cerumen  is  a  very  common  cause  of  deafness,  and 
often  induces  giddiness  and  various  still  more  unpleasant  symptoms.  It 
may  even  cause  absorption  of  the  bony  walls  of  the  meatus.  The  sudden- 
ness of  the  deafness,  the  presence  of  other  catarrhal  symptoms,  and  the 
variability  of  the  power  of  hearing  often  mark  the  deafness  following  on 
sudden  accumulation  of  wax  arising  from  catarrh  of  the  meatus,  even 
before  examination.  The  wax  must  be  removed  by  constant  and  liberal 
syringing  with  warm  water.  The  patient  sitting  with  liis  head  inclined 
over  a  basin,  a  stream  of  water  is  to  be  directed  out  of  a  syringe  liolding 
about  five  ounces  along  the  roof  of  the  meatus,  running  out  l)elo\v.  Soft- 
ening the  wax  with  alkaline  solutions  or  warm  oil  dropped  into  the  ears 
at  night  will  promote  its  discharge.  Often  a  large  mass  comes  away  at 
last,  presenting  a  complete  cast  of  the  meatus,  and  leaving  the  lining  of 
the  meatus  irritable.  Soothing  applications  and  repeated  syringing,  if 
the  wax  recollects,  are  then  required  for  some  time.  The  irritability 
depends,  in  part  at  least,  on  removal  of  the  epidermis  along  with  the  wax. 

Otorrhcea. — Another  common  affection  of  the  meatus  is  inflammation 
of  its  lining  membrane,  sometimes  leading  to  abscess.  Chronic  inflam- 
mation of  the  meatus  is  one  cause,  but  only  one  out  of  many,  of  otorrhcea, 
and  before  putting  otorrhtt?a  down  to  that  cause  the  membrana  tympani 
must  be  carefully  inspected.  If  it  is  healthy  and  the  disease  obviously 
proceeds  from  an  inflamed  condition  of  the  lining  of  the  meatus,  the  next 
thing  to  determine  is  whether  this  is  merely  catarrhal  or  depends  on  any 
constitutional  cachexia,  of  which  struma  and  gout  are  the  most  frequent. 
Any  such  cachexia  having  been  combated,  warm  syringing  and  warm 
fomentations  to  the  inflamed  membrane  are  indicated,  with  leeches  and 
morphia  if  there  is  much  pain.     When  the  acute  stage  has  subsided  mild 


758  DISEASES    OF    THE    EAR. 

mercurial  ointments,  or  a  solution  of  nitrate  of  silver,  five  or  ten  grains 
to  the  ounce,  sliould  be  applied  on  a  camel's-hair  brush. 

In  some  cases  the  disease  becomes  chronic,  and  the  cuticular  lining- 
may  desquamate  from  the  wliole  meatus,  like  the  finger  of  a  glove.  But 
in  these  instances  Mr.  Hinton  says  there  is  almost  always  disease  of  tlie 
deeper  structures.  When  abscess  occurs  in  the  meatus  a  free  and  early 
opening  is  essential. 

Si/phiU(k-  condylomata,  or  secondary  ulcers,  may  form  around  the 
raeatus.  They  are  rare,  but  the  surgeon  ought  to  be  alive  to  the  occur- 
rence of  such  symptoms,  in  order  to  diagnose  them,  by  the  investigation 
of  the  otlier  parts  of  the  body,  and  by  the  history. 

Tumors  of  the  Meatus. — The  tumors  of  the  meatus  are  polypi,  seba- 
ceous tumors,  and  exostoses.  Polypi  usually  have  their  seat  further 
inwards,  and  will  be  afterwards  spoken  of.  Sebaceous  tumors  also  often 
grow  into  the  meatus  from  the  tympanum.  Their  continued  growth  may 
cause  absorption  of  the  base  of  the  skull  and  fatal  irritation  of  the  brain. 
It  is  not  easy  to  recognize  them  from  accumulations  of  wax.  The  treat- 
ment consists  in  puncturing  tlie  swelling,  removing  the  accumulation  of 
epidermal  scales  by  syringing,  and  if  any  distinct  investing  membrane 
can  be  recognized,  drawing  it  out  with  the  forceps. 

Exostoses,  so-called,  occur  in  comparatively  early  life,  and  seem  often 
only  periosteal  deposits,  so  that  "  treatment  is  not  so  inefficacious  as 
might  have  been  feared."  The  appropriate  treatment  consists  in  local 
depletion  and  counter-irritation  with  mercury  or  iodine  internall3^  If 
wax  is  retained  behind  the  tumor  much  patience  and  dexterity  may  be 
necessary  to  remove  it.  In  other  cases  small  ivory  exostoses  spring  from 
the  bony  meatus,  on  which  of  course  treatment  can  have  no  effect,  and 
which  are  usuall}'  too  hard  to  be  safely  removed. 

Examinatioyi  of  the  Tympanum. — The  membrana  tympani,  when  seen 
in  a  healthy  ear,  "  reflects  light  strongly  ;  and  owing  to  its  peculiar  cur- 
vature presents  a  bright  spot  of  triangular  shape  at  its  lower  and  anterior 
portion."  The  white  streak  formed  by  the  handle  of  the  malleus  can 
usually  be  seen  running  vertically  down  it. 

Perforation. — The  examination  is  directed  to  ascertain  (1)  the  presence 
of  perforations  from  injury  or  disease.  Such  perforations  may  be  caused 
in  a  healthy  membrane  by  a  blow  or  a  loud  report,  or  a  wound,  such  as 
is  now  often  made  in  surgical  operation.  These  perforations  may  heal 
without  damage  to  the  hearing ;  or  perforation  may  follow  on  the  ulcer- 
ation caused  by  a  foreign  body  ;  and  here  also,  if  the  perforation  is  not 
large  or  the  ulceration  long  continued,  the  opening  may  heal  and  tlie  pa- 
tient recover  his  hearing.  It  may  be  asserted  broadly  that  the  opening 
in  the  membrana  tymi)ani  is  in  itself  of  subordinate  importance  ;  the  in- 
jury or  the  inflammator3'  lesion  of  the  deeper  structures  is  what  deter- 
mines tlie  presence  or  absence  of  deafness.  Thus  a  small  perforation 
which  heals  rapidly  may  yet  be  the  cause  of  great  loss  of  hearing,  be- 
cause, along  with  the  perforation  of  the  membrane,  there  has  been  injury 
of  the  deeper  parts  ;  nay,  it  is  possible  that  the  very  closure  of  the  mem- 
brane may  have  been  (hjleterious,  by  obstructing  the  escape  of  discharge 
from  tlie  tympanum.  An  interesting  account  of  accidental  lesions  of  the 
membrana  tympani  by  Mr.  Dalby  will  be  found  in  the  6th  vol.  of  the 
Clin.  Soc.  Trans.,  a.nd  in  the  Lancet  for  May  29,  18T5.  "Out  of  twenty- 
two  cases  the  perforation  did  not  heal  in  ten  ;  eleven  healed,  and  one  was 
in  process  of  healing  when  last  seen  ;  in  six  instances  the  hearing  did  not 
suffer  at  all;  in  the  remaining  sixteen  it  was  more  or  less  seriously  im- 


ARTIFICIAL    MEMBRANA    TYMPANI.  759 

paiied."  Mr.  Dalby  also  points  out  that  in  cases  of  injury  in  which  the 
membrane  has  not  given  way  tlie  hearing  is  generally  more  irreparably 
damaged  than  in  those  where  perforation  has  occurred.  In  one  of  these 
cases  the  portio  dura  was  divided  at  the  same  time  that  the  membrane 
was  perforated  (by  a  pair  of  scissors),  causing  immediate  paralysis  of  the 
features. 

In  other  cases,  after  more  or  less  protracted  inflammation  of  the  mem- 
brana  tympani,  it  gives  way  either  as  the  result  of  spontaneous  ulcera- 
tion or  from  some  slight  injury.  It  seems  as  if  the  patient  often  produces 
the  hole  in  picking  his  ear. 

In  cases  of  inflammation  of  the  membrana  tympani  the  presence  of 
red  vessels  on  it  and  the  loss  of  its  natural  lustre  will  mark  the  nature 
of  the  disease.  I  have  seen  very  acute  suffering  produced  by  inflamma- 
tion of  the  proper  substance  of  the  membrana  tympani,  which  subsided 
and  left  the  hearing  unaffected.  When  this  disease  is  acute,  free  local 
depletion,  with  soothing  applications  and  the  internal  use  of  morphia, 
are  the  main  points  of  treatment.  When  the  disease  has  gone  on  to  per- 
foration the  first  thing  is  to  get  the  inflamed  membrane  into  a  jierfectly 
quiet  state.  The  perforation  may  then  heal.  In  other  cases  perforation 
depends  on  some  of  the  diseases  of  the  tympanum  to  be  presently  spoken 
of,  especialh'  that  which  follows  scarlet  fever. 

There  is  not  generally  any  difliculty  in  recognizing  a  perforation  of 
the  membrana  tympani.  It  can  be  seen,  or  a  bubble  of  fluid  is  formed 
in  it  which  presents  a  peculiar  pulsation  ;  or  the  patient  can  blow  air 
through  it  by  holding  his  nostrils,  or  the  surgeon  can  inflate  it  through 
the  Eustachian  tube  by  one  of  the  methods  shortly  to  be  described.  The 
perforation  does  not  necessarily  produce  deafness  or  require  treatment. 
In  fact,  the  loss  of  hearing  is  connected  less  with  the  destruction  of  the 
membrane  than  with  the  diseased  state  of  the  deeper  parts.  In  the  treat- 
ment of  these  perforations  the  first  care  of  the  surgeon  is  (as-  stated 
above)  to  procure  the  subsidence  of  all  inflammation  in  the  membrane, 
and  his  next  to  examine  the  tympanic  cavity  carefully;  for  the  perfora- 
tion is  often  caused  or  accompanied  by  an  obstruction  of  the  tympanum 
from  inspissated  discharge,  and  this  must  be  cured  by  syringing  out  the 
tympanum  with  astringents  and  alkalies  from  the  Eustachian  tube  and 
from  the  perforation,  befpre  the  latter  can  be  got  to  heal.  When  all  the 
neighboring  parts  have  been  got  into  a  healthy  condition  the  nitrate  of 
silver  in  stick  or  solution,  or  powdered  talc,  as  recommended  by  Mr. 
Hinton,  should  be  applied  to  the  membrane,  and  some  astringent  or  stim- 
ulating lotion  dropped  into  the  ear,  so  as  to  fill  the  tympanum  ;  and  then 
the  i)atient  should  force  tlie  air  freely  through  the  Eustachian  tube,  allow- 
ing the  lotion  to  escape  gradually.' 

Artificial  Membrana  Tympani. — When  all  hope  of  the  healing  of  a 
perforation  is  at  an  end,  and  the  patient  is  rendered  very  deaf  l)y  it,  the 
artificial  membrana  tympani  may  be  tried.  This  is  made  either  on  Mr. 
Yearsley's  plan,  with  cotton-wool  moistened  with  glycerin,'^  or  on  Mr. 
Toynbee's  with  a  disk  or  little  ball  of  india-rubber  mounted  on  a  stem. 
If  the  foreign  substance  is  pressed  down,  either  till  it  impinges  on  the 

1  Mr.  Hinton  prescribes  the  following  lotions:  Hyd  Perchlor.  J  gr.,  or  Zinci 
Sulph.  irr.  ij-x,  or  Liq.  Ferri.  Perchlor.  "nix,  or  tannin  'gr.  x-^j  in  an  ounce  of 
water,  combined  in  each  case  witli  from  2  to  30  drops  of  Tinct.  Opii. 

2  A  small  layer  of  cotton-wool  is  saturated  with  glycerin,  and  the  patient  is  pro- 
vided with  a  p.iir  of  forceps  ending  in  a  probe-pointed  handle;  with  the  handle  he 
pushes  the  wool  down  the  ear  till  he  finds  the  place  at  which  its  lodgment  assists  the 
hearing,  and  the  forceps  enable  him  to  withdraw  it  when  required. 


760  DISEASES    OF    THE    EAR. 

perforated  membrane,  or  in  cases  where  the  membrane  is  quite  destroyed 
on  the  stapes  and  fenestra  ovalis,  the  hearing  is  sometimes  verj^  materi- 
ally improved.  This  is  a  matter  of  direct  experiment ;  and  when  the 
artificial  membrane  does  good  the  patient  soon  l)ecomes  much  more  dex- 
terous in  its  application  than  the  surgeon  can  be. 

The  other  chief  phenomena  which  are  seen  in  the  direct  examination 
of  the  membrana  timpani  refer  to  its  curvature  and  tension.  Chronic 
inflammation  causes  rigidity  and  flattening  of  the  membrane,  which  will 
no  longer  bulge  outwards  as  tlie  patient  inflates  the  tympanum  ;  or  the 
membrane  may  have  lost  its  tension  altogether  and  hang  down  relaxed  ;  ^ 
or  the  tympanum  may  be  filled  with  secretion,  driving  the  membrane 
outwards  and  rendering  it  permanently  curved.  In  cases  of  relaxation 
advantage  is  sometimes  derived  from  the  use  of  astringent  lotions  and 
from  the  support  of  tlie  artificial  membrana  tympani.  Cases  of  increased 
tension  and  of  retained  secretion  in  the  tympanum  must  be  regarded  as 
affections  of  the  tympanum. 

Examination  of  the  Eustachian  Tube. — The  Eustachian  tube  is  acces- 
sible from  the  nose,  though  not  very  readily  ;  but  an  easy  and  A^er}-  useful 
method  of  inflating  this  tube  without  an^^  direct  contact  was  devised 
some  years  ago  by  Dr.  Politzer,  founded  on  the  fact  that  the  act  of  swal- 
lowing opens  the  faucial  end  of  the  tube.  All  that  is  necessary  is  to  pass 
the  nozzle  of  an  empty  india-rubber  syringe  into  the  nostril,  hold  both 
nostrils,  so  as  to  prevent  the  escape  of  air,  let  the  patient  hold  a  moutli- 
ful  of  water  in  his  mouth,  and  as  he  swallows  force  the  air  out  of  the 
syringe  into  his  nose.  The  air  being  prevented  from  passing  down  the 
pharynx  by  its  contraction  will  be  directed  against  the  Eustachian  tube, 
and  if  the  tube  is  open  the  patient  will  feel  the  air  pass  into  the  tym- 
panum. Or  the  surgeon  can  hear  it  do  so  by  placing  one  end  of  an  india- 
rubber  tube  about  eighteen  inches  long  (the  ''otoscope")  in  the  patient's 
ear  and  the  other  in  his  own. 

Tlie  direct  examination  of  the  Eustachian  tube  is  made  with  the  Eusta- 
chian catheter,  a  small  curved  catheter  about  six  inches  long.  This  is 
passed  gentl}^  along  the  floor  of  the  nostril  till  it  reaches  the  pharj-nx. 
Then,  if  the  surgeon  is  familiar  with  the  instrument,  he  may  apply  its 
point  to  the  outer  wall  of  the  phar^-nx  and  slip  it  directly  into  the  tube. 
The  more  common  plan  is  to  pass  it  on  till  it  reaches  the  back  of  the 
pharynx,  then  pull  it  forward  and  feel  along  the  outer  wall  for  the  end 
of  the  tube,  which  lies  very  close  to  the  nares.  This  little  manosuvre  be- 
comes easy  with  use,  and  is  much  facilitated  by  practicing  on  one's  self. 
The  catheter  is  known  to  be  lodged  in  the  tube  partly  by  its  end  being 
caught,  but  chiefly  by  finding  that  air  can  be  blown  up  into  the  ear,  or 
solutions  injected,  or  flexil)le  bougies  passed  up. 

The  Eustachian  tube  is  subject  to  numerous  causes  of  obstruction,  pro- 
ducing what  is  called  "throat-deafness."  Such  are  thickening  of  the 
mucous  membrane  of  the  fauces,  often  an  accompaniment  of  enlarged 
tonsils;^  the  inflammatory  thickening  of  cold,  relaxation  of  the  pharyn- 

»  This  is  a  consoquencoof  disease  of  tho  tympfinum,  and  is  often  caused  (according 
to  Mr.  Diilby)  by  the  injudicious  habit  of  constantly  inflating  the  ear.  Its  appro- 
priate treatment  is  by  the  local  application  of  sulphate  of  zinc,  injected  through  tlio 
Eustachian  catheter. 

2  I  am  not  aware  that  there  is  any  proof  that  the  enlarged  tonsils  themselves  ob- 
struct the  orifices  of  the  tubes,  but  "they  are  often  accompanied  by  chronic  thicken- 
ing of  tho  n(Mghboring  m(Mnbrane,  which  does  do  this,  and  which  is  relieved  by  the 
operation  performed  for  the  removal  of  the  tonsils. 


ACUTE    INFLAMMATION    OF    THE    TYMPANUM.  761 

geal  mucous  membrane,  tumors  in  the  pharynx,  stricture  of  the  tube 
itself,  and  foreign  bodies  in  it.  Some  of  these  conditions  can  be  verified 
by  tlie  ordinary  examination  of  the  throat,  others  by  posterior  rhinoscopy, 
by  whicli  method  of  examination  the  orifice  of  the  tube  can  sometimes  be 
seen  ;  others  only  by  the  direct  catheterization  of  the  tube.  In  cases  of 
deafness  which  depend  only  on  obstruction  of  the  Eustachian  tube  the 
inflation  of  the  tympanum  will  sometimes  instantaneously  restore  the 
hearing,  though  only  for  a  time.  This  circumstance  justifies  the  assur- 
ance that  the  hearing  will  ultimately  be  regained. 

Affections  of  the  Tympanum. — Mr.  Hinton  lays  down  the  following 
rules  for  distinguishing  by  means  of  the  tuning-fork  whether  deafness 
depends  on  obstruction  in  the  conducting  apparatus  or  in  the  recep- 
tive part  of  the  organ  of  hearing.  In  the  former  case,  if  disease  of  the 
meatus,  membrana  tympani,  and  Eustachian  tube  have  been  excluded 
by  the  methods  of  examination  above  detailed,  the  obstruction  must  be 
seated  in  the  tympanum.  If  it  be  in  the  receptive  apparatus— the  nerves 
or  brain — no  treatment,  as  far  as  is  known  at  present,  is  likely  to  l)e  suc- 
cessful.    Mr.  Hinton's  rules  are  as  follows.     lie  premises — 

"  That  in  a  normal  state  a  tuning-fork  is  heard  before  the  meatus  after 
it  has  ceased  to  be  heard  on  the  vertex.  That  when  placed  on  the  vertex 
it  is  heard  more  plainly  when  the  external  meatus  is  closed.  Conse- 
quently, when  one  meatus  alone  is  closed,  the  tuning-fork  is  heard  most 
plainly  in  the  closed  ear. 

"The  reason  of  this  fact  appears  to  be  that  the  sound  escapes  freely 
through  the  tympanum  and  meatus,  and  that  when  its  passage  is  impeded 
the  waves  are  reflected  and  affect  the  labyrinth  more  strongly.  Conse- 
quentl}^,  in  cases  of  disease  the  following  inferences  seem  justified: 

"In  cases  of  one-sided  deafness,  if  the  tuning-fork,  when  placed  on 
the  vertex,  is  heard  most  plainly  in  the  deaf,  or  more  deaf,  ear,  the  cause 
is  seated  in  the  conducting  apparatus  ;  if  it  is  heard  loudest  in  the  better 
ear  the  cause  is  probably  in  some  part  of  the  nervous  apparatus. 

"If,  on  closing  the  meatus,  the  tuning-fork  is  heard  decidedly  louder, 
there  is  no  considerable  impediment  to  the  passage  of  sound  through 
the  tympanum. 

"If  the  tuning-fork  is  heard  longer  on  the  vertex  than  when  placed 
close  before  the  meatus,  the  cause  of  the  deafness  is  in  the  conducting 
media. 

"  However  imperfectly  the  tuning-fork  may  be  heard  when  placed  on 
the  vertex,  it  gives  reason  for  suspecting  only,  and  is  not  proof  of,  a 
nerve-affection."' 

Acute  inflammation  of  the  tympanum  is  a  catarrhal  affection  which 
produces  severe  pain,  often  extending  over  the  whole  side  of  the  head 
and  down  the  neck,  aggravated  by  swallowing,  and  sometimes  compli- 
cated with  fever  and  delirium.  The  throat  is  usually  also  inflamed  ;  deaf- 
ness is  sometimes  total.  The  membrana  tympani  may  be  more  or  less 
congested,  and  the  swollen  mucous  membrane  of  the  t^mipanum  can  be 
seen  through  it.  If  air  can  be  blown  into  the  tympanum  it  causes  "  a 
gurgling  or  a  prolonged  creaking."  The  remedies  should  be  of  a  sooth- 
ing nature — leeches,  hot  fomentations,  and  sedative  poultices,  with  pur- 
gatives and  opiates.  The  terminations  of  the  disease  are  threefold — 
either  complete  resolution  takes  place,  which  is  very  common,  or  matter 
discharges  itself  down  the  Eustachian  tube,  or  the  membrana  tympani 
gives  way.     In  the  two  former  cases  the   hearing  is   usually  restored, 

1  Syst.  of  Surg.,  2d  ed.,  vol.  iii,  p.  293. 


7()2  diseasp:s  of  the  ear. 

Ihoiigli  perhaps  slowly;  nor  is  the  perforation  in  the  latter  case  b^y  any 
means  necessarily  attended  with  any  noticeable  deafness.  The  remedies 
recommended  are  the  constant  inflation  of  the  tympanum  witli  steam 
contaiuiiio-  the  vapor  of  iodine  or'acetie  ether;  passing  alkaline  solutions 
through  tlie  nose  or  down  the  meatus,  if  the  membrana  tympani  is  per- 
forated ;  and  attention  to  the  general  health. 

Moisf  and  Dry  Gatarrh  of  the  Tympanum. — Inflammation  of  the  tym- 
panum leaves  sometimes  a  moist,  at  others  a  semi-solid  effusion  in  the 
cavity,  the  two  being  probably  different  stages  of  the  same  process.  The 
kind  of  sound  produced  by  inflation  of  the  tympanum  will  distinguish 
the  kind  of  deposit  in  that  cavity,  the  bubbling  of  the  fluid  being  easily 
distinguishable  from  the  creaking  sound  of  dry  catarrh.  In  the  moist 
stage  astringent  injections  (as  sulphate  of  zinc)  are  most  useful ;  in  the 
dry  condition  the  hydrochlorate  of  ammonia,  4  grs.,  or  bicarbonate  of 
soda,  5  grs.,  or  iodide  of  potassium,  3  grs.  to  tlie  ounce,  ma}'  be  injected 
into  the  tympanum  by  means  of  an  india-rubber  bag  attached  to  the 
Eustacliian  catheter;  or  the  following  plan  may  be  adopted,  as  suggested 
by  Griil)er.  The  head  being  bent  completely  to  the  side  to  be  acted  upon, 
half  a  drachm  of  the  solution  is  passed  into  the  inferior  naris  from  a  glass 
syringe,  and  as  the  patient  swallows  it  is  forced  into  the  tympanum  with 
a  Politzer's  bag.  The  injection  should  be  practiced  two  or  tliree  times  a 
week. 

Accumulation  of  mucus  in  the  cavity  of  the  tympanum,  probably  as  the 
result  of  chronic  catarrh  of  its  lining  membrane,  is,  in  Mr.  Hinton's  opin- 
ion, one  of  the  most  frequent  causes  of  deafness,  which,  although  it  be- 
comes ultimatel}^  irremediable,  ma}',  as  he  believes,  be  usually  cured  if 
the  disease  is  recognized  and  treated  early  enough.  The  diaguosis  will 
rest  parti}'  on  the  patient's  sensations,  partly  on  the  phenomena  above 
described  as  indicating  obstruction  of  the  tympanum,  partly  on  tlie  direct 
examination  of  the  cavity  l)y  the  Eustachian  tube  and  meatus.  The  pa- 
tient is  often  conscious  himself  of  something  moving  about  in  his  ear, 
the  accumulated  mucus  may  cause  a  bulging  of  the  membrane  into  the 
meatus,  and  the  moist  sounds  heard  on  forcing  air  into  the  tympanum 
will  confirm  the  diagnosis.  It  is  chiefly  in  these  cases  that  the  operation 
of  incising  the  membrana  tympani  in  order  to  wash  out  the  cavit_y  is 
recommended.  This  is  a  simple  operation  in  itself,  and  in  its  conse- 
quences seems  to  involve  less  danger  to  the  apparatus  of  hearing  than 
would  at  first  sight  appear  probable.  The  patient  having  been  placed  in 
a  good  light,  and,  if  a  child  or  very  nervous  jierson,  brought  under  the 
influence  of  laughing  gas  or  some  anresthetic,  the  surgeon  makes  a  small 
vertical  incision  with  a  thin  double-edged  knife,  parallel  to  and  behind 
the  handle  of  the  malleus,  and  may  if  he  pleases  wash  out  the  cavity  at 
once  by  inserting  a  syringe  into  the  meatus,  which  closes  it  accurately, 
and  so  forcing  fluid  into  tlie  meatus,  which  will  pass  through  the  wound 
into  the  tympanum,  and  so  into  the  pharynx.  Injections  are  then  to  be 
directed  through  the  tympanum  daily  in  both  directions — i.e.,  through 
the  opening  and  through  the  Eustachian  tube — in  order  to  detach  and 
remove  any  accumulated  secretion.  The  opening  will  heal  in  about  five 
days,  and  if  the  relief  has  not  been  sufficient,  after  a  due  interval  the 
proceeding  may  be  repeated. 

Dinease  of  the  Tympanum  in  Scarlet  Fever. — A  very  frequent  cause  of 
deafness,  and  an  occasional  cause  of  death,  is  the  affection  of  the  t3'm- 
l)anum  which  fijUows  on  scarlatina.  A  similar  affection  occurs,  though 
less  commonly,  after  measles  and  whooping-cough.  The  mucous  mem- 
brane of  the  tympanum  becomes  red  and  swollen,  the  cavity  is  filled  with 


POLYPI. 


763 


pus,  the  membrana  tyinpani  gives  way,  tlie  ossicles  are  destroyed  and 
come  away,  and  often  the  walls  of  the  cavity  are  diseased,  leading  to 
permanent  otorrha;a.  This  is  a  common  cause  of  incuralile  deafness. 
Generally  this  disease  is  not  diagnosed  till  the  otorrhea  calls  the  sur- 
geon's attention  to  it.  In  early  stages,  however,  it  is  possible,  according 
to  Mr.  Ilinton,  to  see  the  matter  in  the  tympanum  tlirough  the  membrana 
tj'mpani,  and  to  give  it  exit  by  incision  of  the  membrane  and  washing 
out  the  cavity. 

For  the  description  of  the  less  known  affections  of  the  tympanum,  such 
as  the  formation  of  adhesions  in  it,  the  anchjdosis  of  the  ossicles  to  each 
other  or  the  wall  of  the  cavity,  the  growth  of  exostoses  on  tlie  ossicles, 
and  the  degeneration  of  the  membrana  tympani,  which  are  not  known  to 
be  connected  with  inflammation,  I  must  refer  to  Mr.  Hinton's  essay  or 
some  of  the  special  treatises  on  tiiese  diseases. 

/)/«ea.se  of  the  Madoid  GelU. — The  mastoid  cells  may  be  affected  with 
inflammation  leading  to  caries  and  necrosis  of  their  walls  in  cases  wliere 
the  tympanum  appears  to  be  unaffected.  In  such  cases  there  will  be  in- 
flammation, tenderness  to  pressure,  redness  and  tumefaction  behind  the 
ear,  and  sometimes  discharge  from  the  meatus.  Under  these  circum- 
stances a  free  incision  must  be  made  upon  the  process,  and  if  the  tissue 
of  the  bone  is  felt  to  be  softened,  or  pus  escapes  from  it,  the  tissue  of  the 
bone  must  be  freely  penetrated,  and  a  free  discharge  obtained,  which 
may  preserve  the  patient  from  the  risk  of  the  transference  of  the  inflam- 
mation to  the  lateral  sinus  or  the  encephalon. 

Polypi. — Aural  pol3'pi  grow  either  from  the  lining  membrane  of  the 
meatus,  from  the  outer  surface  of  the  membrana  tympani,  or  from  some 
part  of  tlie  interior  of  the  tympanum  ;  and 
their  structure  is  said  to  vary  according  to 
their  seat  of  implantation.  The  general 
character  of  the  growth  is  fibrous  or  fibro- 
cellular,  but  those  that  are  connected  with 
the  lining  of  the  meatus  are  apt  to  contain 
glandular  elements  analogous  to  the  glands 
which  are  found  in  that  membrane.^  Their 
more  common  seat,  however,  is  the  tym- 
panum, out  of  which  they  usually  grow  into 
the  meatus,  destroying  the  membrana  tym- 
pani more  or  less  completely.  They  are 
sometimes  multiple,  though  less  often  than 
nasal  polypi  are.  When  the  tympanum  is 
the  seat  of  the  growth  the  restoration  of 
hearing  must  alvvaj-s  be  very  problematical ; 
but  in  those  that  spring  from  the  meatus  a 
favorable  issue  to  the  case  may  fairly  be 
hoped.     The  difficulty  is  to  eradicate  the 

polypus  finally.  Its  removal  is  not  difficult,  either  with  small  ring-forceps 
or  by  means  of  a  snare,  for  which  purpose  Mr.  Ilinton  prefers  the  gimp 
used  by  anglers.  When  the  root  of  the  growth  can  be  fairly  exposed  its 
removal  is  eas}-,  but  it  is  sure  to  grow  again  unless  further  measures  are 

1  Interesting  details  and  illustrations  of  the  structure  of  aural  polypi  are  given  in 
Mr.  Dalby's  LL^ctures  on  Diseases  of  the  Ear,  pp.  141-147,  in  which  he  shows  that 
many  of  them  approach  the  characters  of  sarcoma  and  myxoma,  and  thus  the  ob- 
stinate tendency  to  recurrence  may  in  some  cases  bo  explained,  though  doubtless  it 
is  oftener  a  consequence  of  imperfect  removal.  The  structure  of  recent  examples  of 
polypus  is  much  more  cellular  than  that  of  those  which  have  been  longer  in  growing. 


Fig.  343. 


Aural  polypus 


764  DISEASES    OF    THE    EAR. 

taken.  The  first  tliino-  is  to  keep  the  parts  behind  the  polypus  (tym- 
panum or  meatus)  free  from  any  accumulation  of  discharge  by  copious 
and  assiduous  syringing  with  alkaline  and  astringent  solutions.  The 
next  essential  of  treatment  is  to  repress  the  growth  of  the  tumor  by  the 
constant  ai)i)lication  of  caustic  to  its  root.  "  Liq.  plumbi,  applied  by  a 
camel's-hair  brush  daily  for  a  few  days  before  the  caustic,  greatly  dimin- 
ishes the  pain.  Chloro-acetic  acid,  potassa  fusa,  carefull}^  guarded, 
chromic  acid,  or  chloride  of  zinc,  are  good  caustics.  Nitrate  of  silver  is 
excellent  in  the  later  stages.  The  caustic  is  best  applied  daily  until  a 
decided  improvement  is  produced,  this  being  by  far  the  least  painful  and 
tedious  mode  of  using  it.  At  the  same  time  a  lotion  of  perchloride  of 
mercury  (gr.  i  ad  5j),  with  tinct.  opii  njjv-x,  should  be  used  twice  a  day  ; 
tiie  Eustachian  tube,  if  closed,  should  be  made  pervious  ;  and  if  the  mem- 
brane be  perforated  a  syringing  from  the  meatus  through  the  nostril 
practiced  frequently.  When  the  root  of  the  polypus  shows  manifest  signs 
of  disappearing  w^e  can  often  substitute  for  the  caustic  the  undiluted 
liquor  plumbi  or  the  powdered  talc.  The  time  occupied  in  the  entire 
procedure  varies  from  three  weeks  to  three  or  four  months." 

Affections  of  the  Internal  Ea7\ — The  affections  referred  to  the  internal 
ear  are  little  known  in  respect  of  their  morbid  anatomy,  nor  is  their 
treatment  at  present  at  all  successful.  The  diagnosis  rests  on  the 
method  of  exclusion,  that  is  to  say,  deafness  for  which  no  other  cause  can 
be  found,  in  which  the  external  and  middle  ear  seem  healthy,  and  the 
phenomena  of  hearing  appear  to  indicate  an  affection  of  the  receptive 
and  not  of  the  conducting  media  (see  page  161),  is  judged  to  be  due  to 
some  affection  of  the  labyrinth  or  auditory  nerve  or  cerebrum,  thougli  it 
often  remains  quite  uncertain  what  tliat  affection  is.  In  some  case  nerv- 
ous deafness  follows  on  mumps  or  on  irritation  of  the  trifacial  nerve 
whi(;h  may  be  reflected  to  the  auditory,  as  in  other  cases  it  is  to  the 
optic  (page  589,  note).  In  such  cases  the  deafness  will  probably  be  only 
temporary.  Tumors  and  injuries  to  the  base  of  the  skull  may  occasion 
deafness  from  direct  lesion  of  the  nerve  or  its  roots  in  the  brain.  Hered- 
itary syphilis  sometimes  occasions  deafness,  though  I  know  not  what  is 
the  anatomical  cause.'  In  some  cases  this  deafness  may  subside  under 
the  general  and  local  treatment  suggested  by  the  diathesis.  Nervous 
deafness  also  occurs  from  functional  disturbances,  mental  and  physical, 
of  various  kinds.  It  may  be  caused  by  an  overdose  of  quinine,  and 
cured,  according  to  Mr.  Toy n bee,  by  the  same  drug  in  small  doses.  It 
is  often  accompanied  by  distressing  tinnitus,  and  for  such  cases  as  well 
as  those  which  are  truly  neuralgic  Mr.  Hinton  recommends  the  hydro- 
chlorate  of  ammonia  in  full  doses.  Finally,  in  old  age  deafness  is  often 
the  sign  of  a  loss  of  the  sense,  i.  e.,  of  permanent  and  irremediable  de- 
generation of  the  nerve  or  the  structui'es  in  which  it  terminates.  I  do 
not  speak  here  of  the  congenital  deafness  which  depends  on  malforma- 
tion of  the  internal  parts  of  the  ear  (deaf-mutism),  since  this  affection, 
interesting  as  it  has  I)ecome  of  late,  from  the  successful  education  of  its 
victims,  hardly  falls  within  the  domain  of  practical  surgery. 

Diseases  implicating  the  Brain. — One  of  the  most  formidable  characters 

1  The  deafness  of  hereditary  pj'philis  is  one  of  the  later  or  tertiary  phenomena  of  that 
disease.  It  comes  on  usually  between  the  ages  of  five  and  fiftc^m,  and  often  |irooeeds 
cradually  to  total  deafness.  >[r.  Dalhy  teljs  me  that  three  weeks  is  the  siiortest  and 
five  years  the  longest  period  that  he  has  known  tliis  disease  to  be  in  progress  before 
the  hearing  was  entirely  lost. 


Meniere's   disease.  765 

of  disease  of  the  ear  is  its  liability  to  extend  to  the  brain.  Inflammation  of 
the  meatus  or  mastoid  cells  tends  to  spread  towards  the  lateral  sinus  or 
the  cerebellum,  inflammation  of  the  tympanum  towards  the  middle  lobe 
of  the  brain,  and  that  of  the  labyrinth  along  the  auditory  nerve  towards 
the  medulla.  The  result  is  meningitis,  abscess  in  the  substance  of  the 
brain,  or  phlebitis  of  the  lateral  sinus,  possibly  followed  by  pyaemia. 
The  symptoms  commence  with  pain  in  the  head  and  neck,  and  rigors; 
then  delirium  ensues,  followed  by  paralysis,  coma,  and  death.  In  cases 
of  general  pytemic  infection  from  phlebitis  of  the  lateral  sinus,  the  char- 
acteristic symptoms  of  pyemia  will  be  superadded.  The  affection  fol- 
lows on  all  kinds  of  disease  of  the  ear,  but  mainly,  I  believe,  on  the  acute 
inflammation  of  the  tympanum,  which  is  one  of  the  sequelae  of  scarlet 
fever,  and  which  rapidl}'  spreads  to  the  bone ;  in  fact,  the  more  the  bone 
is  inflamed  and  the  acuter  that  inflammation  is,  the  more  danger  there  is 
of  cerebral  complication.  This  is  strictly  analogous  to  what  we  have 
noted  above  with  regard  to  acute  inflammation  of  bone  in  other  parts. 
But  these  complications  also  follow  in  chronic  diseases  of  the  ear,  though 
in  such  cases  the  discharge  has  generall}'  ceased  on  a  sudden,  and  in  all 
probability  such  obstruction  marks  the  supervention  of  some  acute  dis- 
ease of  the  bone,  which  rapidly  S2)reads  along  the  veins  to  the  interior  of 
the  skull. 

Treatment  can  be  of  any  avail  only  in  the  first  stage  of  the  disease, 
when  pain  in  the  head  and  the  cessation  of  some  habitual  discharge 
gives  warning  to  the  surgeon  of  the  possibility  of  the  inflammation 
spreading  inwards.  Free  leeching  behind  the  ear,  incision  dovvn  to  the 
mastoid  process,  if  there  is  any  pufliness  or  tenderness  there ;  blistering 
behind  the  ears  or  setons  in  the  nape  of  the  neck,  purgatives,  and  the 
encouragement  of  the  discharge  by  assiduous  warm  syringing  and  fomen- 
tation, are  the  measures  which  seem  most  worth}'  of  trial.  Possibly  if  the 
menibrana  tympani  be  entire  it  may  be  well  to  incise  it,  and  wash  out  the 
tympanic  cavity. 

31eniere''s  Disease. — In  connection  with  nervous  deafness  and  affections 
of  the  internal  ear  I  ought  to  mention  the  obscure  and  singular  aff'ection 
called  after  its  describer  "Meniere's  disease,"  in  which  a  person  previ- 
ously in  good  health  sutlers  from  a  severe  attack  of  vertigo,  sometimes 
so  that  he  falls  down  and  cannot  stand  for  a  long  time,  and  this  is  ac- 
companied by  some  tinnitus.  On  recovering  from  this  condition  one  ear 
is  found  to  be  quite  deaf.  No  disease  can  be  detected  in  the  tymi)anum, 
nor  is  tlie  general  health  afterwards  affected.  "The  nervous  lesion,"  as 
Mr.  Dalby  says,  "must  be  situated  in  the  brain  or  the  labyrinth — most 
likely  the  latter," — but  the  pathology  of  the  affection  is  at  present  un- 
known. It  is,  however,  important  to  be  aware  of  it,  and  to  distinguish 
such  symptoms,  caused  b}'  local  disease  in  the  ear,  from  the  more  alarm- 
ing disease  of  the  brain. 


766  DISEASES    OF    THE    URINAEY    ORGANS. 


CHAPTER   XXXVII. 

DISEASES  OF  THE   URINARY  ORGANS. 
SURGICAL    AFFECTIONS     OF    THE    KIDNEY. 

Nephritis. — Acute  inflammation  of  the  kidney  is  a  very  common  affec- 
tion in  surgical  cases,  and  occurs  usually  as' an  extension  of  the  inflam- 
mation of  the  bladder,  which  will  presently  be  described  as  the  result  of 
stricture,  stone,  diseased  prostate,  and  other  common  surgical  affections. 
It  may  also  follow  on  injuries,  or  arise  from  exposure  to  cold,  or  from 
poisoning  by  cantharides,  or  alcohol.  It  is  marked  l\y  rigors,  vomiting, 
pain  in  the  back,  frequent  scanty  micturition,  bloody  or  albuminous  urine, 
frequently  purulent,  and  often  containing  casts  of  the  renal  tubes,  with  a 
good  deal  of  general  fever.  In  spontaneous  cases  anasarca  may  occur 
and  total  suppression  of  urine.  Suppuration  in  the  substance  of  the 
kidney  may  ensue,  marked  by  increase  of  pain  and  retraction  of  the 
testicle,  and  is  rapidly  followed  by  the  unconsciousness  and  sinking 
which  attend  urfemic  poisoning. 

Galculvus  Nephralgia. — The  passage  of  a  calculus  down  the  ureter — 
"  calculous  nephralgia  " — is  attended  with  some  of  the  above  sjmiptoms. 
"  Indeed,  excepting  the  severe  febrile  symptoms,  all  those  of  nephritis 
are  present,"  the  leading  symptoms  being  acute  pain  shooting  down  the 
loins,  retraction  of  the  testicle,  and  vomiting.  The  urine  is  scanty  and 
often  mixed  with  blood.  The  suddenness  of  the  invasion  of  the  disease, 
the  coniparativel^'  healthy  condition  of  the  urine,  and  especially  the  in- 
stantaneous subsidence  of  the  symptoms  as  the  stone  passes  into  the 
bladder,  are  the  diagnostic  signs  from  nephritis.  The  treatment  consists 
in  the  very  free  use  of  the  hot  bath,  cupping  and  fomentations  to  the 
loins,  the  free  administration  of  opium  and  other  narcotics,  and,  if  the 
pains  are  severe,  the  occasional  adrainisti'ation  of  chloroform — not  to 
total  anaesthesia. 

Calculous  Pi/elitis. — Acute  calculous  pyelitis  is  distinguished,  accord- 
ing to  Sir  II.  Thompson,  from  nephritis  by  the  greater  severity'  of  the 
l)ain  in  the  back,  and  the  retraction  of  the  testicle,  and  b}-  the  less  rapid 
course  of  the  disease.  Blood  and  pus  will  be  found  in  intimate  admixture 
with  the  urine. 

Nephritis  ma_y  also  be  confounded  with  abscess  from  diseased  spine, 
witli  lumbago  or  rheumatic  affection  of  the  muscles,  and  with  hysterical 
or  neuralgic  pain  ;  but  the  special  symptoms  of  all  these  conditions  are 
almost  in  tliemselves  sufficient  to  mark  the  difference,  and  the  state  of 
the  urine  is  a  conclusive  proof  of  the  absence  of  nephritis. 

Finally,  inflammation  of  the  bladder  from  stone  or  other  causes  may 
to  a  great  extent  simulate  renal  inflammation,  and,  of  course,  tlie  two 
are  very  often  combined  in  various  jjroportions.  lint  the  localized  pain 
in  the  region  of  the  bladder,  the  absence  of  any  tenderness  in  the  lumbar 
region,  and  the  discovery-  of  the  cause  of  the  cystitis,  will  distinguish  it 
from  nephritis. 


HEMATURIA.  767 

Treatment  of  Nephritis. — Tlie  treatment  of  acute  nephritis  is  directed 
chiefly  to  relieving  tlie  congested  kidney  by  free  diaphoresis  from  the 
skin,  by  free  purging,  and  by  leeches  and  counter-irritation  to  the  loins, ^ 
with  perfect  rest  and  low  diet.  The  vomiting  must  be  combated  by  iiydro- 
cyanic  acid  or  creasote,  and  b}^  mustard-poultice  to  the  pit  of  the  stomach. 
At  tlie  same  time  any  known  cause  of  inflammation  or  obstruction  must 
if  possible  be  removed,  and  as  little  mechanical  interference  with  the 
urinary  organs  practiced  as  the  exigencies  of  the  case  permit. 

Nephrotomy. — The  diagnosis  and  treatment  of  calculus  in  the  kidney 
come  rather  within  the  province  of  works  on  medicine.  The  sui'geon  is 
sometimes  consulted  as  to  the  possibility  of  removing  a  stone  from  the 
kidney  (or  perhaps,  more  accurately  speaking,  from  its  pelvis),  and  the 
attempt  may  be  justifiable  under  certain  circumstances,  thougli  hitherto 
it  has  ended  in  disappointment.  In  a  case  lately  under  Mr.  Callender's 
care  the  stone  was,  I  believe,  found  ;  but  the  patient  died — in  other  cases 
the  diagnosis  has  been  at  fault  or  the  stone  has  not  been  in  an  accessible 
position.  Often,  however,  the  stone  is  ratlier  situated  in  a  cavity  near 
the  kidney  than  in  the  organ  itself,  and  under  these  circumstances  is 
much  more  favorably  situated  for  extraction. 

Chronic  nephritis,  as  a  sequel  of  the  acute  and  the  other  conditions 
which  lead  to  albuminuria,  or  Bright's  disease,  would  form  a  subject  too 
extensive  and  too  purely  medical  for  the  present  place.  I  will  content 
m3'self  with  saying  that  in  all  surgical  cases  the  state  of  the  urine  should 
be  carefully  examined,  and  the  surgeon  should  be  familiar  with  tlie  signs 
of  chronic  degeneration  of  the  kidney,  since  the}'  powerfully  influence 
prognosis,  and  will  often  contraindicate  operations  and  other  active 
treatment  in  diseases  where  otherwise  they  would  be  pressed  upon  the 
patient. 

Hsematuria. — The  passage  of  blood  in  the  urine  is  a  frequent  sj'mptom 
both  in  medical  and  surgical  practice;  and  although  the  treatment  of 
many  of  the  conditions  which  give  rise  to  it  lies  within  the  province  of 
the  physician,  yet  it  is  necessary  to  review  all  of  them  for  the  purpose  of 
diagnosis. 

The  blood  may  come  (1)  from  the  kidney,  including  the  ureter ;  (2) 
from  the  bladder,  including  the  prostate  gland  ;  (3)  from  the  urethra. 

1.  The  sources  of  renal  hamiorrhage  are — rupture  or  laceration  of  the 
kidney  by  blow  or  fall,  cancer  of  the  kidney,  and  possibly  other  tumors  ; 
congestion  from  nephritis  or  from  the  use  of  certain  drugs  ;  the  irritation 
of  a  calculus,  eitlier  in  the  kidney  or  ureter,  to  which  may  be  added  that 
in  some  general  diseases,  such  as  purpura,  the  hjtmorrhagic  diathesis, 
scurv}',  the  "endemic  hematuria,"  lately  spoken  of  in  Africa,  blood 
passes  from  the  kidneys. 

The  diagnostic  symptoms  of  such  of  these  affections  as  lie  within  the 
province  of  surgery  will  be  found  under  their  ap})ropriate  headings,  to 
which  I  will  only  add  that  the  blood  from  the  kidney  is  always  intimately 
mixed  with  the  urine  (giving  it  a  dark  porter-color),  and  that  "  as  a 
general  rule,  such  urine,  passed  without  pain  or  any  other  local  symptom 
whatever,  is  more  likely  to  derive  its  blood  from  the  kidney  than  else- 
where "  (Sir  H,  Thompson).  The  urine  should  be  carefully  examined 
microscopically,  in  order  to  determine  the  presence  or  absence  of  casts 
of  the  kidney-tubes. 

'  The  onmnion  blister  phould  not  be  used  in  tbe>e  cases,  for  fear  of  the  absorption 
of  the  eantharides.  A  bli.-ter  can  be  raised  at  once  by  the  strong  liquor  ammonise  or 
by  chloroform,  covered  with  a  watch-glass  or  oiled  silk. 


768  DISEASES    OF    THE    UEINART    ORGANS. 

2.  The  sources  of  vesical  hiPiiiaturia  are — wound  of  the  bladder  or 
prostate;  tumor,  cancerous  or  villous  ;  calculus  in  tlie  bladder;  conges- 
tion of  the  prostate  gland  ;  ulceration  of  the  coats  of  the  bladder  or  acute 
congestion  in  cystitis. 

IMood  from  the  bladder  is  generally  less  intimately  mixed  with  the 
urine  than  that  from  the  kidney  ;  it  very  commonlv  clots  in  the  bladder 
and  remains  behind  after  the  urine  has  been  passed;  the  urine  first  passed 
is  often  comparatively  clear,  while  at  the  end  of  micturition  the  blood  is 
passed  almost  or  quite  pure.  But  tliese  signs  are  not  alwa3's  to  be  im- 
plicitly relied  on,  and  the  surgeon  must  examine  the  patient  carefully  for 
the  diagnostic  symptoms  of  the  afl'ections  above  enumerated, 

3.  Urethral  haimorrliage  is  caused  by  blows  or  wounds  (including 
laceration  by  the  catheter),  impacted  calculus,  rupture  of  the  corpus 
spongiosum  in  sexual  intercourse  or  chordee ;  tumors  in  the  urethra; 
ulceration,  chiefly  in  syphilis ;  congestion  in  gonorrha3a  or  stricture. 

The  most  reliable  test  of  this  source  of  htBinorrhage  is  wlien  it  can  be 
detected  as  occui-ring  independent  of  micturition,  which  can  almost  always 
be  done  if  the  patient  be  carefully  watched,  or  when  the  blood  collects  in 
the  urethra  and  forms  a  cast  of  it. 

The  source  of  the  hiemorrhage  being  determined  and  its  supposed 
cause,  the  treatment  of  the  latter  is  of  course  the  main  indication,  but 
the  haemorrhage  itself  sometimes  requires  treatment.  The  bladder  may 
be  so  abundantly  occupied  by  clot  as  to  require  its  disintegration  and  re- 
moval piecemeal,  by  means  of  the  injecting  catheter  ;  the  amount  of  blood 
from  the  kidney  ma}'^  be  so  alarming  as  to  demand  the  administration  of 
internal  styptics  ;  urethral  haemorrhage  may  sometimes  be  controlled  by 
pressure,  a  metal  catheter  having  first  been  passed ;  and  perfect  rest  should 
in  all  cases  be  enforced,  whenever  the  bleeding  is  considerable. 

Sn2^p7'essio7i  of  urine  is  an  event  which  is  almost  certainly  fatal,  and 
which  must  be  carefully  distinguished  from  retention.  Obvious  as  this 
distinction  is,  it  is  strange  how  often  the  mistake  is  still  made.  The 
causes  of  suppression  are  general,  while  those  of  retention  are  local;  the 
bladder  is  found  perfectly  empty  on  passing  a  catheter,  or  almost  so ;  the 
patient  experiences  no  ditlicult}'  in  passing  water,  but  has  none  to  pass, 
or  only  a  very  small  quantity.  He  is  troubled  with  vomiting  and  gener- 
ally pain  in  tlie  back,  and  is  feverish;  becomes  stupid,  perhaps  delirious, 
and  then  comatose,  and  almost  always  dies.  Sir  H.  Thompson  mentions 
a  case  in  which  the  patient  recovered  after  fort^'-eight  hours  of  complete 
suppression,  as  I  have  known  another  similar  one.  The  chief  points  in 
the  treatment  are  free  action  on  the  skin  by  the  hot  bath  and  vapor  bath, 
fomentations  and  leeches  to  the  back,  and  free  purgation. 

DISEASES   OF   THE    BLADDER. 

Malformation. — The  bladder  has  been  absent,  the  ureters  opening  into 
the  urethia,  rectum,  or  vagina,  but  the  malformation  is  a  very  rare  one. 

Congenital  Cyd. — Less  uncommon  is  the  presence  of  a  "double  blad- 
der," or  large  congenital  cyst,  of  whicli  a  remarkable  instance  is  sliown 
in  Fig.  844,  which  occurred  in  my  own  practice.  Such  cases  cannot  be 
diagnosed  or  treated  during  life.  Their  main  interest  consists  in  know- 
ing that  sucli  diverticula  may  occur,  and  may  very  easily  become  the 
seats  of  a  calculus,  wiiich  then  would  present  great  ditliculties  in  its 
operative  treatnienl. 

Exiromraion. — The  ordinary  malformation  of  the  bladder,  however, 
is  extroversion.     Tliis  condition  depends  on  a  malformation  of  the  ab- 


MALFORMATIONS  OF  THE  BLADDER. 


769 


Fig.  344. 


dominal  parietes.  In  most  cases  the  whole  of  the  hypogastric  region  is 
deficient,  from  the  navel  to 
the  pubes.  There  is  no  um- 
bilicns  ;  the  anterior  wall  of 
the  bladder  is  also  deficient; 
its  posterior  wall  is  attached 
to  the  skin  and  projects  from 
the  belly  in  the  form  of  a  red 
prominence,  bleeding-  read- 
ily, and  showing  tlie  slit- 
like mouths  of  the  ureters, 
from  which  the  urine  can 
be  seen  distilling.  The  pa- 
rietes extend,  however,  in 
some  cases  lower  than  the 
umbilicus,  which  is  then 
natural.  Bounding  the  ex- 
troverted bladder  is  a  double 
ridge,  like  a  V  inverted, 
which  marks  the  coalescence 
of  the  skin  and  bladder.  The 
penis  is  rudimentar}',  and  is 
marked  by  a  groove  on  its 
dorsal  aspect,  into  the  back 
of  which  as  it  joins  the 
vesical  membrane  the  semen 
is  discharged  in  adult  life. 
The  prostate  is  hardly  to  be 
discerned.  The  testicles  are 
generally  natural.  There  is 
often  hernia  on  one  or  both 
sides.  The  pubic  symphysis 
is  often  deficient. 

The    same    malformation 

occurs     in     the     female     sex        Malformation  of  the  bladder,  showlug  a  large  cyst,  or  false 
also     but  much  more  rarely,     ^'^'^'^ler,  wluch  commuDlcated  with  the  true  bladder.    The 

It  is  not  necessaril}'  compli 


cated  with  any  malforma- 
tion of  the  internal  sexual 
organs,  and  women  so  af- 
flicted have  borne  children. 
The  malformation  is  per- 


position  of  j)arts  has  been  reversed  in  the  preparation,  the 
kidneys  being  seen  below.  The  parts  were  taken  from  a  male 
infant,  wlio  was  born  with  retained  testicles,  a  peculiar  shape 
of  the  abdomen,  the  parietes  of  which  were  deficient  below,  so 
that  the  viscera  protruded  beneath  the  skin.  There  was  a 
nsevus  of  the  skin  of  the  pubes.  The  child  throve  for  a  few 
days,  then  began  to  refuse  the  breast,  passed  blood  in  the  water, 
and  died  on  the  eighth  day.    a,  the  large  cyst  lying  above  in 


fectly  consistent  with  health,    the  preparation.    This  was  the  true  bladder;  its  walls  were 


and  I  have  often  seen  vigor- 
ous adults  affected  by  it.  Its 
inconveniences  are  the  con- 
stant dribbling  of  urine  and 
the  tendency  of  the  exposed 
membrane   to    bleed.      The 


much  hypertrophied,  and  its  interior  covered  with  nsevus 

tissue,   from  which  doubtless  the  bleeding  had  come.    The 

openings  of  the  ureters  and  urethra  were  quite  natural ;  6,  the 

secondary  cyst,  the  walls  of  which  were  very  thin  and  destitute 

of  muscle.    It  showed  no  trace  of  any  vascular  tissue  on  its 

interior.    It  lay  in  the  right  side  of  the  pelvis  and  right  iliac 

fossa.    Death  had  evidently  been  caused  by  its  pressure  on  the 

ureters.    The  kidneys,  c,  d,  are  seen  to  be  much  dilated  and 

latter   infirmity  mav  be    cor-    absorbed  by  pressure,  especially  the  left,  and  the  ureters  were 

rected  by  a  plastic  operation,    coated  and  tortuous.    The  testicles  lay  close  below  tire  kid- 

r.  /.   n       neys. — Path.  Soc.  Trans.,  vol.  xvi,  p.  lO'J  ;  St.  George  s  Hospital 

which    was  first  successfully    Museum,  Ser.  xii,  No.  115. 

performed    in  this  country 

by  me  in  the  year  1863,'  and  a  similar  proceeding  has  been  successfully 

1  Lancet,  1863,  vol.  i,  p.  714. 
49 


770  DISEASES    OF    THE    URINARY    ORGANS. 

repeated  by  Mr.  J.  Wood  and  other  surgeons.  It  consists  in  bringing 
two  skin-flaps  over  the  bltidder,  one  turned  with  its  cutaneous  surface 
downwards,  so  as  to  be  in  contact  with  the  extroverted  mucous  mem- 
brane ;  the  other  with  its  raw  surface  downwards  and  in  contact  with  the 
raw  surface  of  tlie  former.  These  being  united  to  each  otlier  form  a  thick 
bridge  over  the  cleft,  which  ma}'  be  afterwards  implanted  into  the  skin  of 
the  abdomen  till  only  a  narrow  oriOcc  is  left  below,  to  which  a  bottle  can 
easily  be  applied.  But  the  patient  or  his  friends  must  be  instructed  to 
wash  out  the  cavity  frequently  with  acidulated  water,  to  prevent  the  for- 
mation of  phosphatic  concretions.  Attempts  have  been  made  to  divert 
the  course  of  the  ureters  into  the  rectum,  so  as  to  form  a  cloaca  there, 
and  obviate  an}'  incontinence  of  urine,  but  these  have  hitherto  failed. 

Tnver,^ion  of  the  Bladder. — In  connection  with  malformations  I  may 
mention  the  inversion  of  the  female  bladder  which  is  sometimes  met  with 
in  childhood,  and  which  though  not  due  to  malformation  might  easily  be 
mistaken  for  it.  It  seems  to  occur  from  constant  straining  in  making 
water,  and  the  bladder  projects  through  the  urethra,  as  a  pyriform  red 
A\T,scular  tumor  in  which  tlie  orifices  of  the  ureters  can  be  seen.  On  a 
careless  examination  this  might  be  mistaken  for  extroversion,  or  still 
more  fatally  for  a  polypus,  and  it  has  nearly  been  tied  on  that  supposi- 
tion. Treatment  by  careful  reduction,  maintained  by  a  catheter  with  a 
bulbous  end,  and  frequent  cauterization  of  the  expanded  urethra  with 
the  actual  cautery,  has  been  successful  in  restoring  the  power  of  retaining 
the  urine.^ 

Hernia  of  the  Bladder. — The  bladder  may  protrude  as  a  hernia  into  the 
scrotum  or  vagina,  or  may  form  part  of  the  contents  of  an  inguinal  her- 
nia in  the  male,  or  a  femoral  in  the  female.  The  occurrence  is  a  rare 
one,  the  diagnosis  difficult,  and  in  one  case  recorded  by  Pott  the  herni- 
ated bladder  was  opened  by  mistake.  When  by  careful  examination,  the 
surgeon  has  reason  to  apprehend  that  the  bladder  is  herniated — i.  e.,  when 
pressure  on  the  hernia  always  causes  the  immediate  exit  of  urine,  and 
when  a  catlieter  passes  into  or  towards  the  hernial  orifice — double  care 
should  be  exercised  to  reduce  it  and  keep  it  reduced.  In  the  female  when 
it  protrudes  into  the  vagina  it  forms  one  of  the  forms  of  vaginal  C3'sto- 
cele,  which  will  be  found  treated  of  in  a  subsequent  chapter. 

Tumors  of  the  Bladder. — Many  kinds  of  tumors  have  been  found 
springing  from  the  walls  of  the  bladder.  The  innocent  tumors  are  warty 
growths,  polypi,  and  fibrous  tumors.  These,  however,  are  rarely  found, 
and  can  hardly  be  diagnosed,  at  least  in  the  male.  They  cause  merely 
symptoms  of  obstruction  to  the  flow  of  urine,  the  cause  of  which  it  is 
impossible  exactly  to  discover.  In  the  female,  where  the  finger  can  be 
passed  into  the  l)ladder  under  chloroform,  the  diagnosis  might  be  made 
and  the  tumor  removed  by  ligature.  These  tumors  are  too  rare  to  require 
more  than  a  passing  mention.  But  the  tumors  which  are  commonl}^  met 
with  in  practice,  and  which  give  rise  to  definite  symptoms  of  their  own, 
besides  those  which  are  due  to  the  mere  obstruction  due  to  their  position, 
are  the  villous  tumor  and  cancer. 

Villous  tumor  of  the  bladder  is  usually  innocent,  both  structurall}^  and 
surgically  (see  p.  870),  though  a  cancerous  tumor  may  also  sometimes  be 
covered  by  villous  processes  of  mucous  membrane,  as  seen  in  Fig.  845. 
Tlie  true  villous  growths,  however,  consist  merely  of  numerous  processes 
exactl}'  resembling  the  villi  of  the  chorion  in  structure,  very  vascular, 

1   Low<',  in  Lancet,  1862,  vol.  i,  p.  2-50. 


CANCER  OF  THE  BLADDER. 


771 


and  often  developed  at  different  parts  of  the  bladder,  so  as  to  form  mul- 
tiple growths,  many  of  which  are  only  perceptible  on  anatomical  exami- 
nation, and  probably  give  rise  to  no  symptoms.  When  the  growth  has 
attained  a  size  large  enougli  to  form  a  tumor  (as  in  Fig.  346)  it  usually 
gives  rise  to  fits  of  hfiematuria,  which,  however,  as  in  that  case,  may  be 
extremely  irregular,  separated  by  long  intermissions  of  perfect  health. 
Tlie  pain  caused  by  this  tumor  depends  apparently  on  its  situation  in  the 


Fig.  345. — A  mass  of  malignant  disease,  growing  out  of  a  cyst  on  one  side  of  the  bladder,  and  pro- 
jecting to  a  certain  extent  into  its  cavity.  Its  outward  appearance  is  exactly  that  of  villous  tumor,  and 
it  is  only  on  microscopic  examination  that  the  difference  is  perceived.  The  disease  had  existed  for 
many  years,  and  at  times  occasioned  hoemorrhage,  the  source  of  which  could  not  be  detected. — From  the 
Museum  of  St.  George's  Hospital,  Ser.  xii.  No.  24. 

Fig.  346. — Villous  tumor  of  the  bladder,  from  a  patient  *t.  eighty-one,  who  had  suffered  from  attacks 
of  hematuria  occasionally  for  twenty  years.  The  mass  of  the  growth  is  seen  to  be  connected  with  the 
neck  of  the  bladder.  A  portion  consolidated  by  coagulum,  so  as  to  resemble  a  soft  calculus,  was  found 
loose  in  the  bladder,  and  is  represented  in  the  corner  of  the  figure.  The  patient  had  exhibited  no  dan- 
gerous symptoms  till  shortly  before  his  death,  as  the  htematuria  had  yielded  to  astringents.  But  a  week 
before  his  death  complete  retention  of  urine  came  on,  requiring  the  use  of  the  catheter,  and  a  small 
portion  of  the  growth  came  away  in  the  eye  of  the  instrument,  which  on  microscopical  examination 
revealed  the  nature  of  the  disease. — From  a  preparation  in  the  Museum  of  St.  George's  Hospital,  Ser. 
xii,  No.  113. 


bladder.  When  a  small  tumor  (whether  villous  or  malignant)  is  growing 
near  the  neck  of  the  bladder  and  is  tightly  grasped  by  its  muscular  fibres 
during  each  action  of  the  bladder  tlie  pain  is  often  very  considerable, 
indeed,  I  have  known  it  to  be  agonizing,  whilst  a  similar  tumor  might 
exist  in  the  fundus  or  upper  part  of  the  bladder  with  comparatively  few 
symptoms.     The  same  applies  to  retention  of  urine  as  well  as  pain. 

Cancer  of  the  bladder  is  generally  of  the  encephaloid  variety.  I  have 
not  as  yet  met  with  any  other  form  of  cancer  as  a  primary  growth,  though 
authors  admit  the  existence  of  scirrhus,  and  Sir  H.  Thompson  has  re- 
corded one  of  epithelioma.'  Other  forms  of  cancer  affect  tlie  bladder  by 
continuity,  as  in  scirrhus  of  the  rectum,  epithelial  cancer  of  the  vagina, 
etc.  The  symptoms  of  cancer  of  the  bladder  are  usually  persistent  hoema- 
turia,  "generally,"  sa^^s  Sir  H.  Thompson,  "occurring  suddenly,  and  in 

1  Path.  Soc.  Trans.,  vol.  xviii,  p.  162.     There  was  a  similar  growth  in  the  kidney. 


772 


DISEASES    OF    THE    URINARY    ORGANS. 


large  quantities,  rather  than  by  frequent  or  continuous  oozings  from 
capillarj'  vessels,  which  latter  mode  is  more  characteristic  of  villous 
growths."  There  is  usually  much  distress  from  obstruction  to  micturi- 
tion and  from  chronic  cystitis,  great  pain  in  the  bladder  or  perineum, 
and  shooting  down  the  thighs  or  into  the  loins.  The  general  health 
usually  soon  suffers,  and  the  glands  in  the  iliac  fossa  or  in  the  loins  be- 
come enlarged.     Death  generally  occurs  early. 

As  to  the  diagnosis  of  tumor  of  the  bladder.  This  rests  (a)  on  exclu- 
sion of  the  other  sources  of  hgematuria,  (b)  on  direct  examination,  (c)  on 
detection  of  portions  of  the  growth  in  the  urine. 

Reference  may  be  made  to  the  section  on  Htematui'ia  (p.  767)  for  the 
symptoms  attending  the  A'arious  forms  of  bleeding  from  the  urethra. 
The  patient  must  be  carefully  sounded,  when  not  only  will  there  be  no 
sensation  or  sound  of  stone,  but  the  tumor  ma}?^  sometimes  be  easil}''  felt. 
Prostatic  haemorrhage  sometimes  gives  rise  to  a  suspicion  of  tumor,  but 
the  transient  character  of  this  affection  will  distinguish  it,  at  any  rate 
from  the  hasmaturia  due  to  malignant  disease. 

The  tumor,  when  malignant,  sometimes  grows  so  rapidl}^  as  to  fill  the 
bladder  almost  entirely,  or  projects  as  a  large  hard  mass,  easily  felt  with 

Fig.  347. 


Malignant  disease,  nearly  filling  the  cavity  of  the  bladder ;  a  points  to  the  ureter,  which  is  somewhat 
dilated;  b  shows  the  urethra  and  prostate  quite  unaffected;  the  disease  being  limited  to  the  cavity  of 
the  bladder. — St.  George's  Hospital  Museum,  Ser.  xii.  No.  26. 


the  sound.  But  this  is  by  no  means  common,  and  the  absence  of  any 
sensation  of  tumor  does  not  go  for  much  in  the  diagnosis.  At  other 
times  the  surface  of  the  tumor  breaks  down  rapidly,  and  shreds  of  it 
come  away  in  the  urine,  the  structure  of  which  can  easily  be  recognized 
by  microscopic  examination,  and  it  is  said  that  separate  cancer-cells 
may  be  recognized  in  the  urine  ;  but  mistakes  are  often  made  about  this 
from  taking  the  cells  of  epithelium  variously  modified  for  cancer-cells, 
and  in  cases  of  cancer  it  is  so  common  for  no  such  cells  to  be  found,  that 
I  think  little  importance  is  to  be  attributed  to  microscopic  examination. 
In  cases  of  rapidly  growing  cancer,  apart  from  all  direct  examination, 
when  once  the  diagnosis  of  stone  and  of  prostatic  haemorrhage  is  ex- 
cluded, the  course  of  the  symptoms  usually  sufficiently  indicates  the  na- 
ture of  the  case. 


CYSTITIS.  773 

Diagnosis. — To  diagnose  a  villous  growth  is  often  a  very  difficult  mat- 
ter; in  fact,  the  diagnosis  is  often  made  only  conjecturally,  bj'  excluding 
other  sources  of  haeraaturia.  In  a  case,  such  as  that  from  which  the 
illustration  (Fig.  346,  p.  771)  was  taken,  where  the  symptoms  extend 
over  many  years,  and  cannot  be  referred  to  prostatic  causes,  the  diag- 
nosis is  extremel}'  probable,  and  sometimes,  as  in  that  instance,  is  ren- 
dered certain  by  the  accidental  escape  or  detachment  of  a  portion  of  the 
tumor. 

The  treatment  of  either  of  these  forms  of  tumor  can  be  only  palliative, 
i.  e.,  directed  to  subdue  pain  Ijy  opiates  and  to  check  haemorrhage  from 
the  bladder  by  astringents.  In  cancer  the  disease  will  probably  prove 
fatal  within  a  few  months.  Cases  of  villous  tumor  run  too  irregular  a 
course  to  justify  any  confident  prognosis.  Sometimes,  as  in  the  case  re- 
ferred to  above,  the  patient  lives  many  years  in  moderate  comfort.  At 
others  the  growth  rapidly  implicates  the  neck  of  the  bladder,  and  the  ex- 
haustion caused  by  haimaturia  and  cystitis  soon  overcomes  the  patient's 
powers. 

Cystitis. — Inflammation  of  the  bladder  is  divided  into  three  degrees, 
acute,  subacute,  and  chronic.  Most  of  the  cases  which  are  seen  in  sur- 
gical practice  belong  to  the  subacute  or  the  chronic  variety.  The  causes 
are  usually  those  which  produce  obstruction  to  the  flow  of  water  or  direct 
irritation  of  the  mucous  membrane.  Thus  cystitis  is  a  frequent,  or  even 
constant,  complication  of  stricture  and  enlarged  prostate ;  it  is  one  of 
the  symptoms  of  stone  or  other  foreign  body  in  the  bladder,  and  is  very 
liable  to  be  caused  by  the  retention  of  a  catheter  in  the  bladder.  Frac- 
tured spine  usually  produces  cystitis,  and  cystitis  is  often  produced  by 
the  irritation  from  decomposing  urine  in  other  forms  of  paralysis  where 
the  patient  is  unable  to  pass  water.  Some  materials  which  are  elimi- 
nated b}^  the  urine  out  of  the  blood  having  been  taken  as  food  or  ab- 
sorbed from  the  skin  may  cause  cystitis.  The  familiar  example  of  this 
is  the  inflammation  of  the  bladder  sometimes  produced  by  cantharides 
taken  into  the  stomach  or  applied  as  a  blister.  The  bladder  may  also  be 
inflamed  by  the  spread  of  inflammation  from  a  neighboring  organ,  as  in 
gonorrhoea  or  in  inflammation  of  the  prostate.  Finally,  direct  mechani- 
cal violence,  as  in  surgical  operations,  is  a  frequent  cause  of  cystitis,  and 
it  may  originate  spontaneously  either  after  exposure  to  cold,  or  from 
tubercular  irritation,  or  the  softening  of  tubercular  deposit,  or  from  no 
known  cause  whatever.  * 

Anatomy  of  Cystitis. — Inflammation  of  the  bladder  commences  always 
on  its  mucous  surface,  the  membrane  becoming  so  loaded  with  blood  as 
to  assume  a  dark-purple  color,  thickened  and  velvety,  in  some  cases 
coated  with  adherent  Ij-mph  and  phosphatic  deposit  from  the  urine,  in 
others  ulcerated  here  and  there.  The  irritation  which  accompanies  it 
produces  frequent  and  spasmodic  muscular  action.  Often  the  cause  of 
the  aff'ection  involves  obstruction,  and  consequently  much  straining  to 
make  water,  and  from  these  circumstances  muscular  hypertroph3'  is  a 
constant  phenomenon  in  cystitis,  so  that  the  muscular  fibres  stand  out 
under  the  mucous  surface  somewhat  like  the  columnae  carneae  of  the 
heart,  and  they  cross  each  other  in  ever}^  direction,  leaving  small  spaces 
or  alveoli  between  them.  To  this  condition  the  terms  "  columnar  and 
fasciculated  bladder"  are  applied.  The  mucous  coat  of  the  bladder  is 
often  protruded  through  the  openings  of  these  fasciculi,  causing  pouches, 
which  sometimes  do  not  reach  through  the  whole  thickness  of  the  walls 
of  the   bladder  (Fig.    374),  while    at   other   times   they   form    distinct 


774  DISEASES    OF    THE    URINARY    ORGANS. 

and  definite  projections  (Fig.  375),  often  of  very  large  size.  Similar  and 
sometimes  much  larger  pouches  or  cysts  are  found  as  congenital  mal- 
formations (Fig.  344). 

The  symptoms  of  cystitis  in -the  acute  form  are  general  fever,  great 
pain  in  making  water,  frequency  in  micturition,  blood\'  urine,  soon  tnrn- 
ing  pui'ulent,  pain  and  tenderness  to  pressure  in  the  region  of  tlie  blad- 
der, and  pain  extending  down  the  thigh  and  perineum;  often  also  the 
straining  produces  prolapsus  or  piles. 

Formation  of  Ropy  Mucus. — We  commonly  see,  however,  the  less  se- 
vere form,  which  is  variously  described  as  subacute  or  chronic,  in  which 
the  mucous  membrane  of  the  bladder  secretes  an  abundant  deposit  of 
alkaline  mucus  or  muco-pus,  and  in  which  the  urine  is  turbid' and  con- 
tains a  variable  quantity  of  a  mortary  deposit  usually  called  '•'rop^'' 
mucus."  This  deposit  is  formed  of  phosphate  of  lime  mixed  with  pus 
and  mucus,  and  is  ver}"^  viscid,  clinging  to  tlie  vessel  when  inverted  and 
slowly  falling  out  in  a  mass.  The  supernatant  urine,  when  examined 
by  the  microscope,  usually  is  found  to  contain  a  good  deal  of  pus,  and 
the  triple  phosphate  of  ammonia  and  magnesia.  This  phosphate  is  also 
sometimes  found  mixed  with  the  phosphate  of  lime  in  the  sediment.  The 
urine  decomposes,  becoming  intensely  alkaline  and  ammoniacal,  whereas, 
when  the  mucus  is  onlj'  in  small  quantity,  though  the  deposit  is  itself 
alkaline,  the  urine  may  be  acid,^  It  appears,  then,  that  the  essential 
cause  of  the  decomposition  of  the  urine  is  the  mixture  vvith  it  of  the  alka- 
line mucus  or  muco-pus  secreted  by  the  walls  of  the  bladder;  and  this 
decomposition  is  connected,  at  any  rate  by  some  pathologists,  with  the 
chemical  composition  of  urea.  Thus  the  formula  for  urea  being  C2HJN2O2, 
its  elements  are  exactly  the  same  as  those  of  carbonate  of  ammonia, 
minus  2  atoms  of  water.  Thus  2  atoms  of  carbonic  acid  C20^-|-2 
atoms  of  ammonia  N.^Ag  =  C.^O^N^Hg  —  deduct  O^H,^  (2  atoms  of  water), 
and  the  result  is  as  above,  CjH^N^Oj,  or  one  atom  of  urea.  This  decom- 
position readil}'  ensues  out  of  the  body  on  heating  urea  with  an  alkali, 
and  the  decomposition  of  the  urine  is  regarded  (and  certainly  with  the 
highest  probabilit}^)  as  an  analogous  if  not  identical  chemical  change. 
The  carbonic  acid  partly  goes  to  the  base  of  the  phosphate  of  lime,  form- 
ing carbonate  of  lime,  which  is  found  to  constitute  a  part  of  the  mortary 
mass,  and  the  ammonia  is  parti}'  set  free,  partly  unites  in  forming  the 
ammonio-magnesian  phosphate.  This  ammoniacal  urine  again  acts  as  an 
irritant  on  the  bladder  and  propagates  the  inflammatory  condition  by 
which  it  was  caused  ;  the  inflammation  may  even  spread  up  the  ureters 
to  the  pelvis  of  the  kidney,  exciting  inflammation  of  its  lining  membrane, 
in  whicli  case  the  urine  will  be  secreted  alkaline,  and  earthy  phosphates 
may  be  found  on  the  renal  cal3^ces  ;  sometimes  the  inflammation  causes 
the  formation  of  small  abscesses  beneath  the  lining  membrane  of  the 
kidney,  a  condition  to  which  the  term  pyelitis  is  applied. 

Otlier  changes  occur  also  in  the  bladder  besides  the  ordinary  morbid 
phenomena  above  described.  Generally  speaking  the  inflammation  pro- 
duces only  muscular  hypertrophy  accompanied  b}'  no  permanent  change 
of  the  mucous  meml)rane  ;  but  in  some  cases  organized  inflammatory  or 
fibroid  deposit  may  be  found  in  the  submucous  coat.  At  other  times  de- 
posits of  pus  (abscess  of  the  bladder)  occur  in  the  thickness  of  its  walls  ; 
and  there  are  cases  (thougii  chiefly  in  stone  or  foreign  bod}')  where  the 
mucous  coat  is  ulcerated,  or  even  where  ulceration  extends  througli  the 
whole   bladder  and   produces   perforation.      This   ulceration    is    usually 

•  Sir  B.  Brodie's  works,  vol.  ii,  p.  466. 


CYSTITIS.  775 

rnarked  by  acute  localized  agoi\y  in  the  part  affected,  much  aggravated 
by  the  contact  of  instruments.  I  remember  meeting  witli  it  once  in  a 
case  of  stone,  where  it  persisted  long  after  the  removal  of  the  calculus 
(which  was  a  very  small  one)  by  a  single  sitting  of  lithotrity,  and  ulti- 
mately proved  fatal  by  pyaemia. 

Contraction  and  Dilatation  of  the  Bladder. — In  these  cases  of  cystitis 
with  hypertrophy  the  cavity  of  the  bladder  is  usually  contracted,  and 
often  very  much  so.  But  there  are  maii}^  cases  of  passive  obstruction  in 
which,  on  the  contrary,  the  bladder  is  simply  distended  and  much  thinned. 
"This  condition  occurs  not  in  stricture,  but  in  those  cases  of  enlarged 
prostate  where,  by  reason  of  the  size  of  the  prostatic  mass  implicating 
the  muscular  apparatus  at  the  neck  of  the  bladder,  the  viscus  is  incapaci- 
tated from  contracting  and  suffers  passive  distension." — Thompson. 

Treatment. — The  treatment  of  cystitis,  like  that  of  all  surgical  affec- 
tions, to  be  rational  and  successful,  must  be  guided  by  a  knowledge  of 
its  cause.  In  the  rare  cases  where  no  cause  can  be  ascertained  the  treat- 
ment must  be  directed  to  soothing  irritation  and  removing  pain.  For 
these  purposes  rest  in  the  horizontal  posture,  warm  fomentations,  warm 
hip-baths,  and  opiates  by  the  mouth  or  as  suppositories  are  very  useful. 
In  acute  or  subacute  cases  the  application  of  leeches  or  cupping  the  peri- 
neum is  extremely  beneficial.  The  bowels  are  to  be  kept  open  without 
purging.  Hyoscyamus  in  large  doses  is  often  of  great  service.  The 
other  medical  means  must  be  regulated  by  the  acuteness  of  the  attack 
and  the  condition  of  the  urine.  If  the  latter  be  acid  and  the  attack 
moderately  acute,  no  good  can  be  done  by  local  interference,  nor  by  the 
administration  of  the  mineral  acids;  in  fact,  alkaline  carbonates  may 
sometimes  be  given  with  advantage. 

But  in  ordinary  cases  the  attack  is  not  acute,  nor  is  there  any  doubt 
about  its  cause.  The  presence  of  a  stricture,  an  enlarged  prostate,  a 
stone,  a  gonorrhoea,  or  an  injury  of  the  spine  at  once  points  out  that  the 
cystitis  is  but  a  symptom,  and  that  its  cure  must  depend  on  the  surgeon's 
success  in  removing  the  cause  on  which  it  depends.  Still  even  when  this 
is  impossible,  much,  as  Sir  B.  Brodie  remarks,  may  be  done  towards  re- 
lieving the  affection  of  the  bladder.  In  cases  which  are  purelj'  chronic, 
accompanied  by  copious  secretion  of  mucus,  but  with  little  irritation, 
and  in  which  after  death  the  bladder  will  be  found  rather  dilated  than 
contracted,  and  thin  rather  than  h3'pertrophied,  a  condition  to  which  the 
term  catarrh  of  the  bladder  is  properly  ap[)lied,  much  good  is  done  b}' 
washing  the  bladder  out  and  by  injections  acidulated  with  nitric  or  sul- 
phuric acid.  The  exhibition  of  diluent  or  demulcent  draughts  in  toler- 
ably large  quantities,  or  in  some  cases  the  balsams  or  turpentines,  is 
followed  by  improvement.  In  catarrh  of  the  bladder  the  favorite  rem- 
edies are  the  decoction  of  uva  ursi,  or  pareira  brava,  or  a  combination  of 
the  two ;  in  cases  where  there  is  somewhat  more  inflammation  large  doses 
of  the  decoction  of  triticum  repens,  or  a  smaller  quantity  of  bucliu  may 
be  given  ;  alkalies  and  opiates  being  combined  with  these  as  circumstances 
demand.  Sir  H.  Thompson  quotes  with  approbation  a  prescription  of 
Dr.  Gross  :  one  ounce  and  a  half  of  the  leaves  of  the  uva  ursi  and  half 
an  ounce  of  hops  are  infused  for  two  hours  in  two  pints  of  boiling  water 
in  a  covered  vessel,  a  wineglassful  to  be  taken  several  times  a  da}'.  The 
mere  demulcents  are  used  chiefly  as  vehicles  for  other  medicines  and  as 
diluting  the  urine  ;  such  are  barley-water,  gum-water,  decoction  of  mal- 
lovvs  or  of  Irish  moss,  linseed-tea,  etc.  Caution  is  to  be  observed  in 
estimating  the  reaction  of  the  urine.  It  does  not  follow  because  the 
urine  when  passed  is  alkaline  that  the  secretion  is  alkaline.     Acid  urine 


776  DISEASES    OF    THE    URINARY    ORGANS. 

coming  into  an  inflamed  and  irritable  bladder  will  cause  it  to  secrete 
alkaline  mucus,  the  decomposition  of  which  soon  turns  the  secretion 
alkaline.  In  such  cases  there  is  generally  obstruction,  and  the  secretion 
may  be  best  made  healthy  by  removing  the  obstruction,  washing  out  the 
bladder,  and  administering  a  soluble  alkali,  such  as  the  citrate  of  potash. 

Vesico-intestinal  Fistula. — This  may  be  the  place  to  mention  the  occa- 
sional (though  fortunately  rare)  occurrence  of  a  fistulous  communication 
between  the  bladder  and  some  part  of  the  intestinal  tube.  This  painful 
symptom  is  found  usuall}'  in  cancer,  but  there  are  instances  (of  which  I 
have  recorded  a  very  remarkable  one')  in  which  the  formation  of  the 
opening  seems  due  to  common  ulceration  of  the  bowel.  It  occurs  usu- 
ally in  the  male  sex,  but  sometimes  also  in  the  female.  The  communi- 
cation is  either  with  the  large  or  small  intestine.  The  appearance  and 
odor  of  the  urine,  and  probably  the  pain  in  the  part,  first  attract  the  pa- 
tient's attention,  and  then  the  faecal  matter  can  be  detected  either  with 
the  eye  or  the  microscope.  As  the  opening  enlarges,  and  especially 
when  the  large  bowel  is  the  seat  of  the  fistula,  masses  of  solid  fseces  pass 
into  the  bladder,  causing  obstruction  of  the  urethra,  and  probably'  form- 
ing the  nucleus  of  a  phosphatic  stone.  In  such  cases  the  lumps  must  be 
broken  up  with  a  lithotrite  ;  and  if  on  careful  examination  the  surgeon 
is  satisfied  tiiat  the  communication  is  with  the  sigmoid  flexure,  the  de- 
scending colon  should  be  opened.  This  operation  was  performed  in  the 
case  under  m}'  care,  and  with  temporary  success.  The  patient  was  much 
relieved  and  was  about  to  resume  his  ordinar}' avocations,  when  a  relapse 
took  place  in  an  even  severer  form,  and  he  died  fourteen  months  after 
the  operation.  The  cause  of  death  was  found  to  be  the  formation  of  a 
similar  communication  with  the  caecum,  the  original  opening  between  the 
bladder  and  sigmoid  flexure  having  closed. 


DISEASES    or    THE    PROSTATE. 

Acute  inflammation  of  the  prostate  is  genei'ally  a  consequence  of  gon- 
orrhoea, but  may  be  caused  also  by  injuries  (one  of  the  most  frequent 
being  rough  catiieterization),  by  inflammation  of  the  bladder,  by  stricture 
setting  up  inflammation  of  the  urethra  behind  the  obstruction,  by  the 
application  of  caustic,  and  bj'^  the  lodgment  of  a  calculus. 

The  symptoms  of  acute  prostatitis  are  rigors,  feverishness,  pain,  and 
irritation  in  making  water,  with  frequent  calls  to  do  so,  pain  in  defaeca- 
tion,  and  pain  radiating  from  the  loins  down  the  back,  thighs,  and  peri- 
neum. If  there  is  any  tendency  to  piles  they  will  probabl}^  show  them- 
selves, on  examination  l»y  the  rectum,  and  this  examination  is  found  to 
be  very  painful ;  the  prostate  is  swollen,  hard,  hot,  and  very  tender;  and 
if  a  catheter  is  passed,  there  is  acute  tenderness  of  the  prostatic  part  of 
the  urethra.  There  will  [jrobabl}'  be  some  pus  in  the  urine  from  inflam- 
mation of  the  prostatic  urethra,  even  irrespective  of  abscess,  which, 
however,  is  very  lial)le  to  form.  Tiiis  is  marked  l)y  the  continuance  of 
the  feverish  condition  for  several  days,  witii  rigors,  tension,  and  pulsation 
in  the  region  of  tlie  perineum  and  bladder.  The  ditticulty  of  passing 
water  will  also  probably  increase.  Examination  with  the  finger  will  now 
prove  that  the  hard  prostatic  tumor  has  given  place  to  a  soft  swelling,  in 
which  perhaps  the  surgeon  may  detect  fluctuation,  though  from  the  awk- 

1  Med.-Chir.  Trans.,  vols,  xlix  and  1.  See  also  Mr.  Pennell's  and  Mr.  Charles 
Hawkins's  cases  there  referred  to. 


CHRONIC    PROSTATITIS.  777 

ward  position  in  which  it  lies  for  palpation  this  is  not  always  possible. 
These  abscesses  are  not,  however,  always  situated  inside  the  capsule  of 
the  gland,  for  very  similar  symptoms  are  caused  by  suppuration  around 
it — periprostatic  abscess. 

The  diagnosis  of  acute  prostatitis  is  not  usually  ditiicult  if  attention  is 
paid  to  the  course  of  the  symptoms,  and  the  disease  usually  has  a  favor- 
able issue.  It  generally  subsides  of  itself,  on  the  withdrawal  of  irrita- 
tion, or  under  treatment,  or  else  runs  on  to  abscess,  which  bursts,  witli 
free  discharge  into  the  urethra  and  a  sudden  relief  to  the  symptoms. 
But  things  may  not  go  on  so  happily.  Sometimes  acute  inflammation 
leaves  behind  it  the  troublesome  symptoms  of  chronic  prostatitis,  and  I 
have  seen  one  striking  case  in  which  an  abscess  neglected  and  overlooked 
proved  fatal.  The  patient,  a  young  man,  was  admitted  into  hospital  in 
a  feverish  and  semi-unconscious  condition,  and  was  placed  under  the  care 
of  the  physician,  as  suffering  from  fever.  A  gonorrhoeal  discharge  being 
detected  the  surgeon  was  called  in  ;  but  he,  not  suspecting  any  connec- 
tion between  the  gonorrhoea  and  the  fever,  made  no  accurate  examination. 
The  patient  soon  died,  and  upon  post-mortem  examination  no  disease 
whatever  was  found  except  an  unusually  large  prostatic  abscess,  and  the 
inference  was  irresistible  that  if  this  had  been  detected  and  freely  opened 
his  life  might  have  been  preserved. 

The  treatment  of  acute  prostatitis,  before  abscess  has  formed,  consists 
in  the  very  free  application  of  leeclies  around  the  anus  (or  even,  if  it  can 
be  tolerated,  inside  the  bowel)  with  frequent  hip-baths  and  constant  warm 
fomentations  to  the  perineum,  combined  with  the  moderate  use  of  anti- 
mony if  the  patient  is  ^oung  and  strong,  and  free  purging.  If  retention 
of  urine  takes  place  a  catheter  must  be  passed;  otherwise  it  is  very  un- 
desirable to  irritate  the  parts  in  any  way.  But  on  tlie  first  indication  of 
suppuration  an  incision  must  be  made  into  the  softened  part.  This  is 
best  done  from  the  rectum.  It  is  devoid  of  danger,  and  even  if  the  pus 
is  not  found  the  opening  will  probably  relieve  the  congestion  and  the  pus 
will  very  likely  make  its  way  soon  into  the  bowel.  The  opening  is  best 
made  by  putting  the  patient  under  an  anaesthetic,  passing  the  duckbill 
speculum  into  the  rectum  in  the  lithotomy  position,  and  fuily  exposing 
its  anterior  wall,  though  if  he  is  not  nervous  no  anaesthetic  is  absolutely 
required.  Some  abscesses  (chiefl}'  I  believe  the  periprostatic)  are  not 
perceptible  from  the  rectum,  but  fuhiess  and  tenderness  may  be  made 
out  by  palpation  in  the  perineum.  In  these  cases  a  deep  exploratory 
puncture  should  be  made,  with  the  left  forefinger  in  the  rectum,  and  if 
pus  is  found  the  puncture  should  be  extended  into  a  moderately  free  in- 
cision. In  most  cases  no  further  ill  consequences  take  place ;  Imt  in  ex- 
ceptional instances  the  abscess  bursts  into  the  urethra  also,  and  a  recto- 
urethral  fistula  follows,  the  consequences  of  which  are  most  distressing, 
and  its  cure  very  difficult.  The  treatment  would  be  the  same  as  in  the 
cases  where  a  similar  distressing  event  follows  after  lithotomy  ;  but  I 
must  allow  that  in  the  few  cases  of  that  complication  which  I  have 
treated,  and  seen  under  the  treatment  of  others,  the  result  has  been  dis- 
appointing.    I  must  refer  to  the  section  on  Lithotoni}'. 

Chi'onic  Proatalitiii. — The  acute  disease  may  leave  the  prostate  hard- 
ened, somewhat  enlarged  and  tender,  with  irritable  bladder,  frequent 
desire  to  pass  water,  with  some  pus  in  the  urine — probably  frequent 
seminal  emissions — weight  and  pain  in  the  rectum  ;  some  tenderness  in 
def'gecation,  pain  in  sexual  intercourse,  and  loss  of  power  in  propelling 
urine.  This,  like  most  chronic  inflammations,  is  best  treated  by  contin- 
uous counter-irritation.     Sir  H.  Thompson  recommends  the  continuous 


778 


DISEASES    OF    THE    URINARY    ORGANS. 


counter-irritation  of  the  perineum  with  nitrate  of  silver  or  acetum  lyttoe, 
and  the  application  to  the  prostatic  portion  of  the  urethra  of  a  solution 
of  nitrate  of  silver  ten  to  thirt}'  grains  to  the  ounce,'  and  the  adminis- 
tration of  the  bromide  and  iodide  of  potassium,  with  tonics,  change  of 
air,  and  sea-bathing. 

But  it  must  be  recollected  that  very  similar  symptoms  may  follow  on 
prostatic  irritation  and  discharge,  the  result  of  gleet  or  of  syphilis.  The 
subject  of  prostatic  discharges  and  their  treatment  is  not  as  3'et  com- 
pletely understood.  Mr.  Lee  has  lately  published  some  interesting  lec- 
tures on  this  topic  to  which  I  would  refer  the  reader.  {Lancet,  1875. 
"  Lectures  delivered  at  the  Royal  College  of  Surgeons.") 

Enlarged  Prostate. — Enlargement  of  the  prostate  gland  is  an  affection 
of  old  age ;  not  that  all,  or  the  majority  of  old  people,  suffer  from  this 
affection  ;  but  that  it  only  occurs  after  the  middle  of  life."  It  consists 
either  of  a  hypertrophy  of  the  prostate  itself  (Fig.  349)  or  of  a  tumor 
developed  in  the  neighborhood  of  the  gland,  but  separated  from  it  by  a 
capsule  of  fibrous  tissue  (Fig.  348),  or  of  a  combination  of  the  two. 

The  enlargement  very  often  affects 
FiO'  348.  t,he  whole  of  the  gland,  sometimes 

only  one  side ;  sometimes  it  consists 
chiefly  of  an  abnormal  development 
of  the  central  portion — the  uvula 
vesica?.,  or  third  lobe  as  it  is  called. 
The  separate  tumors  consist  of  tissue 
bearing  great  resemblance  to  that  of 
the  prostate  itself,  but  not  perfectly 
developed,  just  as  in  the  adenoid 
tumors  which  have  a  similar  relation 
to  the  female  breast.  Sometimes,  as 
in  Fig.  350,  the  enlarged  prostate  is 
also  ulcerated  on  its  surface,  and 
often  in  old  age,  either  with  or  with- 
out such  ulceration,  the  veins  around 
the  prostate  gland  (prostatic  plexus) 
become  engorged  and  bleed  into  the 
bladder.  I  have  seen  the  urine  al- 
most black  with  blood  for  many  days 
together  from  this  cause.  Haemor- 
rhage from  the  prostate  is  easilj' 
known  by  the  absence  of  stone,  by 
the  absence  of  all  previous  history  and  sj^mptoms  of  cystitis,  by  the  sud- 
denness and  copiousness  of  the  bleeding  (reminding  one  in  this  respect 
of  epistaxis),  and  by  the  enlargement  of  the  organ.  It  rarely  requires 
an}'  treatment.  If  it  does,  washing  out  the  bladder  with  acidulated  lo- 
tions, and  the  administration  of  internal  styptics,  as  acetate  of  lead  or 
gallic  acid,  would  be  indicated. 

'  A  CiitliL'ttT-syringo  is  manufactured  with  a  piston  in  tin;  stem  and  an  oj-e  at  the 
side  This  i.s  lilli'd  like  an  ordinary  syrint:;(',  tlie  distance  to  whicli  the  piston  is  with- 
drawn only  pcrniitliiig  it  to  take  u|)  a  small  quantity  of  tlie  solution.  Then,  wiien 
it  has  arrived  at  the  desired  spot  (which  is  easily  known  by  the  patient's  sensations), 
the  piston  is  slowly  depressed  while  the  eye  is  made  to  rotate  round  the  circumference 
of  the  urethra. 

'^  The  res(!arches  of  Sir  H.  Thompson  (S^'st.  of  Surs^.,  vol  iv,  p.  917)  and  of  Dr. 
Messcr  render  it  jirohablc  that  enlargement  appreciable  on  dissection  exists  in  about 
OJie-third,  and  enlargement  causing  symptoms  in  ab.)Ut  one-tenth,  of  males  over  sixty. 


A  section  of  a  prostate  gland,  in  connection 
with  which  is  a  small  tumor,  separated  from  the 
rest  of  the  gland  by  a  definite  capsule  and  occu- 
pying the  situation  of  the  "  third  lobe."  This 
tumor  consisted  of  csecal  pouches  filled  with  epi- 
thelium, and  connected  togetlier  by  fine  fibroid 
tissue.  There  were  the  usual  symptoms  of  en- 
larged prostate.  The  bladder  is  seen  to  be  much 
hypertrophied,  and  at  the  post-mortem  examina- 
tion was  fouud  full  of  purulent  urine.  The  ure- 
ters, pelvis,  and  infundibula  of  the  kidneys  were 
dilated,  and  the  kidneys  themselves  contained 
numerous  small  abscesses. — From  the  Museum  of 
St.  George's  Hospital,  Ser.  xii,  No.  112. 


ENLARGED    PROSTATE.  779 

Symptoms  of  Enlarged  Prostate. — The  first  effect  produced  by  enlarged 
prostate  is  a  certain  degree  of  difficult^'  and  straining  in  making  water, 
which  is  most  perceptible  at  tlie  end  of  the  evacuation.  This  is  succeeded, 
if  treatment  be  neglected,  by  chronic  cystitis.  For  in  all  obstructions 
to  the  flow  of  urine,  a  certain  amount  being  constantly  left  in  the  bladder, 
the  walls  of  the  bladder  are  continually  irritated;  the  urine  as  previously 
explained  becomes  turbid  and  alkaline;  the  bladder  is  never  fairly  emp- 
tied, and  some  of  the  residue  of  the  urine  must  always  be  left,  by  which 
the  irritation  is  kept  up  and  propagated. •  Then,  if  the  obstruction  con- 
tinues unrelieved,  all  the  usual  sequehe  may  ensue,  dilatation  of  the  uri- 
nary passages,  and  urremia,  inflammation  of  the  ureters  and  kidneys,  and 
pyelitis,  and  in  either  case  speedy  death. 

Diagnosis. — The  diagnosis  is  generally  very  easy.  The  patient  at  first 
believes  himself  to  have  stricture,  and,  of  course,  he  may  have  both. 
But  a  case  of  uncomplicated  enlargement  of  the  prostate  is  very  easil}^ 
distinguished  from  one  of  stricture.  The  patient's  age  and  tiie  absence 
of  previous  history  of  stricture  make  the  diagnosis  of  enlarged  prostate 
most  probable,  and  this  is  easily  confirmed  by  examination  from  the  rec- 
tum, when  the  enlarged  prostate  will  be  felt  as  a  hard  tumor  pressing 
down  into  the  bowel ;  or  by  passing  an  instrument  after  the  patient  has 
made  water,  when  it  will  be  found  tliat  there  is  no  obstacle  till  the  point 
of  the  catheter  passes  under  the  pubes,  when  by  depressing  the  handle 
between  the  patient's  thighs  the  catheter  can  usually  be  easily  made  to 
ride  over  it,  and  all  the  more  so  if  a  full-sized  instrument  be  used,  which 
is,  of  course,  the  direct  reverse  of  what  is  found  in  stricture. 

Treatment. — Unless  it  has  been  long  neglected,  there  is  not  usually 
much  difficulty  in  dealing  with  prostatic  enlargement.  A  catheter  should 
be  passed  daily  with  all  possible  gentleness;  if  there  is  much  muco-pus 
in  the  urine  the  bladder  should  be  washed  out;  if  the  enlargement  of 
the  gland  is  considerable,  as  indicated  by  the  large  amount  of  residual 
urine  in  the  bladder  after  the  patient  has  emptied  it  as  much  as  he  can, 
the  catheter  should  be  passed  more  frequently,  two  or  three  times  a  day, 
or  even  whenever  the  patient  wishes  to  make  water.  The  catheter  should 
not  be  tied  in  unless  there  is  unusual  trouble  in  passing  it.  This  treat- 
ment is  palliative  only,  but  I  am  under  the  impression  that  it  does  tend 
to  prevent  the  further  growth  of  the  disease,  which  seems  to  be  quickened 
by  irritation.  And  it  certainly  saves  the  patient's  life  by  obviating  the 
various  complications  which  otherwise  ensue.  But  it  is  be3'ond  the  power 
of  medicine  to  reduce  the  enlargement  which  has  once  formed. 

Tlie  Prostatic  Catheter. — There  are  some  cases  (by  no  means  so  many 
as  has  been  taught)  in  which  the  passage  of  an  ordinary  full-sized  cathe- 
ter is  difficult.  Sometimes  this  depends  on  lateral  enlargement,  which 
may  be  detected  by  exploration  per  rectum  and  an  appropriate  direction 
given  to  the  instrument.  At  other  times  it  depends  on  the  urethra  being 
really  lengthened  and  pushed  up  into  a  vertical  direction  somewhat  by  the 
tumor.  When  this  is  the  case  a  "prostatic  catheter"  must  be  passed  in 
order  to  reach  the  bladder.  This  is  longer,  and  has  a  larger  curve,  than 
the  ordinary  instrument. 

These  means  will  succeed  in  the  great  majority  of  cases.  But  there 
are  some  in  which  no  dexterity  will  succeed  in  reaching  the  bladder,  either 
from  the  extent  of  enlargement,  or  from  the  existence  of  false  passages. 

1  Surgical  writers  sonietime.s  Ui=e  bingiiage  which  conveys  to  j^tudents  the  idea  that 
the  same  urine  is  constantlj'  retained  in  the  bladder.  This,  of  course,  can  hardly  be 
intended,  but  the  bladder  is  excited  to  inflammation  by  its  never  being  evacuated. 


'80 


DISEASES    OF    THE    URINARY    ORGANS. 


In  such  cases  it  has  been  recommended  (and  the  recommendation  is  in- 
dorsed by  Sir  B.  Brodie,  Works,  ii,  527)  to  thrust  the  catheter  through 
the  substance  of  the  prostate,  as  was  done  in  the  case  from  which  Fig. 
350  was  taken.  But  this  proceeding  is  now,  I  thinlc,  given  up,  at  least 
I  have  not  of  late  years  heard  of  its  being  done.  When  the  enlargement 
is  not  too  considerable  and  the  bladder  can  be  felt  behind  the  prostate, 
most  surgeons  prefer  to  puncture  from  the  rectum.     1  cannot  say  that 


Fig.  349. 


Fig.  350. 


Fig.  349. — Bladder,  symphysis  pubis,  and  enormously  enlarged  prostate.  A  portion  is  removed  from 
the  left  wall  of  the  bladder,  to  show  the  vertical  ascent  of  the  urethra  as  it  enters  the  bladder.  After 
Sir  H.  Thompson. 

Fig.  350. — Great  enlargement  and  ulceration  of  the  prostate  gland.  Retention  of  urine  having  taken 
place  it  was  relieved  by  forciiily  thrusting  a  catheter  through  the  substance  of  the  prostate.  A  bougie 
is  inserted  in  the  artificial  paassage.  A  section  has  been  made  through  one  side  of  the  enlarged  pros- 
tate to  show  the  extent  of  the  hypertrophy.— From  a  preparation  presented  by  Sir  B.  Brodie  to  the  Mu- 
seum of  St.  George's  Hospital,  Ser.  xii.  No.  109. 


this  appears  best  to  myself,  since  the  puncture  will  only  give  temporary 
relief  and  the  sj'mptoms  may  recur.  It  is  quite  true  that  the  irritation 
may  subside  or  the  false  passage  may  heal,  and  then  the  surgeon  may  suc- 
ceed again  in  passing  the  catheter.  But  the  same  advantages  also  attend 
what  I  conceive  to  be  the  better  plan  in  these  cases,  viz.,  to  puncture 
above  the  pubes. 

Fmidure  of  the  Bladder  above  tlie  Puhea. — This  is  an  operation  of  no 
difficulty,  an(l  I  believe  of  little  danger,  when  the  bladder  is  fully  dis- 
tended. A  puncture,  or  small  incision,  is  made  in  the  middle  line  im- 
mediately above  the  pubes  ;  and  the  fat,  if  there  is  much,  may  be  broken 
down  with  the  director  or  handle  of  the  knife.  Then  the  finger  will  feel 
the  fluctuating  bladder  and  a  c(>mmon  trocar  and  canula,  or  a  curved 
one,  if  at  hand,  is  passed  in,  and  a  piece  of  gum  catheter  passed  through 
to  steady  it  and  prevent  its  slii)ping  out.  After  about  a  week  or  ten 
days,  when  the  track  of  the  wound  is  consolidated,  the  instrument  may 
be  removed,  cleaned,  and  changed.  Tiie  advantage  of  this  puncture  is 
that  the  canula  can  be  worn  permanently  with  little  or  no  inconvenience, 
if  it  is  necessary.     A  canula  provided  with  a  shield  and  stopcock  is 


MALFORMATIONS.  781 

adapted,  and  the  patient  removes  the  ping  wlien  he  wants  to  relieve  his 
bladder.  lie  is  thus  spared  all  the  annoyance  of  instrumentation.  The 
bladder,  however,  must  be  kept  carefully  washed  out. 

The  onl}^  time  I  have  as  3'et  had  occasion  to  perform  this  operation, 
the  patient  (who  was  in  a  ver}^  bad  state  at  the  time)  survived,  and  I 
heard  of  him  a  year  afterwards  in  good  health  and  still  wearing  the 
can  u  la. 

Cancer  of  the  Proi^tate. — Cancer  only  rarely  originates  in  the  prostate 
gland,  though  its  primary  occurrence  there  is  indisputable,  and  in  some 
cases  it  remains  confined  to  the  organ.  It  gives  rise  to  acute  pain, 
ha?morrhage,  and  frequent  micturition,  in  fact  to  many  of  the  symptoms 
of  stone,  and  in  a  well-marked  instance  which  occurred  in  my  own  prac- 
tice, it  was  not  till  after  repeated  examination,  and  under  antiesthesia, 
that  I  fully  satisfied  myself  of  the  absence  of  stone;  but  the  distress 
is  usuall^^  even  more  acute  than  in  stone,  and  the  wasting  and  loss  of 
health  are  striking  phenomena.  There  is  more  pain  also  in  neiglibor- 
ing  parts  than  is  usually  felt  in  stone  in  the  bladder.  When  the  tumor 
has  grown  considerably  it  ma}^  be  possible  to  assure  one's  self  of  its 
nature  by  examination  from  the  rectum  ;  but  at  first  it  will  simulate  the 
ordinary  enlargement  of  advanced  life,  and  these  cases  almost  always 
occur  after  middle  age.'  The  cancer  is  of  the  encephaloid  variety  and 
ma_v  spread  to  the  neighboring  organs,  or  may  affect  the  inguinal  glands, 
or  fragments  of  it  may  be  found  in  the  water — in  any  of  which  cases  the 
diagnosis  will  be  clear  enough.  Nothing  can  be  done  except  to  palliate 
the  patient's  sufferings  as  best  may  be. 

Tubercle  is  found  in  the  prostate  in  cases  where  the  whole  urinaiy 
tract  is  affected,  and  cysts  of  the  prostate  are  spoken  of,  but  only  as 
cavities  formed  by  prostatic  calculi,  which  will  be  described  later  on. 
Hydatids  have  been  found  lodged  in  the  neighborhood  of  the  gland,  and 
have  produced  retention  of  urine  by  pressing  on  the  bladder;  but  the 
condition  hardly  allows  of  diagnosis  before  operation.  The  indication 
will  be  to  open  the  bladder  in  the  most  accessible  situation  on  failing  to 
pass  the  catheter.  Then  the  nature  of  the  case  will  probably  be  recog- 
nized, when  the  hydatids  must  be  freely  evacuated  by  incision,  and  all 
remains  of  them  frequentl}'^  washed  out. 

DISEASES    OF    THE    URETHRA. 

Malformations.  —  There  are  cases  of  congenital  obliteration  of  the 
urethra,  but  I  am  not  aware  that  the  deformity  has  been  recognized 
during  life.  In  fact  the  infant  generally  dies  very  soon  after  birth,  other- 
wise there  could  be  no  difficulty  in  cutting  down  to  the  seat  of  obstruc- 
tion, and  opening  the  posterior  part  of  the  urethra,  which  seems  gen- 
erally natural. 

Hypospadias  and  Epispadias. — But  the  malformations  about  which 
the  surgeon  is  usually  consulted  are  hypo-  and  epispadias.  The  former 
is,  in  its  minor  degrees,  a  very  common  malformation,  and  one  of  no  con- 
sequence whatever.  The  urethra  opens  oji  the  lower  surface  of  the  penis 
at  some  distance  behind  the  natural  joosition  of  the  meatus.  When,  as 
is  most  usual,  this  opening  is  only  a  little  behind  the  glans  the  patient 
can  pass  water  naturally,  and  the  semen  will  be  lodged  fairly  within  the 
vagina,  so  that  there  is  no  motive  for  surgical  interference.     The  pre- 

1  Sir  H.  Thompson  says  that  it  has  also  been  noted  in  early  childhood,  but  that  no 
cases  are  on  record  between  the  ages  of  eight  and  forty-one. 


782  DISEASES    OF    THE    URINARY    ORGANS. 

puce  also  is  in  these  eases  usually  somewhat  misshaped,  forming  merely 
a  large  flap  on  the  dorsal  surface  of  the  glaus,  which  falls  in  to  the  skin 
of  the  penis  on  either  side,  but  does  not  form  a  complete  circle.  Hypo- 
spadias, however,  in  its  higher  grades  is  a  very  serious  infirmity.  The 
urethra  opens  at  the  root  of  the  penis,  the  urine  runs  down  over  the 
tliiglis,  so  that  the  patient  is  obliged  to  make  water  sitting,  and  the  semen 
would  be  discharged  externall_y,  if  the  patient  were  capable  of  sexual 
intercourse ;  but  this  is  seldom  the  case,  for  the  penis  is  bound  down  to 
the  scrotum  by  a  firm  band,  which  becomes  very  perceptible  in  erection, 
and  the  organ  curves  downwards,  somewhat  as  in  chordee.  This  band 
is  i)robably  the  remnant  of  the  undeveloped  corpus  spongiosum. 

Elaborate  attempts  have  been  made  to  remedy  this  deformity  by 
plastic  operations,  but,  as  far  as  I  can  learn,  hitherto  without  success. 
Three  several  indications  have  to  be  fulfilled  :  (1)  To  liberate  the  penis, 
so  that  it  may  assume  its  natural  direction  wlien  erect ;  (2)  to  form  a 
new  urethra,  so  that  the  urine  and  semen  may  find  a  channel  to  the 
glans;  and  (3)  to  close  the  original  opening.  The  penis  is  accordingly 
dissected  free  of  the  scrotum,  and  raised  up  to  the  abdomen.  The  neigh- 
boring skin  is  transplanted  from  the  penis  and  scrotum  in  two  layers  laid 
on  each  other  by  their  bleeding  surfaces,  and  with  the  cutaneous  surface 
of  the  inner  flap  turned  towards  the  penis  to  form  the  new  urethra,  and 
after  these  flaps  have  adhered  and  are  healed,  the  fistulous  orifice  is  re- 
freshed and  united  to  the  new  urethra,  a  catheter  being  kept  in  the 
bladder.  The  attempt  is  worth  making  in  healthy  boys  or  3'oung  men, 
and  it  is  said  to  have  been  followed  by  partial  success,  so  that  a  patient 
previously  unable  to  effect  an  entrance  was  rendered  capable  of  sexual 
intercourse,  but  the  fistulous  orifice  remained.  I  have  tried  the  operation 
in  early  childhood,  but  should  not  feel  disposed  to  repeat  it  at  that  age. 
A  A'ery  guarded  opinion  must  be  given  as  to  the  possibility  of  an  infant 
afflicted  with  this  malformation  ever  being  able  to  beget  children. 

The  opposite  malformation — epispadias — in  which  the  urethra  opens  on 
the  dorsal  aspect  of  the  penis,  is  very  much  rarer,  and  is  generally  accom- 
panied with  great  general  malformation  of  the  rest  of  the  external  genitals. 
In  its  extreme  degree  it  constitutes  the  extroversion  of  the  bladder  before 
spoken  of.  Attempts  have  been  made  here  also  to  put  the  parts  in  a  more 
natural  condition  by  plastic  operations.  In  fact  the  operation  which  I 
performed  for  extroversion  of  the  bladder  was  adapted  from  one  which 
had  been  practiced  in  epispadias.  But  it  is  very  doubtful  whether  any 
good  can  be  done  in  such  cases. 

Stricture  of  the  urethra  is  a  disease  which  is  very  frequent  in  every 
rank  of  life,  but  of  which  the  worst  and  most  complicated  examples  are 
found  amongst  the  poor,  who  do  not  understand  the  gravity  of  a  com- 
plaint which  is  so  insidious  at  first,  and  who  very  often  have  not  the  time 
or  the  means  required  for  its  successful  treatment.  I  mention  this,  inas- 
much as,  like  hernia,  and  like  many  other  surgical  affections,  stricture 
would  not,  generally  speaking,  prove  formidable,  certainl}'  would  very 
seldom  lead  to  death,  if  it  were  made  the  subject  of  early  and  intelligent 
treatment. 

6'avy.«f.s'  of  Stricture. — The  cause  of  stricture  is  in  general  either  a  low 
inflammation  of  the  submucous  tissue  of  the  urethra,  or  cicatrization,  the 
result  of  an  injury.  A  very  common  cause  of  stricture  seems  to  be  the 
persistence  of  a  neglected  gonorrlucal  discharge,  and  some  surgeons 
l)elieve  (and  certainl}^  with  much  probal>ility)  that  ulceration  of  the 
uiethra  in  gonorrhoea,  such  as  is  known  to  occur  sometimes,  maj'  often 


CAUSES    OF    STRICTURE. 


783 


prove  the  starting-point  of  cicatrization,  and  so  of  stricture.  However, 
speaking  general!}',  it  is  impossible  to  prove  anything  of  the  kind  ;  the 
urethra  at  the  seat  of  stricture  displays  more  or  less  of  induration  and 
thickening  beneath  its  mucous  surface,  causing  contraction  of  its  canal, 
but  no  such  definite  band  as  we  should  expect  to  be  the  result  of  the 
cicatrization  of  an  ulcer.  And  though  there  can  be  no  question  that 
gonorrha'a  is  a  frequent  cause  of  stricture,  yet  in  many  cases  of  stricture 
it  is  impossible  to  trace  any  connection  witli  gonorrhoea,  or  indeed  any 
cause  whatever. 

Another  cause  of  stricture  may  be  syphilis.  Fig.  352  is  taken  from  a 
case  in  which  the  healing  of  a  syphilitic  sore  led  to  stricture  at  tlie  meatus, 
and  I  have  introduced  it  also  to  show  how  great  destruction  is  sometimes 
allowed  to  take  place  from  a  disease  in  itself  very  readily  curable.     The 

Fig.  351.  Fin.  352. 


Fig.  351. — Stricture  of  the  urethra  about  three  inches  from  the 
meatus  urinarius,  formed  by  a  bridle  which  is  seen  crossing  the 
canal.  A  bristle  is  passed  in  above  and  below  this  bridle;  the 
dilatation  of  the  canal  behind  the  stricture  will  be  noticed. — From 
a  preparation  presented  by  Sir  B.  Brodie  to  the  Museum  of  St. 
George's  Hospital,  Ser.  xii,  No.  49. 

Fig.  352. — Stricture  at  the  orifice  of  the  urethra,  producing 
dilatation  of  the  whole  urethra,  and  extensive  ulceration  with 
abscesses  in  the  tissues  of  the  penis,  communicating  with  the  ulcer- 
ated urethra.  There  were  also  several  perinseal  abscesses.  The 
bladder  is  enormously  hypertrophied  and  the  kidneys  were  much 
absorbed.  The  urine  was  of  course  alkaline  and  loaded  with  mucus 
and  pus.  The  patient  died  soon  after  his  admission  into  hospital. 
The  stricture  of  the  meatus  is  believed  to  have  been  caused  by  a 
syphilitic  sore  contracted  two  and  a  half  years  previously. — St. 
George's  Hospital  Museum,  Ser.  xii,  No.  60. 


simplest  means  would,  no  doubt,  have  sufficed  at  first  to  cure  this  stric- 
ture, which  was,  nevertheless,  permitted  to  lead,  through  A-ears  of  agony, 
to  the  patient's  death. 

The  most  formidable  form  of  stricture  is  that  which  follows  traumatic 
rupture  of  the  wall  of  the  urethra,  after  a  fall  or  blow.  This  kind  of  stric- 
ture is  generally  in  the  part  which  passes  below  the  arch  of  the  pubes, 
although  occasionally,  from  blows  or  wounds,  it  may  occur  elsewhere. 
The  resulting  cicatrix  is  usually  very  dense,  hard,  and  contractile,  so 
that  even  after  complete  dilatation  it  will  recur  again  and  again.  It 
constantly  leads  to  fistula  in  perinseo,  and  occasions  death  or  serious 
complications,  in  spite  of  the  most  judicious  treatment. 


784  DISEASES    OP    THE    URINARY    ORGANS. 

Seat  of  Stricture. — The  most  common  seat  of  stricture  is  said  by  Sir 
B.  Brodie  to  be  the  membranous  portion  of  the  urethra.  The  researches 
of  Sir  II.  Thompson  have,  however,  proved  that  in  tlie  majority  of  the 
specimens  contained  in  museums  the  constriction  is  rather  in  the  bulbous 
than  in  the  membranous  part,  but  it  would  be  hardly  possible  to  detect 
the  dirt'erence  during  life.  Any  anterior  part  of  the  canal  may  be  the 
seat  of  stricture,  tliose  at  tlie  meatus  (Fig.  352)  being  generally  the  result 
of  accidental  circumstances.  Fig.  351  shows  a  stricture  in  the  spongy 
portion  of  tlie  urethra,  and  when  this  is  the  case  it  is  very  common  to 
find  another  farther  back.  Stricture  again  is  said  to  be  met  with  at  the 
prostatic  portion  or  neck  of  the  bladder,  but  its  existence  is  denied  by 
the  best  authors.  Sir  H.  Thompson  has  never  met  with  a  case.  Stric- 
tures are  occasionally  multiple.  John  Hunter  speaks  of  having  met  with 
a  case  in  which  there  were  six,  but  it  is  rare  to  find  more  than  two  or 
three. 

Forms  of  Stricture. — The  anatomical  forms  of  stricture  are  various. 
Fig.  351  shows  an  example  of  what  is  sometimes  called  the  "bridle 
stricture,"  in  which  the  obstacle  is  caused  by  a  bridle  or  band  stretched 
across  the  canal,  wliich  may  with  great  probability  be  referred  to  past 
ulceration,  as  may  also  be  those  (of  which,   however,  no  example  has 

fallen  under  my  own  notice)  in  which  a  lunated 
Fig-  353.  ^  fold  occupies  a  part  of  the  circumference"  of 

the  urethra,  such  as  is  often  seen  in  the  rectum 
after  the  healing  of  an  ulcer.  More  commonly 
the  obstruction  is  a  mere  narrowing  of  the 
canal  at  the  part  affected,  as  if  by  a  diaphragm 
placed  in  it,  the  "annular"  stricture.  (Fig. 
353.)  When  tliis  diaphragm  extends  for  some 
distance  under  the  mucous  membrane  on  either 
side  of  the  point  of  greatest  obstruction,  it  is 
stricture  of  the  urethra.   About  called  the  "  indurated  annular  stricture,"  and 

two-thirds  of  the  tube  is  closed  by  a        i  •  i         i  i  i.      ^  i.i  i   • 

diaphragm  of  no  great  thickness,  in   ^hcn  a  Considerable  part  of  the  canal  is  con- 
which  a  small  circular  hole  is  seen,   strictcd  it  is  denominated  a  "  tortuous  "  or  a 

with  a  bristle  passed  through  it.—    "cartilaginous  "  Stricture. 

From  a  preparation  in  the  Museum  rpj^       practical    importance    of  theSC   distinC- 

of  St.  George's    Hospital,  Ser.  xii,       .  .  '  i 

No.sga.  tions  IS  not  very  great,  except  in  regard  to 

the  obstacles  which  may  be  experienced  in 
the  forcible  dilatation  of  the  stricture.  But  it  must  be  allowed  that  so 
much  is  stricture  (meaning  thereby  real  organic  material  obstruction) 
complicated  by  spasmodic  action  of  the  muscles  around  the  urethra,  and 
of  the  muscular  fibres  which  form  part  of  it,  that  it  is  often  very  difficult 
to  determine  during  life  how  far  the  obstruction  occupies  the  walls  of  the 
tube,  so  that  a  stricture  which  during  life  had  been  supposed  to  extend 
over  along  distance  has  been  found  after  death  to  have  been,  mechanically 
speaking,  insignificant. 

The  si/mptoms  of  stricture  are  at  first  simply  mechanical  difficulty  in 
making  water,  and  consequent  prolongation  of  the  length  of  time  re- 
quired to  satisf^^the  calls  of  nature,  with  (as  the  disease  advances)  some 
straining,  leading  very  likely  to  involuntary  discharge  of  some  of  the 
contents  of  the  bowel,  and  prolapsus.  Still,  there  is  no  evidence  of  any 
alteration  in  tlie  parts  not  immediately  implicated  in  the  stricture,  or  any 
change  in  the  functions  :  and  the  disease  is,  no  doubt,  easily  under  the 
control  of  treatment.  But  if  it  is  neglected,  other  graver  symptoms  super- 
vene, which  are  partly  mechanical  and  partly  vital.  The  difficulty  in 
micturition  may  pass  into  total  retention,  and.  with  or  without  retention, 


URINARY    ABSCESS.  785 

very  grave  ulterior  consequences  may  ensue.  Any  obstruction  to  the 
flow  of  urine  will  lead,  as  it  would  if  tlie  urinary  tract  were  a  piece  of 
lifeless  elastic  tubing,  to  gradual  loss  of  tone  and  distension  of  the  part 
behind  the  obstruction.  Thus,  in  every  such  obstruction,  whether  from 
impacted  calculus  (Fig.  377),  stricture  (Fig.  352),  enlarged  prostate 
(Fig.  848),  tumor  of  the  bladder  (Fig.  347),  or  any  other  cause  apart 
from  the  results  of  vital  irritability,  the  consequences  would  be  dilata- 
tion of  the  part  of  the  uretlira  behind  the  obstruction,  of  tlie  bladder,  of 
the  ureters,  and  finally  of  the  pelves  of  the  kidnej's,  leading  to  absorp- 
tion of  their  cortical  structure,  suspension  of  the  secretion,  and  death 
from  uraemic  poisoning.  But  this  supposes  the  absence  of  vital  irrita- 
bility, which  is  of  course  never  entirely  the  case.  Sometimes  even  in  so 
muscular  an  organ  as  the  bladder  the  eflCects  of  pressure  overcome  those 
of  irritability,  and  it  becomes  distended  and  thinned.  Even  then,  how- 
ever, its  walls  are  inflamed  as  well  as  thinned  ;  but  it  is  much  more  com- 
mon in  the  bladder  for  the  effects  of  irritation  to  overcome  those  of 
pressure,  so  that  the  walls  of  the  bladder  are  thickened  and  fasciculated, 
and  its  cavity  perhaps  diminished,  or  certainly  not  increased.  In  the 
urethra,  on  the  contrary,  which  though  muscular  is  much  less  so  than 
the  bladder,  and  which  is  exposed  more  directly  to  the  action  of  pressure, 
there  is  almost  always  dilatation  behind  the  stricture  (unless  relieved  by 
ulceration  behind  the  obstruction,  leading  to  urinary  fistula),  which  in 
stricture  of  the  meatus  may  involve  the  whole  of  the  urethra  (Fig.  352). 
But  along  with  this,  there  is  also  inflammation  of  its  walls,  leading  to 
ulceration  and  abscess  round  the  urethra.  In  the  ureters  we  commonly 
see  only  the  eff"ects  of  distension,  the  signs  of  inflammation  being  con- 
fined to  some  vascularity  of  the  mucous  membrane  not  usually  percepti- 
ble after  death.  The  kidneys  are  as  often  atfected  by  inflammation  as  b}' 
distension,  and  this  shows  itself  generally  in  the  form  of  small  abscesses 
scattered  about  the  secreting  structure  of  the  organ  (pyelitis),  sometimes 
associated  with  vascularity  of  the  lining  membrane  of  the  pelvis  and 
"calyces  of  the  kidne}^,  and  depending  on  inflammation  spreading  up  the 
mucous  tract. 

Complicatio7is. — Besides  these  fatal  sequelae  of  stricture  there  are  va- 
rious complications  which  must  be  noticed. 

Fistula  in  Perinseo. — The  most  frequent  is  fistula  in  peri^^seo,  when 
the  mucous  surface  of  the  urethra  gives  way  behind  the  stricture  and 
allows  the  urine  to  make  its  way  towards  the  surface  graduall}'  (the  in- 
flammatory condensation  of  the  tissues  around  preventing  extravasation 
of  any  large  quantity  of  urine)  until  it  burrows  through  the  skin  and  the 
water  passes  through  the  unnatural  channel,  sometimes  whoU}^  but  more 
frequently  in  part,  some  of  it  escaping  also  from  the  meatus.  There 
are  often  moi*e  than  one  and  sometimes  many  such  fistuhie,  and  they 
open  not  only  in  the  perineum  but  in  the  penis,  scrotum,  buttock,  or 
groin  also. 

Urinary  Abscess. — When  the  ulceration  which  leads  to  the  escape  of  a 
small  quantity  of  urinous  fluid  from  the  urethra  does  not  proceed  to  the 
surface,  but  remains  limited  by  inflammatory  exudation  (as  in  the  cavi- 
ties seen  in  Fig.  352),  a  small,  hard,  exquisitely  painful  swelling  results, 
which  is  generally  situated  in  the  perineum,  and  hence  called  "abscess 
in  perinaeo ;"  but,  as  it  may  be  (as  in  the  figure)  in  the  penis  or  even  in 
the  groin,  the  more  general  name  "urinary  abscess,"  now  in  common  use, 
is  better. 

Extravasation  of  Urine. — Or  again,  instead  of  merely  giving  way  by 
a  comparatively  slow  limited  process  of  ulceration,  the  urethra  may  yield 

50 


786  DISEASES    OF    THE    URINARY    ORGANS. 

suddenl^y  and  entirely  to  the  pressure/  when  the  urine  is  poured  violentl^y 
out  into  the  tissue  of  the  perineum,  scrotum,  penis,  etc.  This  is  called 
exl7'avai>atw7i  of  u7Hne.  If  the  stricture  be  in  the  spongy  body  (as  in 
Fig.  351)  the  urine  may  be  efiused  only  into  the  penis,  the  perineum 
being  unatlected,  but  this  is  rare.  Generally  speaking,  the  stricture  is 
at  or  about  the  ])ulb  of  the  urethra,  and  the  urine  is  etiused  between  the 
triangular  ligament  (Camper's  ligament  or  the  superficial  layer  of  the 
deep  perineal  fascia)  behind,  and  the  deep  layer  of  superficial  fascia  in 
front.  As  the  latter  membrane  is  attached  on  either  side  to  the  rami  of 
the  ischium  and  pubes,  the  effused  fluid  cannot  pass  on  to  the  inner  side 
of  the  thighs.  The  attachment  of  the  same  meuibrane  to  the  deep  fascia 
around  the  low^er  border  of  the  transversus  perinaei  muscle  prevents  the 
urine  from  passing  backwards  to  the  anus  and  buttock.  But  there  is  no 
obstacle  to  its  passing  forwards  to  the  scrotum,  penis,  and  abdomen,  and 
this  is,  accordingly,  the  path  it  takes.  As  the  inflamed  and  putrid  urine 
comes  into  contact  with  the  cellular  tissue  it  sets  up  acute  phlegmonous 
inflammation,  rapidly  running  on  to  gangrene  with  its  usual  concomitant 
of  low  typhoid  surgical  fever.  At,  or  just  below,  Poupart's  ligament,  the 
superficial  fascia  of  the  abdomen  adheres  to  the  deep  fascia,?',  e.,  there  is 
no  subcutaneous  cellular  tissue,  or  very  little,  and  there  the  inflammation 
ceases  at  least  for  a  time.  Ultimately,  it  is  said,  the  adhesions  which 
connect  the  deep  and  superficial  fascia  may  be  stretched,  and  the.  in- 
flammation creep  down  the  thigh  ;  but  this  must  be  very  rare,  as  the 
patient  usually  dies  if  the  inflammation  does  not  stop  before  this  takes 
place. 

Hitpture  of  the  BIadde7\ — Finally,  a  still  more  terrible  catastrophe  may 
occur,  the  rupture  of  the  bladder,  followed  by  extravasation  of  urine, 
probably  into  the  peritoneal  cavit\',  which  is  necessaril3'  fatal — or  into 
the  pelvic  cellular  tissue,  which  in  all  probability  will  be  so.  This  is  a 
very  rare  effect  of  stricture,  but  undoubted  examples  of  it  are  recorded. 
It  must  not,  however,  be  taken  into  account  in  the  prognosis  or  treat- 
ment of  a  case,  being  altogether  exceptional. 

TreMmeni  of  Stricture. — Although  many  of  the  above-described  symp- 
toms are  vital,  the  origin  and  source  of  the  disease  is  purely  mechanical, 
and  so  must  its  treatment  be  at  first.  As  a  general  rule,  if  an  instrument 
can  once  be  introduced  through  the  stricture  or  strictures  into  the  blad- 
der, the  case  becomes  at  once  amenable  to  treatment.  Nor  is  there  any 
difficulty  in  doing  this  in  an  uncomplicated  ease  of  recent  spontaneous 
stricture.  But  in  old  neglected  cases  and  in  the  worse  forms  of  traumatic 
stricture  it  is  exceedingly  ditlicult,  and  in  some  cases  impossible.  To 
these  cases  the  term  "  impassable  strictures  "  is  applied. 

In  endeavoring  to  pass  an  instrument  for  the  first  time  in  any  case  of 
stricture  its  features  should  first  be  carefully  studied.  We  should  in  the 
first  place  endeavor  to  exclude  the  idea  of  mere  spasm,  or  what  is  called 
spasmodic  stricture  (p.  798),  or  of  mere  prostatic  enlargement  (p.  779), 
and  satisfy  ourselves  that  the  case  is  one  really  of  organic  stricture.  A 
reference  to  the  above  pages  will  indicate  the  diagnostic  symptoms.  The 
urine  should  be  examined  (if  the  patient  can  pass  any)  to  show^  the  state 
of  the  l)ladder;  and  the  condition  of  that  organ  as  to  distension  should 
be  carefully  ascertained.  When  the  bladder  is  considerably  distended 
it  rises  up  from  the  pelvis  into  the  abdomen,  forming  a  definite  rounded 
tumor,  perfectly  dull  to  percussion,  and  sometimes   rather  sensitive  to 


1  This  is  often  accompanied  by  a  feeling  of  sudden  relief  to  the  painful  sensation 
of  straining  under  which  the  patient  has  been  suflfering,  and  a  deceptive  lull  occurs. 


CATHETERIZATION.  787 

pressure,  which  ma}'  reach  up  as  far  as  the  umbilicus,  and  which  can  be 
felt  ill  the  rectum  (unless  the  prostate  is  very  much  enlarged),  and  fluc- 
tuation can  be  communicated  to  the  finger  in  the  rectum  by  tapping  on 
the  abdominal  tumor.  When,  on  the  contrary,  the  abdominal  muscles 
are  merely  rigid  from  spasm  (a  condition  not  unfrequently  mistaken  for 
distension  of  the  bladder)  all  these  symptoms  are  absent  except  the 
sensation  of  resistance  above  the  pubes.  There  is  no  definite  rounded 
tumor,  no  dulness  on  percussion,  no  projection  in  the  rectum,  and,  of 
course,  no  fluctuation  there. 

Besides  the  above  points,  it  is  desirable  (if  the  patient  is  a  person  whose 
answers  can  be  trusted)  to  know  what  has  been  about  the  usual  size  of 
the  stream  latterly  and  what  it  is  now,  since,  if  there  is  a  great  difference 
within  a  very  short  time  it  may  fairl}'  be  conjectured  that  a  good  deal  of 
the  dysuria  depends  on  si)asm.  It  is  also  important  to  ascertain  what  if 
any  attempts  have  been  made  already  to  pass  an  instrument,  and  whether 
they  have  been  accompanied  by  much  pain  and  bleeding,  in  which  case 
the  existence  of  a  false  passage  may  be  suspected  if  the  instrument  failed 
to  draw  off  the  water. 

Catheterization. — When  the  surgeon  has  reason  to  diagnose  the  exist- 
ence of  organic  or  permanent  stricture,  an  instrument  should  be  passed 
at  the  earliest  convenient  moment.  This  need  not  necessaril}-  be  imme- 
diately after  the  case  is  seen,  for  if  there  is  no  retention  of  urine  an  in- 
terval of  rest  in  bed,  with  a  warm  bath  every  night,  and  abstinence  from 
any  recent  cause  of  excitement,  may  form  a  good  preparative,  and  facili- 
tate the  introduction  of  the  catheter  or  bougie. 

Surgeons  vary  as  to  the  kind  of  instrument  which  the}'  habitually  em- 
ploy at  the  commencement  of  a  case  of  stricture.  Some  prefer  the  com- 
mon metal  catheter,  others  the  gum  catheter  with  or  without  stilet,  others 
a  probe-pointed  or  simple  flexilile  bougie,  others  a  solid  metal  bougie. 
The  matter  is  more  one  of  individual  preference  and  of  habit  than  of 
rule,  and  is  hardly  fit  for  discussion  in  an  elementary  work.  But  what- 
ever instrument  is  used,  dexterity  in  its  management  and  the  utmost 
gentleness  in  its  introduction  are  essential  both  to  the  comfort  of  the 
patient  and  to  the  success  of  the  treatment.  Dexterity  can  only  be  ac- 
quired by  practice,  and  therefore  it  is  of  the  utmost  importance  for  stu- 
dents to  embrace  every  opportunity  of  practicing  the  passing  of  catheters 
on  the  dead  subject  and  on  those  who  require  the  passage  of  a  catheter 
without  any  obstruction,  before  undertaking  the  treatment  of  a  really 
difficult  case.  In  the  natural  condition  of  things  there  are  only  two  ma- 
terial obstacles  to  the  introduction  of  an  instrument,  viz.,  hitching  the 
point  in  one  of  the  lacun^B  of  the  urethra,  and  pressing  it  against  the 
triangular  ligament  as  the  point  dips  under  the  pubes.  The  former  . 
hitch  occurs  at  any  part  of  the  spongy  portion,  very  commonly  near  the 
meatus.  Both  can  easily  be  overcome  by  withdrawing  the  instrument  a 
little  and  allowing  it  to  find  its  own  way  without  the  use  of  any  force. 
In  dexterous  hands  a  solid  instrument,  or  even  a  metal  catheter,  ai)[)ears 
rather  to  drop  into  the  bladder  by  its  own  weight  than  to  be  pushed  into 
it;  and  this  dexterity  is  very  well  acquired  b^'  practicing  on  tiie  dead 
subject  until  the  art  of  passing  the  catheter  easily  with  one  hand  is  per- 
fectly familiar.  Though  the  difficulty  from  spasm  and  pain  does  not  exist 
in  the  dead  suliject,  yet  the  laxity  of  the  tissues  causes  a  difficulty  of  its 
own,  and  if  a  man  can  pass  instruments  with  perfect  ease  on  the  dead  he 
has  gained  a  most  important  advantage  for  commencing  his  practice  on 
the  living. 

Besides  these  merel}'  mechanical  obstacles,  however,  there  is  tlie  ditfi- 


788  DISEASES    OF    THE    URINARY    ORGANS. 

culty  resulting,  particularly  in  nervous  i^ersons,  from  real  or  apprehended 
pain,  throwing  the  muscles  around  the  membranous  part  of  the  urethra 
into  spasmodic  action.  This  sometimes  produces  contraction  of  other 
parts  of  the  canal ;  but  as  a  rule  the  spasmodic  resistance  is  not  met  with 
till  the  point  of  the  catheter  passes  under  the  pubes.  If  the  instrument 
be  gently  held  (rather  than  pressed)  against  the  contracted  part  of  the 
tube  the  spasm  will  probabty  soon  relax  and  the  instrument  jump  into 
the  bladder.  Catheters  are  passed  either  in  the  erect  or  recumbent  posi- 
tion. This  depends  in  a  great  measure  on  the  circumstances  of  the  case 
and  the  habitual  practice  of  the  surgeon.  Most  surgeons  prefer  to  pass 
instruments  with  the  patient  standing  against  the  wall,  perfectly  erect, 
with  his  feet  resting  against  the  wall,  and  the  surgeon  seated  in  front  of 
liim  ;  but  if  the  patient  is  nervous  or  unaccustomed  to  instruments  he 
may  easily  faint,  and  the  surgeon  must  he  prepared  for  that  event. 

False  Passage. — When  after  experiencing  some  resistance  the  instru- 
ment is  pressed  forward,  makes  a  sudden  jump  and  remains  fixed,  while 
the  patient  complains  of  pain  and  loses  some  blood,  the  surgeon  may  con- 
clude that  a  "false  passage"  has  been  made.  No  further  attempt  to 
passan  instrument  should  be  made  for  a  few  days  under  these  circum- 
stances. It  is  rare  for  any  formidable  symptoms  to  ensue,  for  the  false 
passage,  being  valvular  towards  the  bladder,  the  urine  does  not  find  its 
way  into  it,  and  there  is  seldom  any  serious  bleeding. 

My  own  practice  in  commencing  the  treatment  of  a  case  of  stricture 
is  first  to  use  a  very  small  gum  catheter  without  a  stilet.  If  this  passes 
easily  I  take  a  larger  size  until  the  measure  of  the  stricture  is  taken.  If 
it  passes,  but  with  much  difficulty,  it  is  best,  if  circumstances  permit, 
to  tie  it  in  for  a  couple  of  da3"s  or  so.  If  this  is  tolerated  the  case  will  be 
found  much  more  tractable. 

Gradual  and  Bapid  Dilatation  of  Stricture. — The  two  most  common 
plans  of  treatment  are  by  gradual  and  by  rapid  dilatation.  In  the  former, 
after  an  instrument  has  been  passed  once  or  twice  on  successive  or  alter- 
nate days,  the  next  larger  size  is  taken,  and  so  on  until  in  a  few  weeks 
the  stricture  is  dilated  so  as  to  admit  a  catheter  the  natural  size  of  the 
tube.  This  size  of  course  varies  in  different  persons.  In  practice  the  No. 
10  of  our  ordinary  English  scale  may  be  taken  as  an  average.^  The  pa- 
tient is  then  taught  to  pass  a  similar  catheter  for  himself,  and  the  sur- 
geon gives  him  such  directions  as  to  the  frequency  of  passing  it  as  he 
thinks  fit,  once  or  twice  a  week,  according  to  the  apparent  tendency  of 
the  stricture  to  contract;  and  he  is  to  be  told  that  although  after  a  few 
years  it  may  no  longer  be  necessary  to  do  this  so  often,  yet  that  it  is 
dangerous  to  neglect  the  occasional  passage  of  an  instrument  in  order 
to  ascertain  whether  there  is  any  tendency  to  reneAved  contraction,  on 
the  first  suspicion  of  which  he  should  immediatelj'  consult  a  surgeon. 

Rapid  Dilatation. — The  other  method,  by  rai)id  dilatation,  is  one  which 
has  been  long  a  favorite  plan  of  treating  stricture  at  St.  George's  Hos- 
pital, and  which  Mr.  Savory  has  recently  strongly  recommended  from 
his  experience  at  St.  Bartholomew's.^     It  is  a  very  convenient  and  very 

^  Th(!  normal  calibre  of  the  male  urethra  is  generally  believed  to  be  represented 
by  a  tuhe  about  one  inch  in  circumference.  Dr.  Fessenden  N.  Otis,  of  New  York, 
believes  that  this  is  too  low.  He  says  that  he  has  met  with  two  cases  in  which  calculi 
measuring  IJ  in.  in  their  largest  and  1^  to  1|  in.  in  their  smallest  circumference 
pa.ssed  without  any  incision,  and  that  he  has  measured  urethrte  even  larger  than  this. 
He  also  figures  an  instrument  for  measuring  the  size  of  the  uretiira  behind  the 
meatus. — Lancet,  July  11,  1874.  But  in  practice  the  patient  may  be  well  satisfied 
when  even  No.  8  can  be  easily  introduced. 

*  See  St.  Barth.  Hosp.  Reports,  vol.  ix. 


TREATMENT    OF    STRICTURE.  789 

rapid  method  of  treating  cases  in  which  confinement  to  bed  is  not  ob- 
jected to  ;  and  is  therefore  peculiarly  appropriate  to  hospital  })ractice. 
As  much  progress  may  often  be  made  in  the  dilatation  of  a  stricture  in 
ten  days  by  this  method  as  would  have  been  in  a  month  by  that  of  grad- 
ual dilatation.  I  cannot  better  describe  the  plan  than  in  Mr.  Savory's 
words : 

"After  an  instrument  has  been  introduced  and  secured  the  patient 
should,  of  course,  lie  quiet — in  the  great  majority  of  cases  he  will  rest 
most  comfortably  on  his  back.  It  is  well  to  move  it  slightl}'  and  very 
gently  in  the  urethra  from  time  to  time.  This  gives  the  surgeon  addi- 
tional assurance  that  all  is  right,  and  tells  him  at  once  the  degree  of 
progress  that  has  been  made  by  the  loosening  of  the  stricture.  The 
instrument  may  be  either  withdrawn  at  the  end  of  twenty-four  hours, 
and  one  a  size  larger  introduced,  or  it  may  be  left  for  two  or  three  days, 
when  it  may  be  replaced  by  a  much  larger  one.  As  a  rule  I  change  the 
first  instrument,  if  it  be  a  small  one  (No.  1,  2,  or  3),  at  the  end  of  twenty- 
four  or  forty-eight  hours,  when  I  can  usually  pass  No.  4  or  5,  leaving  that 
in  for  two  or  three  days,  when  No.  1,  8,  or  9  can  be  easil}^  substituted. 
As  to  cliange  of  instrument,  I  am  chiefly  guided  by  the  size  of  the  cathe- 
ter and  the  amount  of  suffering  experienced  by  the  patient.  A  large 
instrument  maj'  be  retained  longer  than  a  small  one,  and  the  withdrawal 
of  the  original  instrument  and  the  substitution  of  another  often  gives 
relief  when  the  patient  is  restless.  Of  course,  patients  vary  much  in 
their  abilit}'  to  bear  a  catheter  in  the  urethra.  To  some  it  seems  to  give 
little  or  no  trouble;  they  make  no  complaint,  feed  and  sleep  well,  and, 
in  short,  give  no  signs  of  disturbance  of  any  kind  ;  while  others  complain 
very  loudly,  declare  their  utter  inability  to  bear  the  instrument  any  longer, 
and  urgently  demand  its  withdrawal,  sometimes  withdrawing  it  them- 
selves. In  my  experience  these  latter  cases  form  the  exception  to  the 
rule,  and  even  in  these  I  think  the  difficulty  ma}^  usually  be  overcome. 
In  the  worst  cases  of  stricture,  where  only  the  smallest  instruments  can 
be  passed,  the  chief  difficulty  in  treatment  is  overcome  if  an  instrument 
can  be  retained  for  twenty-four  or  forty-eight  hours. 

"  In  my  opinion  the  mode  of  action  of  this  plan  of  treatment  contrasts 
favorably  with  that  of  any  other.  The  stricture  is  overcome,  the  abnor- 
mal tissue  is  removed,  by  constant  pressure.  The  great  influence  of  pres- 
sure in  producing  absorption  is  a  well-recognized  fact.  We  are  familiar 
not  only  with  many  physiological,  but  also  with  raau}^  pathological  illus- 
trations of  its  potency.  And  it  comes  in  very  happil}'  for  the  remedy 
of  stricture.  When  an  instrument  is  then  introduced  it  is  tightly  grasped 
by  the  contracted  portion  of  the  canal,  but  is  loose  and  free  elsewhere, 
so  that  pressure  is  brought  to  bear  at  the  very  spot  where  it  is  required, 
and  there  only ;  and  in  proportion  to  the  amount  of  good  effected  is  the 
degree  of  its  action  reduced.  It  acts  not  b}^  mechanical  force,  but  by  a 
physiological  process.  Of  all  methods  of  treatment  this  undoes  the  mis- 
chief in  the  most  natural  manner  ;  and  herein,  I  submit,  is  its  claim  to 
be  considered  the  best." 

Tiie  drawbacks  to  the  plan,  besides  the  confinement  which  it  entails, 
are  that  in  some  patients  the  retention  of  the  instrument  causes  pain 
and  inflammation,  and  that  frequentl}',  if  after-treatment  be  neglected, 
the  recontraction  is  even  more  rapid  than  the  dilatation  has  been.  But 
the  former  danger  can  easily  be  guarded  against  by  carefully  watching 
the  case  and  withdrawing  tlie  catheter  if  it  really  seems  to  be  setting  up 
miscliief,  of  which  the  condition  of  the  urine  will  be  even  a  more  trust- 
worthy guide  than  the  complaints  of  the  patient.     And  the  tendency  to 


790  DISEASES    OF    THE    URINARY    ORGANS. 

recoutraetion  after  cure  can  easily  be  obviated  by  a  somewhat  more  fre- 
quent passage  of  the  catheter  than  is  needed  after  gradual  dilatation. 

Method  of  Ti/ing  a  Catheter  in  the  Bladder. — A  few  directions  are 
needed  as  to  the  mode  of  tying  in  a  catheter.  This  can  be  done  in  va- 
rious ways.  Tlie  easiest,  though  not  the  most  secure,  is  to  tie  a  tape 
round  the  end  of  the  catheter  with  a  clove  hitch,  or  to  pass  tapes  tlirough 
the  rings  made  on  the  ends  of  catheters  which  are  intended  to  be  retained, 
and  then  to  secure  the  ends  of  the  tapes  under  one  or  two  pieces  of  strap- 
ping rolled  circularly  round  the  penis.  The  insecurity  of  this  plan  de- 
pends on  the  loosening  of  the  strapping  by  the  various  conditions  of  erec- 
tion and  flaccidity  of  the  penis.'  A  more  secure  plan  is  to  pass  the  tapes 
which  hold  the  catheter  through  the  substance  of  a  T-bandage,  or  of  a 
broader  piece  of  tape  arranged  after  the  manner  of  a  T-bandage.  The 
tape  attached  to  the  catheter  ought  to  be  loose  enough  to  allow  the  instru- 
ment a  little  movement  in  the  bladder  but  tight  enough  not  to  permit 
it  to  slip  out.  The  T-bandage  should  be  as  tight  as  is  comfortable  to  the 
patient. 

Mr.  Savory  believes  that  a  silver  instrument  can  be  as  conveniently 
retained  as  a  gum  catheter.  My  own  inclines  to  the  general  opinion  that 
a  soft  catheter  is  less  irritating  than  a  metallic  one;  but  the  difference  is 
certainly  not  very  great. 

The  same  instrument  should  not  be  left  in  the  bladder  too  long.  I 
once  saw  a  case  in  which  the  prolonged  retention  of  a  metal  catlieter  in 
the  bladder  caused  ulceration  of  its  coats  and  perforation  leading  into 
the  peritoneal  cavity.  This  is  of  course  very  rare,  but  it  is  very  common 
to  see  a  catheter  become  coated  with  phosphatic  deposits,  and  this  in- 
creases the  irritation  of  the  bladder. 

So  much  for  the  treatment  of  strictures  in  which  the  catheter  can  be 
passed. 

Treatment  of  Impassiahle  Stricture. — Should  the  surgeon  be  unable  to 
pass  any  instrument,  the  treatment  of  the  case  will  vary  according  as 
there  is  or  is  not  retention.  When  there  is  not,  the  attempt  will  be  put 
off  till  another  day,  the  patient  being  prepared  for  the  renewed  attempt 
as  above  prescribed  (p.  Y86).  But  if  he  is  suffering  from  retention  of 
urine,  unless  the  bladder  be  distended  to  an  alarming  extent,  a  full  dose 
of  laudanum  (say  30  or  40  drops)  should  be  given  in  a  little  hot  water, 
and  he  should  be  put  into  a  hot  bath  until  he  begins  to  feel  faint.  Then 
if  the  retention  has  been  relieved  in  the  bath  (which  is  often  the  case)  he 
should  be  put  to  bed  and  left  quiet  till  another  day,  otherwise  the  surgeon 
should  try  to  introduce  the  catheter  while  the  patient  is  still  in  the  bath. 
If  this  attempt  also  fails,  careful  examination  is  to  be  made  to  ascertain 
how  far  the  distension  of  the  bladder  has  gone  and  whether  there  is  an}'' 
sign  of  fulness  or  great  pain  in  the  perineum.  If  not,  the  same  meas- 
ures may  be  repeated,  and  I  have  seen  cases  treated  with  success  after  nu- 
merous repetitions  of  sucih  attempts  ;  but  they  are  of  course  not  free  from 
the  risk  of  extravasation  of  urine  occurring  unexpectedly,  on  which  ac- 
count Mr.  Cock''  recommends  the  puncture  of  the  bladder  per  rectum  in 
preference  to  perseverance  in  the  attempt  to  pass  the  catheter  when  a 
patient  and  sufllcient  trial  has  proved  fruitless.  At  an}'  rate,  at  some 
period  or  other,  surgical  relief  must  be  given.  Three  courses  are  open, — 
to  puncture  the  distended  bladder  from  the  rectum  or  above  the  pubes, 


'  For  private  patients  who  have  to  wear  a  catheter,  a  little  apparatus  is  sold  to 
buckle  round  the  penis,  with  rings  to  wliich  the  catheter  is  attached. 
*  Med.-Chir.  Trans.,  vol.  xxxv,  )>.  153. 


PUNCTURE    OF    BLADDER    PER    RECTUM.  791 

or  to  force  a  way  into  it  with  the  catlieter.  The  latter  ("  forced  catheter- 
ization") is  no  longer  employed,  except  possibly  by  some  surgeons  in 
cases  of  great  enlargement  of  the  prostate,  under  which  heading  it  has 
been  discussed. 

Puncture  of  the,  bladder  f 7' ovi  the  rectum  is  a  simple  operation,  and  in 
the  cases  which  I  have  seen  it  has  proved  quite  as  successful  as  the  con- 
dition of  the  patients  permitted.  It  is  to  be  employed  in  impassable 
strictures  at  such  a  time  as  in  the  judgment  of  the  surgeon  is  desirable. 
It  must  lie  remembered  that,  even  allowing  that  ultimately  the  retention 
of  urine  may  be  relieved,  whether  instrumentally  or  otherwise,  before  ex- 
travasation occurs,  this  argument  is  not  of  itself  conclusive,  in  order  to 
show  that  the  operation  of  puncture  is  not  desirable,  since  every  liour 
which  elapses  increases  the  patient's  sufferings  and  the  inflammation  of 
the  urinary  organs,  while  the  repose  that  follows  the  puncture  is  of  course 
complete  ;  and  after  the  canula  has  lieen  retained  some  time  in  the  bladder, 
the  stricture  being  no  longer  irritated  by  constant  straining  and  the  con- 
tact of  inflamed  urine,  will  probably  become  much  more  tractable.  The 
matter  must  be  left  to  the  surgeon's  judgment,  weighing  the  circum- 
stances of  each  case.  The  fact  that  no  case  of  stricture  has  been  admitted 
into  St.  George's  Hospital  which  was  held  to  require  puncture  by  the 
rectum  from  the  time  of  Sir  E.  Home  down  to  the  year  1852,  when  Mr. 
Cock's  paper  was  read  at  the  Medico-Chirurgical  Society,  certainly  shows 
that  the  operation  is  not  often  rigidly  necessary  ;  while  the  fact  that  it 
has  been  very  frequently  performed  there  in  the  comparatively  few  years 
which  have  elapsed  since  that  date  proves  that  Mr.  Cock  succeeded  in 
showing  that  in  many  cases,  even  if  not  rigidly  necessary,  its  more  early 
performance  is  advisable.  The  operation  itself  is  done  thus.  The  patient 
is  put  up  in  the  lithotomy  position  and  had  better  be  narcotized.  The 
surgeon,  being  provided  with  a  long  curved  trocar  and  canula  made  for 
the  purpose,  examines  the  bladder  with  great  care  with  his  left  forefinger 
in  the  rectum  in  order  to  define  the  posterior  border  of  the  prostate  gland, 
and  to  make  himself  sure  that  the  fluctuation  of  the  urine  in  the  bladder 
can  be  felt  with  that  finger  when  percussion  is  made  on  the  bladder  above 
the  pubes.  Having  ascertained  this  beyond  doubt,  he  passes  the  canula, 
without  the  trocar,  up  the  rectum  and  fixes  it  with  his  left  forefinger  just 
behind  the  prostate  on  the  place  where  the  fluctuation  of  the  bladder  is 
felt.  His  assistant  holds  the  shield  of  the  canula  in  this  exact  position 
while  he  takes  the  trocar,  passes  it  through  the  canula,  and  then  drives 
it  into  the  bladder  with  a  decisive  plunge,  as  though  he  vvished  to  bring 
it  out  through  the  abdominal  wall  above  the  pubes.  There  can  be  no 
risk  in  plunging  it  in  boldly,  if  the  bladder  is  well  distended,  while  if  it 
be  more  gently  introduced  it  may  either  not  perforate  the  bladder  at  all, 
or  to  so  short  a  distance  as  to  slip  away  again  readily.  It  is  well  to  pass 
a  long  piece  of  gum  catheter  through  the  canula  in  order  to  fix  it  more 
securely  in  the  bladder,  and  it  is  to  be  tied  in  in  much  the  same  way  as  a 
catheter  (see  p.  790).  The  canula  is  not  to  be  stopped,  but  the  urine  can 
be  conducted  into  a  vessel  below  the  bed  by  fixing  an  india-rubber  tube 
to  it ;  otherwise  it  must  soak  into  oakum  or  tow,  which  is  to  be  frequently 
changed.  After  seven  to  ten  days  a  cautions  attempt  should  be  again 
made  to  pass  the  catheter,  and  if  this  is  successful  the  canula  is  to  be 
withdrawn  ;  otherwise  it  may  be  left  even  for  as  long  as  a  month.  In  a 
case  under  my  own  care,  however,  it  became  necessary  to  withdraw  it 
after  about  three  weeks,  in  consequence  of  the  diarrhoea  caused  by  the 
dribbling  of  water  into  the  rectum,  although  no  instrument  could  be  in- 


792  DISEASES    OF    THE    URINARY    ORGANS. 

troduced.  Tlie  patient,  however,  was  relieved  of  his  retention  and  was 
satisfied  with  this  relief,  and  so  I  lost  sight  of  him. 

Puncture  of  the  bladder  above  tiie  pubes  is  not  usually  necessary  in 
cases  of  stricture  unless  when  they  are  complicated  with  extreme  enlarge- 
ment of  the  prostate  gland.  Moderate  enlargement  of  the  prostate  does 
not  preclude  the  possibility  of  puncture  per  rectum  as  shovvn  by  a  prep- 
aration in  the  Museum  of  St.  George's  Hospital  from  a  patient  of  Mr. 
Tatum,  in  wliom  the  canula  slipped  out  accidentally  and  the  puncture  was 
repeated.  No  diHicult_y  was  experienced  either  time,  though  there  was 
considerable  enlargement  of  the  prostate  gland.  The  operation  of  punc- 
ture above  the  pubes  has  been  described  in  speaking  of  enlarged  prostate. 

The  aspirator  has  of  late  been  often  used  for  the  relief  of  stricture,  by 
evacuating  the  bladder  above  the  pubes.  I  hope  it  is  not  merely  from 
ignorance  that  I  am  somewhat  skeptical  as  to  the  real  value  of  this  method 
of  puncturing  the  bladder.  No  doubt  it  will  afford  relief  for  the  time, 
and  without  any  serious  danger  if  the  bladder  is  much  distended,  but 
the  puncture  will  heal  immediately  and  the  relief  will  be  transient.  In 
severe  strictures,  when  any  operation  for  puncture  of  the  bladder  is  re- 
quired, my  own  impression  is  that  the  operation  through  the  rectum  will 
ultimately  be  found  to  be  the  most  serviceable.  At  the  same  time,  the 
use  of  the  aspirator  is  perfectly  rational,  and  further  experience  will  teach 
us  its  real  value. 

Treatment  where  there  is  no  Retention. — Such  is  the  treatment  of  im- 
passable stricture  when  complicated  with  retention  of  urine.  There  are, 
however,  strictures  which  the  surgeon  finds  impassable,  and  yet  there  is 
no  retention.  In  such  cases  much  time  and  patience  should  be  employed. 
Rest  in  bed,  free  purgation,  and  the  constant  use  of  the  warm  bath,  will 
get  the  organs  into  a  quiet  state,  and  some  day  the  surgeon  will  succeed 
in  reaching  the  bladder,  an  attempt  which  is  greatly  facilitate'd  b}'^  anaes- 
thesia. But  if  he  does  not,  what  must  be  done?  The  patient  is,  perhaps, 
free  from  retention  while  quiet,  but  is  liable  to  it  at  any  time  after  exer- 
cise, exposure  to  weather,  drinking,  or  sexual  intercourse,  and  his  life  is 
made  a  torment  to  him  by  constant  ineffectual  instrumentation.  For 
such  cases  there  is  no  resource  except  the  old  operation  for  stricture 
called  "la  boutonniere,"  or  perineal  section,  which  must  be  carefully 
distinguished  from  Syme's  operation,  or  external  urethrotom}^  on  a 
grooved  staff,  an  operation  which  can  only  be  performed  when  the  stric- 
ture is  not  impassalile.^ 

Perineal  Section. — The  operation  of  perineal  section  is  thus  performed. 
The  patient  is  to  be  secured  in  the  lithotomy  position,  the  perineum 
having  been  shaved.  A  large  grooved  staff  is  to  be  passed  down  to  the 
anterior  face  of  the  stricture  and  carefully  maintained  in  position  by  an 
assistant.  If  a  false  passage  is  known  or  suspected  to  exist,  the  surgeon 
must  take  the  greatest  care  to  ascertain  that  the  staff  has  not  passed 
down  it,  but  is  in  the  middle  line,  i.  e.,  in  the  urethra.  If  there  is  a 
fistula  in  perinajo  thi'ough  which  a  director  or  female  catheter  can  be 
passed  into  the  bladder,  as  is  often  the  case,  it  facilitates  the  operation 
ver}'  materially. 

An  incision  should  now  be  made  in  the  raphe  of  the  perineum  in  nearly 
its  whole  extent.  As  the  incision  must  deepen  at  its  lower  part,  it  saves 
tinae  and  lessens  the  risk  of  losing  the  middle  line  to  make  this  incision 


'  Mr.  Syme  ii.sed  to  dwoU  with  chanictftristic  force  on  the  fact,  in  whicli  all  .surgeon.s 
of  much  experience  in  urinarj*  diseases  concur,  that  there  are  really  very  few  stric- 
tures which  are  impa.ssablo,  ifonly  the  surgeon  is  dexterous  and  fiatient.  The  necessity 
for  perineal  section  ougiit,  to  say  the  least,  to  occur  very  rarely. 


ABSCESS    IN    PERIN^O.  793 

boldly  by  placing  the  left  forefinger  in  the  rectum  as  a  guide ;  then  plunging 
the  knife  with  its  edge  upwards  deep  into  the  perineum  above  the  finger, 
so  as  just  to  avoid  the  rectum,  and  cutting  outwards.  The  staff  is  then 
to  be  exposed  b}'  reversing  the  knife  and  dissecting  carefully  until  its 
point  is  reached.  Now  commences  the  difficult  part  of  the  operation, — 
the  attempt  to  find  the  posterior  part  of  the  urethra  by  a  dissection  con- 
ducted along  the  course  of  the  canal.  If  there  is  an  instrument  passed 
through  a  fistulous  passage  into  the  bladder,  the  posterior  part  of  the 
urethra  cannot  of  course  be  missed,  but  it  does  not  follow  that  the  dis- 
section will  be  conducted  along  the  urethra,  still  less  when  there  is  no  such 
guide.  Indeed,  I  have  seen,  after  death  from  this  operation,  anatomical 
evidence  that  the  surgeon  had  made  a  kind  of  artificial  urethra,  i.e.^  had 
dissected  along  the  side  of  the  urethra,  leaving  the  stricture  on  one  side 
only  very  imperfectly,  if  at  all,  divided.  The  parts  should  of  course  be 
held  asunder,  and  the  urethra  looked  for  as  carefully  as  possible.  But  it 
is  seldom  possible  to  see  any  distinction  between  the  structures,  and  the 
only  precaution  which'  can  be  taken  is  to  keep  steadily  in  the  middle  line 
until,  possibly,  a  gusii  of  urine  takes  place  and  the  director  can  be  passed 
into  the  bladder.  In  any  case  even  when  the  surgeon  cannot  assure  him- 
self of  the  position  of  the  urethra,  it  is  always  easy  to  reach  the  neck  of 
the  bladder  by  putting  the  left  forefinger  on  the  edge  of  the  subpubic 
ligament — always  easily  felt  when  the  tissues  of  the  perineum  have  been 
divided  deeply  enough,  and  then  entering  the  knife  below  it.  And  I  have 
known  a  successful  issue  in  such  a  case,  though  the  surgeon  has  not  been 
conscious  of  exposing  the  vesical  portion  of  the  urethra.  When  the 
director  has  been  passed  into  the  bladder,  a  catheter  should  if  possible 
be  conducted  along  it  from  the  wound,  and  tied  in.  If,  however,  it  is  not 
possible  to  get  the  catheter  into  the  bladder  at  once,  the  operation  may 
nevertheless  be  quite  successful  if  onl}'  the  stricture  has  been  freely  divided. 
The  patient  should  be  left  alone  for  a  few  days,  and  when  the  parts  have 
consolidated  somewhat,  but  not  so  much  as  to  oppose  the  obstacle  of 
cicatrization,  an  instrument  will  probably  be  easily  passed  under  chloro- 
form. I  have  followed  this  course  with  complete  success.  The  instru- 
ment must  be  changed  as  often  as  is  necessary,  at  first,  perhaps,  every 
three  days,  and  afterwards  every  five  or  seven  (an  anaesthetic  being  given, 
if  it  is  absolutely  required)  until  the  parts  have  completely  cicatrized. 
And  after  this,  as  after  every  other  method  of  dilating  stricture,  the 
dilatation  must  be  maintained  by  the  constant  passage  of  instruments. 

Treatme)it. — The  complications  of  abscess  and  fistula  in  perina^o  are 
unfortunately  very  common.  The  former,  however,  rarely  leads  in  itself 
to  any  graver  consequence  than  considerable  pain  to  the  patient  and  con- 
finement to  bed  for  a  time.  The  abscess  in  perinteo  is  rarely  of  large  size. 
It  commonly  forms  a  small  hard  very  painful  lump  in  the  central  line, 
much  too  small  and  deep  to  permit  any  fluctuation  to  be  felt,  but  known 
to  be  an  abscess  by  the  presence  of  stricture,  by  the  pain,  and  usually 
also  by  rigors  and  other  feverish  symptoms.  No  time  should  be  lost  in 
lajnng  it  open  ;  it  would  be  very  reprehensible  to  wait  until  the  matter 
has  come  forward,  and  till  the  surgeon  can  feel  fluctuation.  The  patient 
should  be  brought  to  the  edge  of  the  bed,  placed  in  the  lithotoni}'  posi- 
tion, and  a  deep  puncture  should  be  made  with  a  lancet  or  (better)  with 
a  scalpel,  great  care  being  taken  to  keep  in  the  middle  line,  when  matter 
mixed  with  urine,  and  usuall}'  very  foul,  will  be  evacuated,  to  the  great 
relief  of  the  patient.  It  is  undesirable  to  tease  him  at  first  with  instru- 
ments. The  urine  very  seldom  comes  through  the  wound,  for  though 
the  abscess  is  formed  by  ulceration  of  the  urethra  its  small  orifice  is 


794  DISEASES    OF    THE    URINARY    ORGANS. 

generally  closed  by  inflammation,  otherwise  the  pus  would  flow  out  by 
the  urethra  and  there  would  be  little  pain  and  no  pressure  on  the  tube, 
or  increase  of  dysuria.  Even  if  urine  do  escape,  the  cure  of  the  stric- 
ture will  soon  cure  the  fistula. 

Treatment  of  Fistula  in  Perinseo. — Fistula  in  perinreo  is  generally  the 
result  of  a  much  more  chronic  action  than  abscess.  Their  origin  is  in 
some  sense  the  same,  only  that  of  abscess  is  accompanied  by  more  irrita- 
tion, probably  from  the  greater  putridity  of  the  urine;  while  the  fistula 
results  from  the  gradual  extension  of  ulceration  from  the  urethra  to  the 
surface  with  no  increase  of  the  obstruction,  and  few  if  any  symptoms. 
These  fistula?  accompany  all  kinds  of  tight  strictures,  but  are  particularly 
prone  to  accompany  the  traumatic,  which  are  the  tightest  of  all.  They 
have  been  known  in  such  cases  to  form  the  onl}''  channel  for  the  urine, 
the  urethra  being  absolutely  obliterated.  Such  unnatural  channels,  how- 
ever, can  never  properly  replace  the  natural  urethra ;  they  are  very 
liable  to  partial  obstruction  from  sabulous  deposit,  causing  low  inflam- 
mation of  the  urethra  and  bladder  behind  them,  and  they  are  a  source  of 
great  discomfort  to  the  patient,  by  incapacitating  him  from  passing  water 
in  the  usual  manner.  Their  cure  is  to  be  sought  in  the  restoration  of  the 
proper  channel  for  the  urine,  by  passing  catheters  increasing  gradually 
in  size,  or  by  otherwise  dilating  tlie  urethra  to  its  normal  extent.  When 
this  is  done,  the  fistula  will  generally  close  of  itself.  If  it  does  not,  the 
reason  usually  is  that  a  drop  of  water  passes  into  the  urethral  end  of  the 
fistula  every  now  and  then  and  keeps  it  irritated.  The  best  way  to  pre- 
vent this  is  bj"  instructing  the  patient  in  the  use  of  the  catheter  till  he 
can  easil}'  pass  a  full-sized  instrument  for  himself.  This  he  must  do  every 
time  he  wants  to  make  water,  and  must  stop  the  end  of  it  with  his  finger 
as  he  withdraws  it,  so  that  no  drop  of  urine  can  get  into  the  mouth  of  the 
fistula.  This  plan,  if  sedulously  persevered  in  for  a  week  or  two,  can  hardly 
fail  to  cure  the  fistula,  unless  its  persistence  dei^ends  on  the  chronic 
thickening  and  low  inflammation  of  its  walls,  in  which  case  the  tissue 
should  be  destroyed  by  passing  a  red-hot  wire  down  the  fistula,  or  by 
passing  a  wire  down  the  fistula  to  meet  a  catheter  passed  into  the  urethra 
and  then  connecting  the  wire  with  the  galvanic  battery,  or  sometimes 
these  fistulae  heal  on  the  stimulation  of  their  walls  with  the  tinct.  lyttae, 
or  by  means  of  a  probe  coated  with  the  nitrate  of  silver.  In  some  very 
rare  cases,  a  plastic  operation  may  be  justifiable.  The  tissue  through 
which  the  fistula  runs  is  laid  open  freely  and  deeply  until  the  urethra  is 
reached,  a  grooved  staff  having  been  previously  passed.  All  the  diseased 
tissue  which  can  be  recognized  is  pared  awa^^  and  the  parts  sewn  together, 
a  catheter  being  kept  in  the  bladder.  Such  an  operation,  however,  is  very 
rarely  indeed  called  for. 

Urinary  fistulae  may  also  be  produced  by  otlier  causes,  such  as  the  im- 
paction of  a  foreign  body,  a  wound,  as  in  lithot'^m}^,  and  in  rare  cases  by 
the  bursting  of  an  abscess  into  the  urethra.  I  once  saw  a  very  healthy- 
looking  man  with  a  large  fistula  of  which  he  could  give  no  account,  except 
that  it  appeared  to  him  to  form  after  prolonged  sitting  on  the  driving- 
box,  and  who  certainly  had  no  stricture.  In  some  wounds  or  injuries  of 
the  urethra  the  tube  becomes  completely  obliterated,  and  this  gives  rise 
to  the  most  obstinate  form  of  fistula. 

Anie-Hcrotal  Fistula. — The  most  difficult  form  of  urinary  fistula  to  treat 
is  that  which  opens  in  front  of  the  scrotum,  called  on  that  account  "ante- 
scrotal  fistula."  It  is  caused  usually  by  syphilitic  sores  on  the  skin, 
which,  having  ]>ecome  phagedenic,  have  opened  into  the  urethra,  or  by 
sloughing,  tlie  result  of  accident.     The  main  obstacle  to  their  closure  is 


EXTERNAL    URETHROTOMY.  795 

the  constant  clisturbance  of  their  edges  by  the  varying  size  of  the  penis 
in  erection,  and  this  is  especially  the  case  after  plastic  operations,  for  the 
sutures  which  haA^e  been  put  in  seem  to  act  as  irritants,  and  the  patient 
is  very  liable  to  frequent  erections.  Patience,  however,  on  the  part  of 
the  surgeon  and  the  patient  will  usually  procure  their  healing  after  re- 
peated operations.  I  once  saw  a  case  of  ante-scrotal  fistula  from  injury, 
in  which  thirteen  operations  were  practiced,  and  ultimately  the  fistula 
was  perfectly  cured.  In  these  cases  it  is  well  to  dissect  up  the  skin  freely 
around  the  fistula  and  to  make  free  lateral  incisions,  so  that  the  edges  of 
the  incision  may  meet  over  the  fistula  without  any  tension  whatever.  It 
may  even  be  necessary  to  transplant  flaps  from  the  neighboring  i)art  of 
the  penis,  and  to  divide  the  prepuce  freely  from  the  glans,  in  order  that 
the  erection  of  the  peuis  shall  produce  as  little  effect  on  the  wounds  as 
possible.  The  wound  is  to  be  united  either  longitudually  or  transversely, 
as  may  seem  to  produce  least  tension  on  the  sutures.  The  evacuation  of 
the  urine  is  verj^  troublesome  after  such  operations.  It  is  best,  on  the 
whole,  I  think,  for  the  surgeon  himself  to  i)ass  a  metal  instrument  three 
times  a  day  with  all  imaginable  care  not  to  disturb  the  sutures,  and  to 
stop  the  catheter  while  he  withdraws  it.  If  a  catheter  is  tied  in  it  irri- 
tates the  wound,  and  the  urine  is  apt  to  dribble  away  beside  it. 

Recurrent  Strictures. — There  are  cases  of  urinary  fistula  with  stricture 
in  which  the  stricture  can  be  passed,  but  cannot  be  dilated.  The  patient 
suffers  constantly  from  rigors'  after  the  passage  of  the  instrument,  and 
any  progress  tiiat  may  be  made  at  one  time  is  soon  lost  again.  In  such 
cases  the  stricture  must  be  divided  either  by  internal  or  external  urethro- 
tomy. 

Syme^s  operation — that  of  external  urethrotomy  on  a  grooved  staff — is 
thus  performed.  The  patient  being  in  the  lithotomy  position,  a  "shoul- 
dered" staff  is  passed  into  the  bladder,  viz.,  a  staff  which  is  narrower  at 
the  end  than  it  is  in  the  stem.  We  may  suppose  that  the  end  which 
passes  through  the  stricture  into  the  bladder  is  the  size  of  No.  I  or  No.  2 
catheter,  while  the  stem  is  the  size  of  No.  8  or  No.  10.  At  the  junction 
of  the  two  parts  there  will  be  a  projecting  "shoulder,"  and  this  shoulder 
will  necessarily  be  arrested  by  the  mouth  of  the  stricture.  A  groove 
commences  on  the  shoulder,  i.e..,  on  the  thicker  part  of  the  staff,  and 
runs  along  the  convexity  of  the  staff,  though  not  quite  to  the  end.  The 
surgeon  passes  his  left  forefinger  into  the  rectum,  and  passes  the  point  of 
the  knife,  with  its  edge  looking  upwards,  into  the  raphe  of  the  perineum 
a  little  above  his  finger,  so  as  not  to  wound  the  rectum,  but  to  open  the 
perineum  deei)ly  and  almost  expose  the  stafi"  in  the  urethra  at  a  single 
Incision,  which  is  to  be  drawn  upwards  nearly  to  the  scrotum.  The 
shouldered  part  of  the  staff  with  its  groove  will  now  be  very  perceptible  in 
the  wound,  and  should  be  further  exposed  if  necessary  by  a  few  touches 
of  the  knife.  Then  the  point  of  the  knife  is  to  be  inserted  in  the  com- 
mencement of  the  groove,  where  it  is,  of  course,  in  front  of  the  stricture, 
and  the  knife  is  to  be  steadily  pushed  along  in  the  middle  line,  so  long  as 
any  resistance  is  experienced.  The  staff  is  then  to  be  pushed  on  until 
its  thick  portion  will  pass  freely  into  the  bladder.  Great  care  must  be 
given  to  tiiis  part  of  the  operation,  to  see  that  the  stricture  has  really 

1  These  rigors  are  in  some  cases  most  distressing.  They  are  apt  to  recur  whenever 
an  instrument  is  passed,  accompanied  by  a  definite  and  often  considerable  rise  of 
temperature,  and  great  malaise,  a  condition  sometimes  spoken  of  as  "  urethral  fever." 
They  are  best  avoided  by  giving  the  patient  a  glass  of  hot  brandy  and  water  with  a 
full  dose  of  laudanum  in  it  and  wrapping  him  up  warm  in  bed  immediately  after  the 
passage  of  the  instrument. 


796  DISEASES    OF    THE     URINARY    ORGANS. 

heen  divided  quite  freely  enough,  for  if  this  has  not  l)een  effectually  done, 
recurrence  is  almost  certain.  Then  the  staff  is  to  be  withdrawn  and  a 
full-sized  gum  catheter  passed  from  the  penis  and  tied  in.  There  is  some- 
times a  difiicult)'  in  introducing  the  catlieter  after  the  withdrawal  of  the 
staff.  This  may  be  obviated  by  passing  a  director  from  the  wound  into 
the  bladder  before  the  staff  is  withdrawn,  or  by  the  use  of  a  staff'  in  which 
the  shouldered  part  screws  on  to  the  thin  portion,  and  when  the  stric- 
ture has  been  divided  is  unscrevved,  leaving  the  central  part  to  serve  as 
a  conducting  rod,  over  which  a  large  catheter  open  at  the  end  is  passed 
down  and  the  rod  withdrawn.  But  after  all  it  is  not  a  point  of  very  much 
importance  whether  a  catheter  be  passed  into  the  bladder  immediately'' 
after  the  division  of  stricture  or  not.  In  a  few  days,  when  the  wounded 
parts  have  a  little  consolidated,  there  will  be  no  difficulty  in  passing  the 
instrument  (under  chloroform  if  necessary)  if  only  the  stricture  has  been 
freely  divided. 

Syme's  operation  is  now  used  chiefly,  if  not  entirely,  in  cases  of  very 
hard  traumatic  strictures  complicated  with  fistulae  in  perinseo.  Such 
strictures  are  very  difiicalt  to  treat  by  gradual  dilatation,  or  by  rupture, 
and  are  hardly  amenable  to  internal  division,  though  there  is  no  harm  in 
trying  this  if  the  surgeon  thinks  fit.  But  the  free  division  of  all  the 
morbid  tissue,  and  the  constant  retention  of  a  large-sized  instrument 
afterwards,  certainly  afford  the  best  prospect  of  a  cure,  after  which  con- 
stant catheterization  must  not,  for  many  years  at  least,  be  neglected. 

Rupture^  or  Forcible  Dilatalion^  of  Strictm-e.  —  Another  successful 
method  of  treating  rebellious  strictures  which  admit  tlie  introduction  of 
a  small  instrument  is  by  what  is  generally  called  in  England  "rupture" 
of  the  stricture,  and  in  France  "forced  dilatation."  This,  however,  like 
every  other  violent  method  of  treating  stricture,  should  be  reserved  only 
for  cases  of  exceptional  occurrence,  viz.,  those  in  which  there  is  unusual 
sulfering  from  catheterization,  or  in  which  no  progress  can  be  made  in 
dilating  the  stricture,  or  the  patient  suffers  constantly  afterwards  from 
fever  and  rigors,  or  after  dilatation  the  stricture  immediately  recontracts. 
Numerous  plans  have  been  devised  for  this  end.  At  first,  the  simple 
plan  was  followed  of  passing  a  central  rod  and  sliding  over  it  tubes  in- 
creasing in  size  till  the  desired  dilatation  was  reached.  This,  however, 
is  a  very  imperfect  device,  since  the  tube  is  liable  to  catch  and  tear  the 
mucous  membrane  at  tiie  site  of  resistance.  Two  methods  are  now  em- 
ployed, in  each  of  which  a  dilatable  instrument  is  first  passed,  consisting 
of  two  blades,  attached  to  each  other  at  the  point,  but  separable  in  tlie 
rest  of  their  urethral  portion  and  fastened  on  to  a  central  rod.  The  dila- 
tation is  effected  in  the  one  case  (Sir  II.  Tiiompson's  plan)  by  turning  a 
screw  in  the  handle,  which  causes  a  small  lever  to  project  from  the 
central  stem  and  so  drive  the  blades  asunder.  In  the  other,  wliich  is  the 
one  in  common  use,  a  tube  is  forced  down  over  the  central  stem,  and 
thus  separates  the  blades  to  the  required  extent.  This  instrument  was 
invented  by  a  French  surgeon,  M.  Perreve,  and  lias  been  somewhat 
modified  and  introduced  into  English  practice  by  Mr.  Holt,  whose  name 
it  generally  bears  in  this  country.  Mr.  Richardson,  of  Dublin,  and  otliers 
have  also  modified  Perreve's  instrument.  The  great  risk  in  the  use  of  any 
of  these  instruments  is  that  of  passing  it  down  a  false  passage.  In  these 
cases  of  obstinate  stricture  there  are  generally  false  passages,  and  some- 
times the  instrument  slips  into  them  so  easily  and  they  run  so  much  in  the 
direction  of  the  l)ladder  tliiit  it  is  very  difficult  to  know  whether  the  point 
is  in  the  bladder  or  not  unless  the  urine  can  be  seen  to  escape.  Accord- 
ingly- Mr.  Holt  has  had  the  stem  of  Perreve's  instrument  perforated,  con- 


INTERNAL     URETHKOTOMY.  797 

verting  it  into  a  minute  tube,  through  which  a  drop  of  urine  will  escape, 
unless  (as  frequently  hai)pcns)  the  little  hole  is  obstructed  b}'  clot;  in 
that  case  the  surgeon  should  not  proceed  farther,  if  there  is  any  question 
about  false  passage,  until  by  examination  by  the  rectum  and  palpation 
of  the  abdomen  he  has  coniijletely  satisfied  himself  that  he  is  reall}'  in 
the  bladder.  The  tube  is  to  be  aj^ijlied  to  the  central  rod  (the  handle 
being  opened  for  the  purpose  V»y  removing  all  the  screws),  and  driven 
smartly  home,  in  doing  which  the  stricture  will  be  felt  to  give  way.  The 
instrument  is  then  withdrawn  with  the  tube  still  in  it,  and  the  urine  is 
drawn  off  with  a  fuU-siz^d  catheter.  Two  tubes  are  supplied  with  the 
instrument:  if  the  larger  one  has  been  used.  No.  10  will  pass;  if  the 
smaller.  No.  8.  As  a  general  rule  the  catheter  sliould  not  be  left  in,  but 
it  is  well  to  draw  the  water  off,  both  as  a  proof  that  the  stricture  is  prop- 
erly dilated,  and  in  order  to  spare  the  patient  the  pain  of  passing  water 
soon  after  the  operation.  Chloroform  may  be  given  or  not  according  to 
the  wishes  of  the  patient  and  the  surgeon.  In  very  tight  and  hard  stric- 
tures it  is  perhaps  necessary,  and  in  all  cases  where  the  operation  is 
really  required  it  must  be  j)ainful,  though  soon  over.  The  patient  should 
keep  liis  bed  for  a  couple  of  days,  and  then  the  catheter  should  be  re- 
introduced and  the  case  treated  as  an  ordinary  one  of  stricture  which 
has  been  dilated  up  to  that  size.  It  is  not  always  possible,  or  at  least 
easy,  to  pass  the  same  catheter  as  at  the  time  of  operation,  but  in  all 
cases  which  I  have  seen  (except  one  of  traumatic  stricture)  tiie  case  was 
very  easily  managed  afterwards. 

In  this  proceeding  it  seems  doubtful  wdiat  is  the  real  action  generally 
on  the  stricture.  We  speak  of  it  farailiarl}'  as  "rupture,"  but  there  seems 
good  reason  to  think  that  it  is  often  little  more  than  a  forcible  dilatation, 
or  if  there  is  any  rupture  it  is  confined  to  the  submucous  tissue,  and  there 
is  no  breach  of  surface  in  the  urethra.  If  this  is  so,  it  evidently  dimin- 
ishes the  risk  of  inflammation  from  foul  urine  being  extravasated  or 
passing  over  a  raw  surface.  I  have  seen  death  after  this  operation,  but 
it  was  in  the  person  of  a  man  whose  urinary  organs  were  in  so  advanced 
a  condition  of  disease  that  he  could  not  in  any  case  have  lived  long. 

Internal  Urethrotomy. — Another  method  of  treating  rebellious  or  con- 
tractile strictures  is  b}-  internal  division,  and  this  is  indubitably  superior 
to  rupture  in  stricture  situated  far  forwards,  and  possibly  in  traumatic 
stricture  ;  though  it  ma}'  be  questionable  whether  in  traumatic  stricture 
not  in  the  spongy  body,  the  freer  division  produced  b}'  Syme's  operation 
is  not  preferable.  The  general  use  of  Syme's  operation  and  of  the  method 
by  forcible  rupture  renders  the  use  of  internal  urethrotomy  rare  in  this 
countr}'.  It  is  performed  in  two  ways,  ?'.  e.,  by  incising  the  stricture 
from  behind  forwards,  or  from  before  backwards.  The  former  is  the 
safer  course,  and  the  one  usually  followed.  Many  instruments  have  been 
invented  for  this  purpose,  but  the  one  most  in  use  is  Civiale's,  which  may 
be  taken  as  the  type  of  them  all.  The  principle  of  all  is  that  of  the  bis- 
touri  cache,  i.  e.,  a  stem  containing  a  knife  which  is  projected  b}'  pressing 
on  a  handle.  In  Civiale's  urethrotome  the  head  of  the  instrument  is  bul- 
bous, and  in  this  bulb  a  small  knife-blade  is  concealed.  The  position  of 
the  stricture  is  clearl}'  ascertained,  and  it  is  felt  by  the  bulb  in  passing 
tiirough  it.  Then  as  the  Inilb  is  witiidrawn  the  knife-i)lade  is  projected 
from  it,  and  the  whole  tissue  of  the  stricture  is  freely  incised,  the  inci- 
sion being  directed  by  preference  to  the  floor  of  the  urethra,  and  care 
must  be  taken  that  the  incision  extends  completely  through  tlie  obstruc- 
tion.    After  the  division  a  full-sized  catheter  ought  to  pass  easily,  and  it 


798  DISEASES    OF    THE    UKINARY    ORGANS. 

is  well  to  retain  it  for  the  first  twent^'-four  hours,  and  to  pass  instruments 
frequently  afterwards. 

Incisions  from  before  backwards  require  a  guide  to  be  passed  through 
the  stricture.  Maisonneuve's  guide  is  a  flexible  filiform  bougie,  on  the 
end  of  which  a  grooved  rod  is  screwed.  This  bougie  being  passed 
through  the  stricture,  the  grooved  rod  is  screwed  on  to  it,  and  is  passed 
on.  The  filiform  bougie  coils  up  in  the  bladder,  and  guides  the  rod  down 
the  urethra,  through  the  mouth  of  the  stricture.  Then  a  semi-sharp 
lancet-shaped  knife  is  passed  down  the  groove,  which  incises  or  tears  the 
stricture,  l)ut  is  not  sharp  enough  to  wound  the  normal  urethra.  Sir  H. 
Thompson  has  devised  a  grooved  catheter  for  the  same  purpose,  along 
which  a  sheathed  knife-blade  is  passed.  When  this  comes  to  the  point 
of  resistance  the  knife  is  unsheathed  and  the  stricture  divided.  A  large 
gum  catheter  is  then  passed  over  the  grooved  conductor,  and  the  latter 
withdrawn. 

The  advantages  claimed  for  internal  incision  over  rupture  are  that  its 
results  are  said  to  be  more  permanent.  I  have  not  sufficient  experience 
of  the  matter  to  enable  me  to  pronounce  an  opinion  of  my  own.  Sir  H. 
Thompson,  whose  experience  of  internal  urethrotomy  extends  to  above 
100  cases,  recommends  it  "  for  all  non-dilatable  strictures  situated  from 
two  to  four  inches  from  the  external  meatus,"  and  for  these  somewhat 
rare  cases  I  doubt  not  that  it  is  both  safe  and  easy;  but  for  strictures 
situated  behind  the  scrotum  I  should  long  hesitate  before  resorting  to  it. 
In  any  case  it  appears  that  tlie  extent  of  the  incision  through  the  stric- 
ture is  not  in  itself  a  matter  of  any  great  importance  ;  but  it  is  highly 
important  to  make  sure  that  no  part  of  the  stricture  is  left  undivided. 

Spasmodic  Retention — The  retention  which  proceeds  from  organic 
stricture  is  to  be  carefully'  distinguished  from  that  which  is  due  to  spasm 
only.  To  the  latter  the  somewhat  incorrect  term  "  spasmodic  stricture  " 
is  usually  applied.  "  Spasmodic  retention,"  or  "spasm  of  the  urethra," 
better  expresses  the  nature  of  the  case,  since  there  is  really  no  stricture 
in  the  proper  sense  of  the  term.  I  have  already  stated  that  much  spasm 
almost  always  attends  organic  stricture,  and  therefore  the  retention  of 
urine,  as  well  as  the  difficult}^  in  i)assing  instruments,  in  cases  of  stric- 
ture, depends  usually  to  a  great  extent  on  spasm  induced  by  irritation  of 
the  stricture.  But  the  cases  here  spoken  of  are  unaccompanied  as  far  as 
is  known  by  any  anatomical  change  in  the  tissue  of  the  urethra.  Spas- 
modic retention  occurs  in  gonorrhoea,  from  excesses  in  drinking,  from 
prolonged  voluntar\'  retention,  from  the  use  of  cantharides  or  turpentine, 
after  surgical  operations  about  the  pelvis,  from  morbid  conditions  of  tlie 
urine,  and  from  unknown  causes. 

It  ma}'  be  known  from  the  retention  which  accompanies  stricture  or 
enlarged  prostate  by  its  sudden  occurrence,  micturition  having  been 
quite  natural  up  to  the  time  when  retention  took  place;  and  from  that 
caused  by  impaction  of  stone  b}^  direct  examination.  In  some  cases,  as 
when  retention  complicates  surgical  operations,  the  history  points  out 
the  nature  of  the  case. 

There  is  seldom  any  difficulty  in  passing  a  catheter,  and  as  this  settles 
the  case  at  once,  and  spares  tlie  [)atient  a  good  deal  of  time  and  some 
distress,  it  is  better  in  ordinary  cases  to  take  a  medium-sized  gum  cath- 
eter, and  pass  it  rapidly.  The  muscles  may,  as  it  were,  be  taken  by 
surprise,  and  the  catheter  reach  the  bladder  at  once.  If  not,  the  ob- 
struction will  be  found  to  be  at  the  point  where  the  membranous  part  of 


RETENTION    AND    INCONTINENCE    OF    URINE.  799 

the  urethra  is  surrounded  by  its  muscles,  and  gentle  steady  pressure  for 
a  few  seconds  will  often  carry  the  instrument  in.  If  this  attempt  does  not 
succeed,  the  patient  should  be  put  into  a  liot  bath  till  he  is  nearly  faint, 
having  previously  had  a  full  dose  of  laudanum,'  and  then  in  almost  all 
cases  the  spasm  will  yiekl.  In  some  rare  instances  it  may  be  desirable  to 
administer  an  anaesthetic. 

Retention  of  urine  is,  as  will  have  been  seen  from  the  foregoing  pages, 
and  from  the  chapter  on  Stone,  a  common  symptom  of  a  variety  of  morbid 
states.  In  children  it  proceeds  most  commonly  from  impaction  of  a  stone 
in  the  urethra,  or  from  a  ligature  round  tlie  penis,  and  in  very  rare  cases 
from  tumor  of  the  bladder  or  urethra,  or  from  abscess  pressing  on  the 
urethra.  In  men  stricture  is  by  far  the  most  common  cause,  though  it 
ma}^  proceed  from  spasm,  or  from  lacunar  or  other  abscess  pressing  on 
the  urethra,  from  prostatitis,  from  stone,  or  from  various  general  diseases. 
In  old  age  retention  is  commonly  associated  with  enlargement  of  the 
prostate. 

Stricture  of  the  Female  Urethra. — In  the  female  sex  retention  is  gen- 
erally due  to  nervous  causes  (hysterical  retention)  or  to  pressure  (as  in 
parturition).  It  may  be  caused  by  stone,  and  in  some  very  rare  cases 
has  been  known  to  be  due  to  stricture.  Stricture  of  the  female  urethra 
is  an  exceedingly  rare  affection,  but  does  undoubtedly  occur.  Its  usual 
cause  is,  I  believe,  injury  in  parturition  or  otherwise.  Careful  examina- 
tion is  necessary  to  distinguish  it  from  hysterical  retention.  It  is  best 
treated  by  rupture  or  internal  incision. 

Retention  from  obstruction  of  any  kind  (spasmodic  or  otherwise)  must 
be  carefully  distinguished  in  the  first  place  from  suppression  (p.  168),  and 
in  the  next  place  from  the  kind  of  retention  which  is  caused  by  paralysis, 
and  from  the  atony  which  follows  overdistension.  Both  of  these  are  suc- 
ceeded b,y  overflow  of  urine,  a  condition  sometimes  incorrectly  spoken 
of  as  incontinence.  There  is  no  difficulty  in  distinguishing  between 
retention  from  obstruction  and  that  from  paraljsis.  In  the  former,  after 
the  obstruction  has  been  overcome,  the  bladder  will  discharge  its  contents 
with  natural  force.  In  the  latter  (which  is  very  rare,  and  which  is  ac- 
companied b}'  other  paralytic  symptoms)  the  urine  merely  runs  out  under 
external  pressure  when  the  catheter  is  passed,  but  there  is  no  muscular 
action  in  the  bladder  itself,  and  there  is  no  obstacle  whatever  to  account 
for  the  retention.  Atony  from  overdistension  occurs  in  numerous  classes 
of  obstruction,  enlarged  prostate,  stricture,  tumor,  etc.  After  a  certain 
amount  of  retention  the  urine  begins  to  dribble  awa}'  from  dilatation  of 
the  neck  of  the  bladder.  The  treatment  consists  in  relieving  the  ob- 
struction and  keeping  the  bladder  constantly  empty. 

Incontinence  of  urine  is  in  the  great  majority  of  cases  the  result  of 
overflow  from  distension,  and  ought  not  to  be  spoken  of  as  a  substantive 
disease  at  all,  being  merely  a  sym[)tom  of  obstruction.  At  other  times 
it  means  the  overflow  of  paralysis,  or  of  the  irritability  of  the  bladder 
so  often  connected  with  paralysis.  Hence  the  lirst  thing  in  the  treatment 
of  incontinence  of  urine  in  the  adult  is  to  ascertain  whether  there  is  not 
one  of  those  two  conditions  present,  which  in  the  very  great  majority  of 

1  Sir  H.  Thompson  says  that  the  Tinct.  Ferri  Perchloridi,  in  doses  of  15  to  20 
minims,  administered  four  or  six  times  at  intervals  of  a  quarter  of  an  hour,  will  re- 
lieve the  sjijism. 


800  DISEASES    OF    THE    URINARY    ORGANS. 

cases  there  is.^  A  veiy  few  cases  will  I'einain  in  which  the  urine,  though 
health}',  cannot  be  retained  for  any  length  of  time  in  the  bladder.  This 
happens  sometimes  in  persons  broken  down  b}'^  sexual  excesses,  and  in 
other  morbid  conditions  of  the  nervous  system.  The  treatment  must  be 
regulated  by  the  apparent  cause.  In  some  very  rare  cases  of  prostatic 
enlargement  incontinence  is  caused  by  the  projection  of  the  "  third  lobe  " 
into  the  neck  of  the  bladder,  keeping  it  constantly  patulous,  a  condition 
for  which  there  is  no  remedy. 

E)U(i-esis  in  Childhood. — Bat  the  condition  of  pure  incontinence  which 
is  commonly  met  with  is  the  juvenile  incontinence,  or  "  enuresis  "  of 
childhood,  much  more  commonly  seen  in  boys  than  girls,  in  which  the 
child  becomes  a  nuisance  to  himself  and  ever}'  one  else  by  constantly 
wetting  the  bed,  and  in  some  severer  cases  cannot  hold  his  urine  in  the 
daytime.  In  some  very  rare  instances  there  is  also  a  similar  incontinence 
of  feces.  Yet  there  is  no  evidence  of  spinal  disease,  the  urine  is  natural, 
and  the  child  in  other  respects  health}',  though  many  of  these  children 
are  dull  and  stupid. 

In  many  cases,  no  doubt,  the  habit  is  to  be  referred  to  mere  wilfulness, 
and  may  be  corrected  by  appropriate  punishment,  or  by  moral  means.  It 
is  well  known  that  it  is  very  liable  to  spread  in  a  school  into  which  a  case 
has  once  been  admitted.  But  there  are  many  cases  in  which  the  child  is 
as  desirous  to  get  rid  of  the  infirmity  as  any  one  else  can  be,  and  I  have 
seen  more  than  one  instance  in  which  a  ligature  has  been  tied  so  tight 
round  the  penis  as  to  cut  into  the  urethra  by  a  boy  who  was  determined 
to  rid  himself  of  the  habit.  In  these  cases  the  first  thing  is  to  make  sure 
of  the  absence  of  worms,  then  to  see  that  the  child  is  awoke  every  three 
hours  and  made  to  pass  urine,  to  act  freely  on  the  skin,  to  give  tonics, 
especially  steel  and  strychnine,  and  to  administer  cold  douches  to  the 
spine.  13elladonna  is  the  drug  which  in  my  experience  has  acted  most 
favorably  in  these  cases,  beginning  with  |-th  of  a  grain  of  the  extract 
three  times  a  day,  and  raising  the  dose  till  the  characteristic  symptoms 
of  poisoning  (of  which  paralysis  of  the  bladder  is  one)  begin  to  show 
themselves.  Other  practitioners  speak  highly  of  chloral.  Sir  H.  Thomp- 
son says  that  in  obstinate  cases  the  application  of  a  solution  of  the 
nitrate  of  silver,  10  grains  to  the  ounce,  to  the  neck  of  the  bladder  may 
be  beneficial. 

The  complaint  almost  always  subsides  before  the  patient  grows  up. 

I  will  merely  add  that  I  once  saw  a  case  in  which  the  dilatation  of  the 
neck  of  the  bladder  by  a  stone  projecting  into  the  urethra  was  mistaken 
for  juvenile  incontinence.  Of  course  such  an  error  could  only  arise  from 
want  of  examination. 


1  "  There  is  no  principle  more  important  to  rememher  in  the  treatment  of  diseases 
of  the  urinary  organs  than  this, — that  an  involuntary  flow  of  urine  in  the  adult  indi- 
cates a  distended,  not  an  empty,  bladder." — Thomp.son. 


CALCULUS. 


801 


CHAPTER    XXXVIII. 

CALCULUS. 

Stone,  whether  in  the  kidney  or  bladder,  is  produced  by  the  aggrega- 
tion of  some  of  the  ordinary  urinary  deposits,  which  we  may  divide  with 
Mr.  Poland  into  two  classes, — those  allied  to  the  urates  and  derived  from 
the  organic  constituents  of  the  urine,  and  those  derived  from  the  inor- 
ganic salts  of  the  urine, — the  phosphates  and  carbonates.  A  familiarity 
with  the  external  appearance  of  these  deposits  in  the  urine  and  with  their 
microscopical  characters  is  necessary  for  any  successful  treatment  of 
urinary  diseases. 

Lithates. — Of  these  deposits  the  urates  or  lithates  of  ammonia  and  of 
soda  are  the  most  common.  They  form  a  variously  colored  cloud  in  the 
urine,  sometimes  pure  white,  at  others  almost  purple,  most  commonly 
yellowish-red,  which  generally  clears  entirely  on  being  heated.  Such  de- 
posits occur  constantly  as  an  occasional  phenomenon  in  conditions  of 
perfect  health,  especially  in  cold  weather,  and  no  importance  is  to  be  at- 
tributed to  the  circumstance.  But  their  constant  or  habitual  presence 
shows  that  either  the  digestive  or  cutaneous  functions  are  disordered, 
and  should  induce  a  strict  examination  and  proper  eliminative  measures. 

The  microscopical  appearances  of  the  lithates  are  that  they  eitlier  form 
a  completely  amorphous  deposit,  or  that,  as  shown  in  the  annexed  dia- 
gram, tliere  are  minute  spheres,  having  protruding  from  them  acicular 
spicuUie,  which  are  regarded  as  being  those  of  uric  acid. 

Uinc  acid  is  also  a  very  common  deposit.  It  occurs  in  the  form  of 
acicular  prisms  or  of  rhombic  plates,  such  as  are  shown  in  Fig.  .355,  and 


Fig.  354. 


Fig.  355. 


Lithate  of  ammonia. 


Uric  acid  deposits. 


these  often  attain  a  very  large  size,  so  as  to  be  perfectly  visible  to  the 
eye  as  "red  sand,"  or  even  to  form  a  minute  calculus.  Dr.  Golding  Bird 
attributes  the  formation  of  uric  acid  deposits  to  the  following  causes  : 
"  (1)  the  waste  of  tissues  being  more  rapid  than  the  supply,  as  in  fever, 

51 


802 


CALCULUS. 


Fig.  356. 


rheumatism,  etc.;  (2)  the  supply  of  nitrogen  in  the  food  being  greater 
than  is  required  for  the  reparation  of  the  tissues,  as  in  over-indulgence, 
especially  in  the  use  of  animal  food  ;  (3)  the  process  of  digestion  being 
insufficient  to  assimilate  an  ordinary  and  normal  supply  of  food,  as  in 
dysjiepsia;  (4)  obstruction  to  the  cutaneous  outlet  for  nitrogenized 
secretions,  as  met  wfth  in  diseases  of  the  skin,  variability  of  climate,  etc. ; 
(5)  congestion  of  the  kidneys  from  injury  or  disease."  Imperfect  respira- 
tion is  also  said  to  be  a  cause  of  excess  of  uric  acid  in  the  urine.  The 
treatment  will  be  regulated  by  a  knowledge  of  the  causes. 

O.ralafc  of  lime  is  another  common  deposit  in  the  urine,  and  often 
forms  a  calculus  in  the  kidney  or  bladder.     The  microscopic  appearances 

are  twofold — the  octahedral  cr3'stals 
(shown  on  the  left  of  the  diagram)  and 
the  dumb-bell  shaped  cr^'stals  (on  the 
right).  The  oxalic  diathesis  is  variously 
regarded  either  as  being  allied  to  the 
lithic  or  the  saccharine  diathesis — to 
gout  or  diabetes.  Its  causes  are  either 
indigestion,  exhaustion,  or  the  abuse  of 
saccharine  food  or  fermented  liquors. 
Attention  to  the  cutaneous  and  diges- 
tive functions,  the  regulation  of  the 
diet,  and  the  use  of  the  mineral  acids 
are  the  main  indications  of  treatment. 

Tlie  rarer  deposits  in  our  first  class 
are  the  uric  or  xantliic  oxide,  which 
closely  resembles  uric  acid,  and  the 
cystic  oxide  or  cystine,  which  in  external 
appearance  resembles  the  pale  lithates, 
and  under  the  microscope  appears  as  six-sided  prisms  superimposed  on 
each  other  into  a  mass.  This  seems  to  indicate  a  more  profound  dis- 
turbance of  health  than  the  other  deposits,  and  to  require  more  support- 
ing and  tonic  treatment. 

The  inorganic  deposits  are  the  phosphates  and  carbonates.  The  phos- 
phates of  soda  or  of  soda  and  ammonia  (alkaline  phosphates)  which  exist 
in  the  urine  are  perfectly  soluble  and  do  not  give  rise  to  deposits  or  con- 
cretions;  but  the  earthy  phosphates — those  of  lime  and  of  ammonia  and 
magnesia — are  insoluble  in  water,  and  when  set  free  from  their  solution 
in  the  urine  are  easily  thrown  down.  This  precipitation  is  readily  effected 
by  ammonia;  and  we  have  seen  above  (page  7'14)that  in  inflammation  of 
the  bladder  urea  is  converted  into  carbonate  of  ammonia  by  the  agency 
of  the  mucus  secreted  by  the  bladder.  Thus  a  deposit  of  phosphates  is 
constant  in  inflammation  of  the  bladder,  and  any  of  the  numerous  causes 
which  diminish  or  destroy  the  proper  proportion  of  acid  in  the  urine,  as 
inflammation  of  the  kidney,  spinal  injury  or  disease,  the  ingestion  of  large 
quantities  of  alkali,  nervous  exhaustion,  and  many  other  morbid  states 
may  produce  phosphatic  urine. 

Fho^'phate  of  Lime. — The  deposit  of  phosphate  of  lime  generally  occurs 
as  a  white  cloudy  mass,  often  mistaken  for  mucus  or  muco-pus,  and  as  it 
is  precipitated  by  heat  it  is  often  hastily  confounded  with  albumen  ;  but 
the  precipitate  is  redissolved  by  acids.  It  is  generally  amorphous  under 
the  microscope,  but  it  is  also  found  (especiall}-  after  standing)  in  the  form 
of  splicrules,  which  may  coalesce  into  a  dumb-bell  or  rosette-like  form,  or 
of  oblique  hexagonal  prisms.  (Fig.  357.) 

The  trijjle  phosphate  of  ammonia  and  magnesia  forms  large  and  very 


Oxalate  of  lime  deposits. 


KINDS    OF    CALCULI. 


803 


conspicuous  crystals  in  the  form  of  triangular  prisras,  with  truncated  ex- 
tremities, or  of  foliaceons  or  stellate  prisms.  The  urine  is  often  very  fetid, 
frequently  acid  or  neutral.  (Fig.  358.) 


Fig.  358. 


Phosphate  of  lime. 


Triple  phosphate. 


Both  kinds  of  phosphatic  deposit  may  be  mixed  in  the  urine,  as  they 
so  commonly  are  in  the  formation  of  the  stone. 

Garhonate  of  Lime. — The  carbonate  of  lime  is  a  rare  deposit,  which 
still  more  rarely  collects  into  a  calculus.  Under  the  microscope  the  de- 
posits may  sometimes  be  seen  as  minute  spherules,  which  adhere  together 
something  like  a  drumstick. 

These  are  the  ordinaiy  prismatic  deposits,  but  the  student  must  learn 
also  to  recognize  the  various  other  deposits  found  in  the  urine,  such  as 
the  epithelium  of  the  kidney  or  bladder,  blood-cells,  pus-globules,  casts 
of  the  renal  tubes,  spermatozoa,  and  the  various  substances  which  are 
found  in  decomposing  urine.  It  is  most  important  to  detect  the  pres- 
ence of  blood-globules,  and  still  more  so  that  of  renal  casts,  as  proof  of 
disease  of  the  kidneys. 

The  kinds  of  calculi  correspond  in  a  great  measure  to  those  of  the 
deposits.  They  are  commonly  formed  in  the  kidney,  and  come  down 
into  the  bladder,  where  they  grow,  and  sometimes  to  an  enormous  size. 

Fig.  359.  Fig.  .360. 


Fig.  359. — Urate  of  ammonia  calculus  from  a  child,  aged  five.  It  contains  a  little  uric  acid,  and  traces 
of  earthy  phosphates  disposed  in  layers. — From  one  of  Mr.  Poland's  plates. 

Fig.  360. — Uric  acid  calculus.  The  external  part  shows  the  laminated,  the  internal  the  foliaceous  ap- 
pearance. In  the  latter  situation  some  oxalate  of  lime  is  mixed  with  the  uric  acid. — From  a  plate  in 
Mr.  Poland's  essay,  after  a  calculus  in  the  Museum  of  the  College  of  Surgeons. 


804 


CALCULUS. 


Sometimes  the}^  form  in  tlie  bladder  spontaneously,  and  at  other  times 
are  deposited  round  a  foreign  body. 

Lithate  or  ui-ate  of  ammonia  seldom  forms  an  entire  calculus  except 
in  children,  though  it  is  often  found  as  a  deposit  in  the  alternating  cal- 
culi. Urate  of  ammonia  calculi  are  of  a  whitish  color,  and  usually  are  of 
an  amorphous  non-laminated  appearance. 

Lilhic  Acid. — The  lithic  or  uric  acid  is  the  commonest  of  all  forms  of 
pure  calculi.  It  is  of  a  very  hard  consistence,  and  usually  of  a  dark-red 
or  brownish  color,  though  often  the  nucleus  is  pure  white.  The  surftice 
is  tolerabl}'  smooth  in  most  cases.  On  section  it  is  laminated  or  radiat- 
ing (foliaceous).  The  laminated  stones  when  broken  are  apt  to  separate 
into  hard  sharp  fragments  very  liable  to  wound  or  irritate  the  bladder 
and  urethra. 

Oxalate  of  Lime. — The  oxalate  of  lime  calculus  is  believed  to  be  the 
next  in  frequency  after  the  uric  acid.     Its  peculiar  form  has  given  it  the 


Fig.  361. 


Fig.  362. 


Fig.  361. — External  view  of  a  mulberry  calculus. 

Fig.  362. — Oxalate  of  lime,  or  n  ulberry,  cajculus,  showingits  internal  arrangement  "  in  an  imperfect 
laminated  manner,  like  fortification  agate,"  and  the  deposit  of  a  white  material,  doubtless  phosphates 
in  portions  of  its  interior. — From  one  of  Mr.  Poland's  plates. 


name  of  the  mulberry  calculus,  from  the  number  of  small  knobs  or  pro- 
jections which  are  found  on  its  exterior,  and  which  certainly  present  a 
remarkable  resemblance  to  a  mulberry,  and  this  is  increased  by  its  color, 
which  usually  "  varies  from  a  gray  to  a  rich  brown  or  almost  black. " 
This  calculus  forms,  of  course,  in  acid  urine,  but  it  often  sets  up  a  good 
deal  of  irritation,  and  then  the  urine  becomes  alkaline,  and  phosphates 
are  deposited  on  the  exterior  of  the  stone. 

As  rarer  varieties  of  oxalate  of  lime  calculi  are  mentioned  "  hempseed  " 
calculi,  small  smooth  bodies  found  in  considerable  numbers  in  the  kidney, 
and  the  crystalline  calculi  of  oxalate  of  lime,  which  are  more  or  less 
white. 

Xanthic  and  Cystic  Oxide. — The  xanthic  oxide  and  the  cystic  oxide 
calculi  are  extremely  rare ;  of  the  former,  indeed,  only  four  specimens 
were  known  to  Mr.  Poland.  The  cystic  oxide  calculus  is  not  quite  so 
rare.  It  is  found  in  the  kidney,  is  often  multiple,  and  there  seems  some 
hereditary  predisposition  to  its  formation.  It  is  distinguished  by  its 
waxlike  lustre  on  fracture,  by  its  containing  a  good  deal  of  sulphur,  and 
by  its  changing  color  with  age  from  a  pale  yellow  to  brown,  gray,  or 
green. 

Phosphate  of  lime  calculi  are  chiefly  found  deposited  around  a  nucleus 
of  some  other  substance,  which  may  be  a  lithic  acid  or  oxalate  of  lime 
calculus,  or  may  be  a  foreign  liody.  It  is  usually  of  vesical  origin,  and 
forms  a  confused  mass,  not  laminated,  but  "resembling  mortar,  or  a 


TESTS    FOR    CALCULI. 


805 


granular  semi-crystalline  powder,  enveloped  in  a  tenacious  mucus." 
There  are  the  "bone-earth"  calculi;  but  there  are  others  of  renal  origin, 
consisting  of  neutral  phosphate  of  lime,  which  are  "  pale  brown,  with  a 
smooth  polished  surface  regularly  laminated." 

Triple  Phosphate. — The  triple  phosphate  does  not  very  commonly  form 
a  calculus  by  itself.  There  are  only  three  specimens  in  the  Museum  of 
the  Royal  College  of  Surgeons,  and  one  or  two  at  Guy's  Hospital,  one 
of  which  is  figured  by  Mr.  Poland,  a  remarkable  specimen,  in  which  the 
triple  phosphate  has  been  deposited  round  a  piece  of  tobacco-pipe. 

Fumble  Calculus. — But  the  majority  of  phosphatic  calculi  are  of  the 
mixed  kind,  and  these  mixed  phosphatic  calculi  have  the  remarkable 
property  of  melting  in  the  blowpipe  flame,  from  which  circumstance  the 
concretion  has  received  the  name  of  the  "  fusible  calculus." 

Alternating  Calculi. — Many  calculi  are  of  the  "alternating"  variety, 
in  fact,  few  are  absolutely  pure;  but  in  those  properly  called  alternating. 


Fig.  363. — Phosphate  of  lime  calculus,  formed  round  a  nucleus  of  lithic  acid,  showing  the  laminated 
variety  of  the  phosphatic  calculus.— After  one  of  Mr.  Poland's  plates. 

Fig.  364.— Alternating  calculus.  The  nucleus  is  urate  of  ammonia,  mixed  with  oxalate  of  lime;  this 
is  followed,  tirstly,  by  oxalate  of  lime,  secondly  by  uric  acid,  and  lastly  by  alternate  layers  of  urate  of 
ammonia  and  earthy  phosphates. — After  Poland. 


the  condition  of  the  urine  has  varied  during  the  period  of  growth  of  the 
stone,  so  that  the  calculus  is  composed  of  definite  concentric  layers  of 
different  deposits  alternating  with  each  other.  In  a  very  great  majority 
of  cases  the  external  layers  are  formed  of  the  phosphates  ;  and  phosphatic 
calculi  are  very  seldom  succeeded  by  any  other  form. 

Carbonate  of  lime  calculus  is  exceedingly  rare  in  the  bladder,  but  the 
small  concretions  which  are  often  found  in  the  ducts  of  the  prostate  some- 
times consist  almost  entirely  of  this  substance,  and  are  usually  exceed- 
ingly numerous. 

Pseudo-calculi. — There  are  various  forms  of  pseudo-calculus,  or  con- 
cretions of  organic  matter.  These  are  the  fibrinous,  consisting  of  con- 
densed fibrin  or  albumen  ;  the  urostealith,  consisting  of  small  collections 
of  some  resinous  or  fatty  matter  ;  and  "  blood  calculi,"  composed  of  the 
remains  of  blood-clot,  with  some  phosphate  of  lime.  But  their  occurrence 
is  so  very  exceptional  that  they  are  of  little  practical  importance. 

Tests  for  Calculi. — The  following  table  was  drawn  up  by  Dr.  Bence 
Jones  as  containing  the  easiest  and  most  practical  directions  for  the 
chemical  examination  of  urinary  calculi : 


806 


CALCULUS. 


A.   Destroj'ed  by  heat ;  combustible;  leaving  only  a  small  residue. 

\.   Become  red  on  the  addition  ofnitric  acid,  and  form  a  murexide. 

a.  Soluble  in  carbonate  of  potash,  evolvinf)-  no  ammonia;  soluble 
in  caustic  ammonia  or  potash  ;  on  the  addition  of  an  excess  of  acid 
crystallizes  in  angular  crystals,  not  soluble  in  water. 

~b.  yoluble  in  carbonate  of  potash,  evolving  ammonia;  soluble 
in  water  when  boiled  ;  solution  in  water  with  a  few  drops  of  am- 
monia, when  evaporated,  crystallizes  in  needles. 

2.  Do  not  become  red  on  the  addition  of  nitric  acid. 

a.  Soluble  in  ammonia,  not  crystallizing  when  evaporated  ;  in- 
soluble in  carbonate  of  potash;  dissolves  without  effervescing  in 
nitric  acid,  leaving  a  lemon-colored  residue;  soluble  in  strong 
sulphuric  acid,  not  precipitated  by  dilution. 

I).  Soluble  in  ammonia,  crystallizing  in  six-sided  plates  when 
evaporated;  soluble  in  strong  caustic  potash;  the  solution  when 
boiled  for  a  few  moments,  on  the  addition  of  a  drop  of  dilute  ace- 
tate of  lead,  gives  sulphuret of  lead. 

c.  "With  difficulty  soluble  in  ammonia,  not  crystallizing  ;  with 
nitric  acid  becomes  bright  yellow;  solution  in  caustic  potash  pre- 
cipitable  by  acetic  acid  in  an  amorphous  form  ;  emits  an  odor  of 
burnt  feathers  on  ignition. 

B.   Not  destroyed  by  heat ;  non-combustible  ;  leaving  a  considera- 
ble residue. 

1.  Soluble  with  hydrochloric  acid;  effervesces  before  heating  ; 
soluble  in  mineral  acids  with  effervescence;  solution  in  acid  when 
neutralized  gives  a  precipitate  with  carbonated  alkalies  and  oxalate 
of  ammonia  ;  soluble  in  dilute  acetic  acid  with  effervescence. 

2.  Soluble  with  hydrochloric  acid;  effervesces  after  heating; 
soluble  in  mineral  acids  without  effervescence;  solution  in  acid 
when  neutralized  gives  a  white  precipitate  with  carbonated  alkalies 
and  oxalate  of  ammonia;  insoluble  in  acetic  acid  ;  decomposed  by 
strong  sulphuric  acid,  yielding  carbonic  acid  and  carbonic  oxide; 
and  when  boiled  with  carbonate  of  soda,  oxalate  of  soda  is  found 
in  the  solution  and  precipitated  by  chloride  of  calcium. 

3.  Soluble  with  hydrochloric  acid  ;  do  not  effervesce  either  before 
or  after  heating. 

a.  Solution  in  acid  with  excess  of  ammonia  gives  a  white  crys- 
talline precipitate;  with  half  its  bulk  of  phosphate  of  lime  (bone- 
earth)  is  very  fusible  before  the  blowpipe,  and  gives  off  an  ammo- 
niacal  odor  ;  dissolves  in  acetic  acid  without  effervescence. 

h.  Solution  in  acid  with  excess  of  ammonia  gives  an  amorphous 
precipitate;  with  twice  its  bulk  of  phosphate  of  ammonia  and 
magnesia  is  very  fusible  before  the  blowpipe. 

c.  Solution  in  acid  with  excess  of  ammonia  gives  a  white,  partly 
crystalline,  partly  amorphous  precipitate;  without  addition  easily 
fusible  before  the  blowpipe. 

4.  Not  acted  upon  by  acids  or  alkalies;  fused  with  twice  its  bulk 
of  carbonate  of  soda  forms  glass. 


Uric  acid. 

Urate  of 
Ammonia. 


I   Uric  or 

I   Xanthic  oxide. 

J 

(Cystic  oxide  or 
Cystine. 


Fibrinous. 


Carbonate  of 
Lime. 


I   Oxalate  of 
!   Lime. 


Phosphate  of 
I  Ammonia  and 
Magnesia. 

Phosphate  ot 
Lime. 

Mixed 
Phosphates. 

Silica. 


Calculus  in  the  bladder  is  a  complaint  which  affects  all  ages  and  both 
sexes,  but  by  no  means  equally.  Males  are  far  more  liable  to  be  affected 
than  females  at  all  periods  of  life.  This  seems  due  chiefly  to  the  differ- 
ences in  the  urethra  of  the  two  sexes :  for  although  at  a  late  period  of 
life  we  could  suppose  that  differences  in  habits  might  account  for  it,  yet 
no  such  cause  can  be  imagined  in  infancy,  where,  however,  the  exemption 
of  females  is  quite  as  striking.  And  renal  calculus,  which  is  the  first 
stage  of  most  cases  of  vesical  calculus,  is  common  enough  in  the  female. 
The  cause  of  stone  is  at  present  unknown.  It  is  far  more  common  in 
some  parts  of  England  than  in  others,  and  far  more  common  in  some 
foreign  countries  than  in  any  part  of  England  ;^  but  the  reason  for  the 

'  So  frequent  is  it  in  the  Northwestern  Provinces  of  India,  that  I  have  been 
assured  by  a  surgeon  stationed  there  that  he  has  operated  eight  times  in  the  same  day. 


SOUNDING     FOR    STONE.  807 

difference  is  not  apparent.  If  there  is  any  determining;  cause  in  either 
tlie  air,  water,  diet,  or  habits  of  the  natives  of  the  affected  districts  it  has 
not  as  yet  been  satisfactorily  pointed  out.  Sedentary  habits,  indulgence 
in  acid  intoxicating  drinks,  and  all  other  causes  which  favor  the  deposit 
of  uric  acid  or  oxalate  of  lime  in  the  urine  may,  of  course,  lead  to  their 
deposit  in  such  quantity  as  to  form  a  stone.  Phosphatic  stones  also  form 
in  the  kidney  under  any  conditions  which  increase  the  elimination  of 
phosphates,  and  in  the  bladder  from  any  inflammatory  condition,  espe- 
cially when  a  nucleus  is  present  on  which  the  phosphates  may  be  deposited ; 
but  why  stone  should  form  in  little  children  who  seem  to  have  no  reason 
for  any  such  formation,  why  it  should  be  so  comparatively  common  in 
the  children  of  the  poor  and  almost  unknown  in  those  who  are  better  fed 
and  tended,  and  why  it  should  prevail  among  children  in  one  district 
while  it  is  hardly  ever  seen  amongst  those  similarly  circumstanced  and 
fed  in  another  part  of  the  country,  are  questions  to  which  no  answer  has 
as  yet  been  given  which  has  commanded  universal  assent,  or  which  has 
assumed  any  practical  imi)ortanoe. 

Syv^ptoms. — The  symptoms  of  stone  in  the  bladder  are  very  much  the 
same  whatever  the  composition  of  the  stone  may  be,  though  the  rougher 
and  more  angular  the  stone,  the  more  pronounced  will  be  the  symptoms. 
They  are  pain  in  making  water,  referred  especially  to  the  end  of  the  penis, 
and  causing  children  to  be  always  pulling  the  prepuce,  so  as  to  produce 
considerable  elongation  of  it.  There  is  usually  pain  on  making  any  active 
exertion,  such  as  running  or  jumping,  or  jolting  in  a  carriage,  though 
this  is  not  always  the  case  ;  and  pain  is  often  absent  in  cases  of  ver}^  large 
stones.  Blood  in  the  water  is,  I  believe,  a  symptom  always  present  at 
some  period  or  other  of  every  case  of  stone,  though  it  may,  of  course,  be 
absent  at  the  time  when  the  case  is  under  examination.  There  is  often 
a  good  deal  of  straining  at  stool,  leading  to  prolapsus  of  the  rectum  in 
children.  Many  of  these  symptoms,  however,  may  be  produced  by  mere 
irritation  of  the  bladder,  and  the  evidence  of  the  sound  is  necessary  be- 
fore we  can  pronounce  definitely  on  the  presence  of  stone.  And  even 
this  is  not  always  conclusive.  There  may  be  a  stone,  but  from  some 
accidental  implication  in  the  walls  of  the  bladder,  or  from  its  being  con- 
tained in  a  cyst  (as  in  Fig.  375),  the  sound  may  fail  to  strike  it.  The 
latter  is  a  very  rare  complication,  but  the  former  is  common  enough. 
We  constantly  see  patients  who  Imve  been  sounded,  and  the  surgeon  has 
felt  the  stone  ;  but  on  proceeding  to  operate  he  cannot  feel  it.  Believing 
that  either  the  stone  has  been  passed  by  the  urethra,  or  that  he  has  made 
a  mistake,  he  puts  off  the  operation,  and  the  next  time,  or  even  after 
several  such  trials  (I  have  known  as  man3'  as  five),  the  stone  has  been 
felt  and  removed.  When  therefore  the  symptoms  are  well  marked,  the 
surgeon  should  not  too  confidently  pronounce  that  there  is  no  stone, 
merely  because  he  cannot  feel  it.  Again,  there  have  been  cases  (and  I 
confess  it  has  occurred  to  myself,  even  when  assisted  by  veiy  able 
colleagues)  in  which  the  sensation  communicated  to  the  sound  by  some- 
thing lying  outside  of  the  bladder  has  so  exactly  resembled  that  of  a 
stone  that  the  bladder  has  been  cut  into  and  no  stone  found.  This 
mortifying  error  is  caused  by  the  sound  striking  some  point  of  bone,  I 
believe  generally  the  spine  of  the  ischium,  others  say  the  sacrovertebral 
angle.  Bearing  this  in  mind,  it  is  unsafe,  I  think,  to  operate  for  stone 
unless  as  well  as  the  sensation  the  ring  of  the  stone  has  been  heard,  or  the 
stone  has  been  felt  (as  it  sometimes  may)  with  the  finger  in  the  rectum. 
The  ring  or  sound  communicated  to  the  instrument  by  striking  a  stone  is 
of  course  decisive.     It  varies  in  loudness.     When  a  large  hard  stone  (as 


808  CALCULUS. 

of  uric  acid)  is  fairly  struck  with  tlie  point  of  tiie  sound  it  rings  so  loudly 
as  to  be  audible  at  a  good  distance ;  wlien  the  calculus  is  soft  and  phos- 
phatic,  or  the  sound  cannot  be  moved  freely  in  the  bladder,  the  ring  will 
not  be  so  distinct.  A  few  words  may  be  useful  about  sounds.  The  in- 
strument in  common  use  is  a  solid  polished  steel  bougie,  the  shape  of  a 
common  catheter,  made  in  one  piece  with  a  smooth  flat  handle.  It  has 
the  disadvantage  that  in  consequence  of  its  comparativel}'  large  curve, 
the  point  is  directed  so  far  upwards  that  it  may  ride  over  the  stone  and 
fail  to  strike  it ;  especially  if  there  be  any  enlargement  of  the  prostate, 
behind  which  the  stone  lies  in  a  kind  of  pouch.  Then  again  it  is  often 
desirable,  if  the  stone  has  not  been  hit  at  once,  to  vary  its  position  by 
emptying  the  bladder,  or  on  the  other  hand  to  distend  the  bladder  with 
water  and  so  disengage  its  walls  from  the  stone.  All  these  desiderata 
are  accomplished  by  the  beaked  catheter-sound.  This  is  a  catheter  with 
a  small  bore,  and  an  enlarged  or  "  lobbed  "  extremity.  It  has  the  length 
and  the  curve  of  a  lithotrite,  i.  e.,  it  is  straight  till  within  about  1^  inches 
of  its  end,  where  it  is  turned  up,  so  to  form  a  "beak."  There  is  a  stop- 
cock near  its  handle,  and  the  handle  itself  is  a  sort  of  flat  shield  on  which 
the  flnger  and  thumb  can  easil_y  rest,  and  can  accurately  appreciate  sensa- 
tions from  any  object  which  the  beak  may  touch.  The  smallness  of  its 
shaft  as  compared  with  its  end  render  it  much  more  movable  in  the 
urethra  and  neck  of  the  bladder  than  the  common  sound  is.  If  introduced 
with  the  stopcock  closed  it  acts  as  a  common  sound,  but  its  small  end  can 
be  more  easily'  applied  to  ever}'  part  of  the  bladder,  or  can  be  reversed  so 
as  to  feel  behind  the  prostate.  By  opening  the  stopcock  it  is  converted 
into  a  catheter,  and  as  the  bladder  is  emptied  the  stone  often  drops  down 
and  the  sound  touclies  it,  and  then  if  the  surgeon  thinks  right  an  inject- 
ing syringe  can  be  applied  and  tlie  bladder  filled  to  distension  and  care- 
fully investigated. 

Calculi  are  often  numerous,  and  it  is  very  desirable  to  ascertain  if 
possible  with  some  approach  to  precision  what  the  size  of  the  stone  is, 
and  whether  there  is  only  one  or  several  in  the  bladder.  An  experienced 
surgeon  will  usually  form  a  tolerably  correct  idea  of  the  size  of  a  stone 
from  striking  it,  and  examination  with  the  sound  will  sometimes  enable 
him  also  to  guess  at  the  presence  of  more  than  one  stone,  but  the  only 
sure  way  to  ascertain  either  of  these  particulars  is  to  sound  with  the 
lithotrite.  By  catching  the  stone  in  one  or  two  positions  an  accurate 
idea  of  its  size  is  obtained,  and  often  the  surgeon  having  one  stone  in 
the  grasp  of  the  forceps  can  distinctly  ascertain  the  presence  of  another. 

The  endoscope,  a  tube  illuminated  by  a  lamp  at  its  extremit}'  and  closed 
by  a  piece  of  glass,  was  introduced  some  3"ears  since  as  a  means  of  look- 
ing down  the  urethra,  and  seeing  the  face  of  a  stricture  or  the  wall  of  the 
bladder,  and  some  surgeons  have  professed  to  be  al)le  thus  to  determine 
the  presence,  nature,  size,  and  number  of  foreign  substances  in  the  blad- 
der;  but  the  dilliculty  of  the  investigation  is  so  great,  and  the  portion  of 
tissue  seen  at  one  time  is  so  minute,  that  I  believe  I  am  not  wrong  in 
saying  that  the  endoscope  is  now  generally  disused. 

Terminalions  of  Stone. — If  the  symptoms  of  stone  be  allowed  to  per- 
sist unrelieved  the  patient  usually  dies  from  general  disorganization  of 
the  urinary  organs,  the  result  of  obstruction  and  inflammation ;  sometimes 
from  pyajmia  brought  on  by  phlebitis  of  the  veins  around  the  prostate; 
sometimes  by  ulceration  and  perforation  of  the  bladder.^     In  any  case, 

'  Stones  have  been  known  to  travc:l  by  ulceration  tli rough  the  bladder  into  the 
scrotum  or  perineum,  from  which  they  have  been  extracted  by  an  incision. 


LATERAL    LITHOTOMY.  809 

the  mode  of  death  is  a  very  painful  one,  and  it  is  desirable  to  attempt 
the  removal  of  the  stone  even  in  cases  where  the  surgeon  feels  that  there 
is  but  little  chance  of  success. 

Operations  for  Stone. — Two  methods  only  are  at  present  known  for 
I'eraoving  calculi.  Chemical  solvents  have  been  sought  for  ceuturies  ; 
sometimes  it  has  been  believed  tliat  the  discovery  has  at  last  been  made; 
the  electric  current  also,  it  has  been  imagined,  might  be  used  for  their 
disintegration ;  but  hitherto  all  such  plans  have  failed,  and  though  it 
seems  most  probable  that  ultimately  stones  will  be  dissolved  iu  the 
bladder,  we  have  at  present  to  deal  with  lithotomy  and  lithotrity. 

Comparison. — The  preference  of  one  method  to  the  other  is  regulated 
on  some  such  general  rules  as  these : 

1.  In  male  children  litliotomy  is  very  successful ;  lithotrity,  on  the  con- 
trary, is  not  ver}'  appropriate,  in  consequence  of  the  small  size  of  the 
urethra,  and  the  irritability  of  the  bladder.  Hence  most  surgeons  re- 
ject lithotrity  absolutely  in  childhood,  and  if  it  is  ever  to  be  practiced  it 
should  be  only  when  the  stone  is  judged  to  be  so  small  that  it  may  easily 
be  pulverized  at  one  sitting.    B3'  childhood  I  mean  any  age  up  to  fifteen. 

2.  Lithotrity  is  not  to  be  recommended  in  cases  of  tight  stricture.  It 
is  true  that  if  the  symptoms  are  not  urgent  the  stricture  may  tirst  be 
cured  ;  still,  stricture  is  often  associated  with  an  irritable  condition  of 
the  urethra  and  bladder,  highly  unfavorable  for  the  success  of  the  crush- 
ing process.  In  slighter  cases  of  stricture  there  is  not  the  same  ob- 
jection. 

3.  Lilhotrit}-  has  no  chance  of  success  in  patients  suffering  from  ex- 
tensive renal  disease.  It  is  true  that  such  patients  usually  die  after 
litliotom}',  but  if  it  is  judged  necessary  to  perform  any  operation  at  all, 
lithotomy  is  on  the  whole  the  best. 

4.  In  cases  of  very  large  or  very  numerous  stones  the  lithotrite  may 
perhaps  not  have  room  to  work.  Such  cases  must  be  dealt  witli  by 
lithotomy,  and  even  when  the  stone  does  not  fill  the  bladder,  but  still  is 
so  lai-ge  that  it  would  require  numerous  sittings,  and  the  patient  is  at  all 
irritable,  it  is  doubtful  which  is  best.  The  composition  and  hardness  of 
the  stone  become  now  questions  of  much  importance,  since  a  large  con- 
cretion can  be  rapidly'  broken  up  if  it  consists  chiefly  of  soft  phosphates 
and  the  do'bris  will  pass  with  but  little  pain,  whereas  a  uric  acid  or  oxal- 
ate of  lime  stone  is  broken  into  sharp  fragments,  many  of  them  of  con- 
siderable size,  very  apt  to  lodge  in  the  urethra  or  to  inflame  the  coats 
of  the  bladder. 

5.  Iu  the  female,  as  a  rule,  lithotrity  is  easy  if  the  stone  be  small,  but 
in  larger  concretions,  and  in  the  case  of  children,  lithotomy  may  become 
necessary. 

Lateral  Lithotomy. — The  operations  of  lithotomy  are  numerous.  The 
one  in  almost  universal  use  in  England  is  the  lateral  operation,  which 
accordingly  I  shall  first  describe. 

The  pei'ineum  is  to  be  shaved  if  necessary.  The  staff  is  then  to  be 
passed,  and  the  patient  is  to  be  drawn  to  the  edge  of  the  table  with  the 
buttocks  slightly  projecting  over  the  edge,  the  feet  aud  hands  secured 
together,  the  hand  grasping  the  dorsum  of  the  foot.  Thej'  are  secured 
either  with  the  garters  or  shackles.'     The  kuees  are  held  apart,  the  pa- 

^  The  "  liihotomy  position  "  is  used  in  many  operations  on  the  genital  organs  both 
of  the  male  and  female.  Three  methods  are  in  use  for  maintaining  the  patient  in  this 
attitude,  i.  e.,  in  the  sitting  posture  with  the  feet  grasped  in  the  hands,  and  the  knees 
widely  separated.      L  The  lithotomy  garters,  two  bandages  of  some   firm  webbing 


810 


CALCULUS. 


tient's  bod}'  kept  quite  perpendicular  to  the  table,  the  staff  held  vertical 
by  a  steady  assistant,  with  its  point  well  in  the  bladder,  and  if  possible 
restino:  on  the  stone.      Then  an  incision   is  made  from   the  left  side 


Fig.  365. 


A  dissection  of  the  perineum,  showing  the  position  of  the  bulb  of  the  urethra  and  the  floor  of  the 
ischio-rectal  fossa.  (After  Pirrie.)  The  incision  in  lateral  lithotomy  is  commenced  just  over  the 
bulb,  but  the  operator  makes  that  part  of  the  incision  superficial,  so  that  the  bulb  and  its  artery- 
escape.  He  divides  the  floor  of  the  ischio-rectal  fossa  (the  anterior  fibres  of  the  levator  ani),  and 
reaches  the  membranous  part  of  the  urethra,  as  shown  in  the  next  figure. 

of  the  central   point  of  the   raphe   to    the  point  midway  between   the 
anus  and  the  tuber  ischii  and  drawn   backwards  into  the  ischio-rectal 


about  eight  yards  long  and  terminating  in  a  loop.  The  whole  bandage  is  first  passed 
through  the  loop,  and  into  the  loop  so  formed  the  forearm  is  passed,  and  it  is  drawn 
tight.  Then  the  hand  is  made  to  grasp  the  foot  and  the  bandage  is  wound  around 
them  in  successive  turns  of  figure  of  8,  and  the  end  firmly  pinned.  2.  The  "  shackles  " 
consist  of  a  h'ather  footpiece  securely  laced  over  the  ankle,  and  a  leather  band  around 
the  wrist.  To  the  footpiece  is  attached  a  ring  and  to  the  wristpicee  a  hook.  The 
pieces  are  put  on  while  the  patient  is  taking  the  anicsthelic,  and  when  he  is  insensi- 
ble he  is  put  in  proper  position,  and  the  hook  passed  into  the  ring.  3.  Mr.  Clover 
has  lately  invented  a  very  handy  crutch — a  piece  of  iron  about  a  foot  long,  ending  at 
either  side  in  a  bend,  to  which  a  strap  is  attached.  The  thighs  being  Hexed  on  the 
abdomen  and  abducted,  are  supported  by  the  bent  ends,  and  prevented  from  moving 
by  the  straps,  and  thus  are  kept  bent  and  open.  Of  the  three  plans  the  shackles  are 
much  superior  to  the  lithotomy  garters,  bfing  less  troublesome  to  apply  iind  more 
secure  from  slipping.  Mr.  Clover's  crutch  is  very  easily  and  quickly  ajjplic^d,  and 
answers  its  purpose  very  well ;  but  does  not,  I  think,  keep  the  patient  quite  so  steady. 
When  none  of  these  apparatus  is  at  hand  common  bandages  will  do  very  well,  ap- 
plied like  the  lithotomy  garters. 


LATERAL    LITHOTOMY. 


811 


region  as  far  as  is  judged  necessary.  This  incision  should  divide  the 
skin  and  superficial  parts.  The  surgeon  then  puts  his  left  forefinger 
into  the  upper  angle  of  the  wound,  deepens  the  incision  till  he  can  dis- 
tinctly feel  the  groove  of  the  staff,  puts  the  point  of  his  knife  into  the 
groove,  and  then  pushes  the  knife  on  till  it  reaches  the  bladder.  Having 
reached  the  bladder  he  withdraws  the  knife,  enlarging  the  wound  a  little 
as  he  does  so,  by  lateralizing  the  edge  of  the  knife  and  pressing  it  a  little 
on  the  parts.  Then  he  pushes  his  left  forefinger  along  the  concavity  of 
the  staff  till  it  reaches  the  bladder,  which  it  will  do  if  he  have  made  the 
wound  free  enough.  Having  placed  his  forefinger  on  the  stone  he  with- 
draws the  staff,  and  passes  the  forceps  along  the  upper  side  of  his  finger. 
When  the  forceps  have  reached  the  bladder  he  opens  them,  and  then  a 
gush  of  urine  occurs.  The  stone  is  often  thus  carried  into  the  grasp  of  the 
forceps,  otherwise  it  must  be  caught  by  them  (taking  care  that  the  coats 
of  the  bladder  are  not  caught  also)  and  withdrawn  in  the  axis  of  the  pelvis. 
If  the  stone  is  not  very  large  there  is  no  difficulty  about  this ;  but  if  it 
is,  gradual  dilatation  of  the  wound  with  the  stone  and  forceps  by  a  sort 
of  corkscrew  motion  is  necessary.  After  the  stone  has  been  removed 
the  bladder  should  always  be  carefully  searched  to  see  whether  there  is 
another. 

A  few  words  about  each  step  of  this  operation  is  necessary. 

In  the  first  place  it  is  essential  that  the  stone  should  be  felt  with  the 
staff  itself  upon  which  the  surgeon  is  to  make  his  incision.     It  is  not 

Fig.  366. 


The  second  step  of  the  operation  for  stone.    The  knife  entering  the  groove  of  the  stafF  in  the  mem- 
branous portion  of  the  urethra. — After  Pirrie. 

enough  that  a  calculus  has  been  felt  on  a  previous  occasion,  nor  even 
with  another  instrument  while  the  patient  is  on  the  table.     In  order  to 


812  CALCULUS. 

be  certain  that  the  stone  is  really  present  and  the  staff"  properly  lodged 
in  the  bladder,  the  stone  shonld  be  struck  with  the  staff  itself. 

As  to  the  shape  of  the  staff  there  are  different  fashions.  Most  sur- 
geons use  a  staff"  of  the  same  shape  as  a  catheter.  At  Guy's  Hospital,  the 
"straight"  start'(which,  however,  is  not  accurately  straight),  is  preferred, 
the  supposed  advantage  being  that  there  is  less  risk  of  the  knife  slipping 
out  of  the  groove.  But  as  tliis  ought  never  to  happen  in  careful  hands, 
and  the  straight  staff"  is  more  diflicnlt  to  find  in  the  perineum,  I  fail  to 
see  any  advantage  which  it  has ;  nor  can  I  see  the  necessit}'^  of  making 
the  groove  on  the  side,  instead  of  in  the  centre  of  the  staff.  The  rectan- 
gular staff"  was  for  some  time  in  favor  with  some  good  surgeons,  but,  I 
believe,  is  now  generally  disused.  It  has  the  great  drawback  of  being 
very  awkward  to  pass  and  very  liable  therefore  to  make  a  false  passage, 
a  drawback  very  imperf"ectly  counterbalanced  by  its  one  advantage,  tiiat 
its  angle  is  easily  found  in  the  perineum.^  As  for  the  position  of  the 
staff"  in  the  bladder,  some  surgeons  direct  that  it  should  be  inclined  to 
the  left  side,  in  order  to  pi'esent  its  groove  more  readily  to  the  operator. 
This  seems  to  me  a  matter  of  indiff'erence  ;  the  main  point  is  that  it  shall 
be  steady  and  not  slip  out  of  the  bladder,  and  this,  I  think,  is  best  se- 
cured if  the  assistant  liolds  it  vertically,  hooking  it  against  the  pubes. 

The  main  dangers  in  the  operation  are  as  follows : 

Danger)^  of  the  Operation.— There  ma}^  be  unavoidable  haemorrhage 
from  some  unusual  distribution  of  the  arteries.  This  proceeds  generally 
from  the  internal  pudic  furnishing  an  accessory  internal  pudic,  instead 
of  bifurcating  in  its  usual  position  under  cover  of  the  ramus  of  the 
ischium,  or  from  an  abnormal  course  of  the  artery  of  the  bulb.  Again, 
ver}'  free  hfemorrhage  may  take  place  in  old  persons  from  the  veins  about 
the  prostate  and  neck  of  the  bladder.  The  only  thing  that  can  be  done 
is  to  tie  any  divided  artery  if  possible,  or  if  the  vessel  cannot  be  secured 
to  hasten  to  complete  the  operation,  and  then  plug  the  wound  with  "the 
petticoat  plug,"  i.e.,  a  large  catheter  or  tube  passed  through  a  piece  of 
stout  clotli  into  which  a  quantity  of  lint  is  pressed  sufficient  to  fill  and 
make  considerable  pressure  on  the  sides  of  the  wound.  Avoidable  luem- 
orrhage  proceeds  generally  from  the  artery  of  the  bulb  if  the  wound  be 
deepened  too  much  at  its  front  part,  for  it  must  be  recollected  that  the 
incision  commences  over  the  position  of  the  arterj^  But  in  children  this 
artery  is  so  small  that  its  division  is  of  no  consequence,  in  fact,  I  believe, 
that  it  is  almost  always  divided.  It  is  said  that  the  internal  pudic  may 
be  cut  if  the  incision  is  extended  too  far  outwards ;  but  this  seems  im- 
possible if  the  artery  occupies  its  natural  situation,  and  probablj'^  in  the 
cases  in  which  this  has  liappened  the  artery  has  been  abnormal.  The 
great  danger  in  lithotomy  is,  that  the  urethra  should  be  broken  across 
and  puslicd  before  the  finger  into  tlie  pelvis  ;  or  that  the  knife  should  leave 
the  groove  of  the  staff",  and  so  the  incision  be  m:ide  not  into  the  bladder, 
but  between  it  and  the  rectum.  In  either  case  the  surgeon  does  not  reach 
the  bladder,  and  I  have  seen  cases  in  which  an  inexperienced  lithotoniist 
under  tlicse  circumstances,  believing  that  he  had  reached  the  bladder, 
witlidrew  the  staff",  and  in  one  case  was  obliged  to  give  up  the  operation 
altogether;  in  another,  completed  it  by  the  help  of  a  senior  colleague, 
but  with  great  risk  and  difficulty.     This  is  avoided  by  making  the  inci- 

•  If  the  rectangular  staff  is  ever  to  be  used,  the  apparatus  invented  by  Dr.  Buchanan 
should  be  employed.  In  this  aii})aratu.s  aflcr  the  stafl"  is  lodged  in  the  bladder  a  di- 
rector is  fixed  on  to  it  which  t(!rminatcs  in  a  point.  This  point  pierc(^s  the  perineum 
and  is  r(!ceived  into  a  hole  in  the  angle  of  the;  staff.  The  surgeon  has  now  nothing 
to  do  but  follow  the  groove  of  the  director  straight  into  the  bladder. 


LITHOTOMY.  813 

sion  into  the  staff  free  enough  to  admit  the  finger,  and  never  letting  the 
point  of  the  knife  quit  the  groove  as  it  is  being  pushed  into  the  bladder, 
nor  taking  the  staff  out  till  the  finger  is  in  actual  contact  with  the  stone. 
One  of  the  great  difficulties  in  lithotom}'  in  little  children  is  to  make  the 
incision  large  enough  to  admit  the  finger  without  wounding  the  rectum 
or  other  parts  around.  Much  has  been  said  as  to  the  danger  of  incising 
the  whole  of  the  prostate  and  thus  laying  open  the  cellular  tissue  l)eneath 
the  rectovesical  fascia,  whereby  it  is  supi)osed  the  urine  from  the  bladder 
is  admitted  into  the  meshes  of  the  cellular  tissue,  infiltrating  it  and  pro- 
ducing diffuse  cellulitis.  This  doctrine  rests  on  high  authority,  yet  it 
has  been  much  questioned.  In  childi-en  the  whole  prostate  must  neces- 
sarily be  divided,  for  tho  gland  is  too  small  to  allow  an  entrance  to  the 
bladder  otherwise  ;  yet  children  never  suffer  from  the  diffuse  sui)puration 
which  is  supposed  to  be  the  result  of  such  division.  And  as  Sir  H. 
Thomi)son  has  justly  observed,  the  effect  of  the  passage  of  an  irritating 
fluid  like  urine  over  the  fibres  of  the  cellular  memiirane  would  be  to  close 
the  interstices  between  the  fibres,  not  to  open  them.'  It  is,  no  doubt, 
prudent  not  to  carry  the  deep  incision  farther  than  is  absolutel}'  neces- 
sary ;  yet  it  appears  to  me  safer  in  the  case  of  large  stones  to  make  a 
sufficient  incision  than  to  lacerate  the  prostate  and  the  neighboring  tis- 
sues, as  is  often  done  in  such  cases.  For  small  stones,  a  very  moderate 
incision,  dilated  by  the  forefinger,  suffices;  for  larger  calculi,  a  freer  cut 
is  required,  or  if  the  stone  sticks  in  the  incision  a  blunt-pointed  straight 
bistoury  may  be  passed  along  it,  and  the  constricting  parts  nicked  here 
and  there. 

When  the  finger  is  placed  on  the  stone,  the  latter  may  be  so  small  and 
smooth  as  not  readily  to  be  grasped  by  the  forceps.  The  scoop  is  then 
very  useful.  This  is  an  instrument  exactly  resembling  a  small  spoon 
with  a  very  long  handle.  It  is  slipped  under  the  stone,  which  is  held  in 
it  by  the  forefinger. 

When  the  operation  is  over  some  surgeons  always  pass  in  a  straight 
tube  which  is  tied  in  ;  but  this  is  not  necessary,  except  in  order  to  repress 
lu^morrhage,  as  stated  above. 

The  rectum  is  to  be  unloaded  before  the  operation,  and  will  then  almost 
certainly  escape  injury  if  the  surgeon  is  moderately  dexterous.  A  gentle 
purge  should  be  given  on  the  second  night  before  operation,  and  the  lower 
bowel  should  be  complete!}'  emptied  by  an  injection  exhibited  about  eight 
hours  before  the  operation.  This  will  both  unload  the  bowel  and  prevent 
the  patient  being  disturbed  for  a  day  or  two  afterwards.''  If  it  should 
happen  that  the  rectum  is  injured  the  wound  in  it  should  be  united  if  pos- 
sible, and  may  very  probably  heal,  otherwise  the  resulting  fistula  is  very 
intractable  (see  below). 

The  after-treatment  is  very  simple.  The  urine  runs  into  some  tow  or 
carded  oakum  placed  beneath  the  patient  and  frequently  changed  ;  and 
if  he  is  irritable,  he  is  to  be  kept  tolerably  under  the  infiuence  of  opium. 

Causes  of  Death  after  Lithotoviy. — The  main  causes  of  death  after 
lithotomy  are  pyaemia,  hfemorrhage,  peritonitis,  diffuse  inflammation,  and 

1  The  student  must  recollect  that  the  "  cellular"  tissue,  though  capable  of  being 
distended  into  cells  or  spaces,  yet  in  the  living  body  contains  no  such  spaces — all  its 
fibres  are  in  close  contact,  and  the  old  term  "cellular  membrane"  is  far  more  ex- 
pressive of  its  real  condition. 

2  In  children  the  rectum  often  protrudes  during  the  operation.  This  gets  it  more 
out  of  the  way,  and  the  advice  usually  given  to  repress  the  prolapsus  is  undoubtedly 
wrong. 


814  CALCULUS. 

sinking  from  renal  disease.  The  operation,  particularly  when  protracted, 
as  in  the  case  of  very  large  stone,  may  prove  fatal  by  the  immediate  shock. 
The  danger  of  the  operation  depends  mainly  on  three  things:  the  state 
of  the  general  health,  and  especially  of  the  urinary  organs  ;  the  age  of 
the  patient,  and  the  size  of  the  stone.  In  persons  of  almost  any  age, 
-who  are  of  sound  constitution,  aud  in  whom  the  kidneys  are  healthy  and 
the  bladder  not  extremely  degenerated,  lithotomy  is  a  very  successful 
operation.  In  children  death  is  very  rare;  the  small  proportion  (about  5 
per  cent,  on  an  average)  wlio  die  being  chiefly  weakly  infants  exhausted  by 
previous  suftering  or  laboring  under  visceral  disease.  But  when  the  stone 
is  of  large  size,  and  there  are  evidences  of  very  acute  inflammation,  that 
inflammation  has  usually  extended  to  the  ureters  and  kidneys,  and  any 
slight  injury  would  probaV)ly  prove  fatal,  still  more,  the  formidable  oper- 
ation by  wliich  alone  a  large  stone  can  be  removed.  The  inference  is  that 
no  delay  is  admissible  in  cases  of  stone.  When  the  symptoms  become 
more  accurately  known  to  the  public,  and  the  necessity  of  seeking  com- 
petent advice  at  an  early  period  is  generally  recognized,  stones  will  be 
disposed  of  when  of  small  size  by  lithotrity,  lithotomy  in  the  adult  will 
become  an  even  rarer  operation  than  at  present,  and  stone  will  be  only 
rarely  a  cause  of  death. 

Becto-vesical,  or  Recto  urethral  Fistula. — After  the  operation  for  stone, 
a  fistulous  communication  may  be  left  either  with  the  bladder  or  urethra. 
The  latter  is  far  more  common,  for  the  wound  in  the  neck  of  the  blad- 
der generally  heals,  and  the  patient  regains  the  power  of  retaining  his 
urine ;  but  it  passes  into  the  rectum  and  becomes  a  source  of  constant 
annoj'ance  and  irritation.  Recto-urethral fistula  occurs  also  (as  mentioned 
above)  from  prostatic  abscess,  though  rarely ;  and  I  have  known  it  follow 
on  too  free  incisions  for  anal  fistula.  The  cure  is  by  no  means  easy.  If 
the  catheter  can  be  passed  into  the  bladder  without  going  into  the  rectum, 
the  urine  should  be  drawn  off  in  this  way  every  time  the  patient  wants  to 
make  water ;  and  a  few  weeks'  perseverance  in  this  treatment  may  be 
successful — the  edges  of  the  fistula  being  stimulated  with  the  tinct.  lyttae 
or  the  galvanic  cautery.  But  unluckily,  it  is  only  in  rare  cases  that  this 
can  be  done.  A  plastic  operation  is  then  necessary  and,  of  all  other 
plastic  proceedings,  seems  to  me  one  of  the  most  disappointing.  It  may 
be  performed  in  one  of  two  ways.  The  patient  (under  chloroform  or  not) 
is  placed  in  the  prone  position  with  his  legs  separated  and  hanging  over 
the  table.  A  duckbill  speculum  in  the  rectum  exposes  the  fistula,  which 
is  to  be  pared  and  its  edges  united,  and  a  catheter  passed  into  the  bladder 
and  kept  open,  so  that  the  urine  shall  flow  out  constantly.  If  this  fails 
the  surgeon  may  lay  the  parts  freely  open  into  the  anus,  endeavor  to 
separate  the  urethra  from  the  rectum,  and  unite  the  tissues  over  a  cathe- 
ter passed  into  the  bladder,  so  as  to  close  the  urethra  and  leave  the  rectal 
wound  to  granulate.  I  have,  however,  treated,  and  seen  others  treat, 
these  fistuUe  after  lithotomy,  and,  I  confess,  with  very  little  success. 

Mecliav  Lithotomy. — The  lateral  operation  appears  to  me  to  be  the  best 
suited  for  all  ordinary  cases.  In  some  instances,  however,  where  the 
stone  seems  impacted  in  the  urethra  or  neck  of  the  bladder  (as  seen  in 
Fig.  377),  the  median  operation,  which  often  bears  the  name  of  Mr.  AUar- 
ton  in  consequence  of  his  having  revived  it,  and  recommended  its  general 
adoption,  may  be  preferred,  and  it  is  also  an  easy  and  ready  way  of  re- 
moving small  stones  in  childhood. 

A  grooved  staff"  is  passed  into  the  bladder ;  the  left  forefinger  in  the 


LITHOTOMY. 


815 


Fig.  3G7. 


rectum  feels  the  groove  just  as  it  disappears  in  the  prostate  gland.  The 
surgeon  plunges  the  point  of  his  knife 
into  the  groove,  at  or  near  this  point, 
holding  the  edge  upwards  and  taking 
care  not  to  perforate  the  rectum.  He 
pushes  the  knife  on  a  little  way  so  as 
first  to  nick  the  prostate  gland,  and  with- 
draws it,  making  at  the  same  time  a  free 
division  of  the  raphe  of  the  perineum, 
leaving  a  conical  wound  at  the  bottom 
of  which  the  groove  of  the  staff  is  ex- 
posed. A  director  is  then  passed  along 
the  groove  of  the  staft'  into  the  bladder, 
and  when  the  stone  lias  been  felt  with 
this  director  the  staff  may  be  withdrawn. 
A  pair  of  dilating  forceps  are  passed 
along  the  director,  and  the  wound  di- 
lated until  the  finger  passes  into  the 
bladder,  when  the  operation  is  completed 
in  the  usual  way. 

Other  Methods  of  Perineal  Lithotomy. 
— The  aim  of  the  operation  is  to  avoid 
the  danger,  or  supposed  danger,  of  in- 
cising the  prostate.  Its  drawback  is  the 
difficulty  of  removing  anything  like  a 
large  stone  through  the  wound  without 
a  most  injudicious  amount  of  violence. 
Other  surgeons  join  with  a  lateral  or 
median  incision  of  the  perineum  inci- 
sions into  the  prostate  gland,  made  by 

means  of  a  lithotome,  which  is  a  bistOUri    lithotomy  was  performed,  the  incision  being 

cache  with  one  or  two  blades,  made  to  "^"^^  '"  ''''  "'^'^'^°  ""^'  '"■  '"^  P'^""''"™ 
project  at  different  angles  so  as  to  incise 
both  lobes  of  the  prostate  horizontally 
(Boyer);  or  with  a  curvilinear  incision  on 
each  side  (Dupuytren) ;  or  horizontally 
on  one  side  and  obliquely  on  the  other 
(Senn) ;  or  obliquely  upwards  and  down- 
wards on  both  sides  (Vidal  de  Cassis). 

Such  operations  are  known  as  bilateral  lithotom}-.  Others,  again,  make 
the  incision  in  the  middle  line  of  the  perineum  while  incising  the  prostate 
with  the  knife  in  various  directions.  But  these  operations  are  little  if  at 
all  practiced  in  this  country,  experience  having  shown  to  the  satisfaction 
of  the  great  majority  of  surgeons  that  the  lateral  operation  is.  on  the 
whole,  the  best ;  as  affording  more  room  than  any  of  the  others  if  the 
stone  be  large,  and  being  equally  safe,  if  not  more  so,  when  it  is  small. 
It  is  true  that  it  has  its  difficulties  and  dangers,  but  they  seem,  on  the 
whole,  less  than  those  attending  on  the  other  methods. 

Rectal  Lithotomy. — It  remains  to  speak  of  two  plans  which  are  occa- 
sionally resorted  to,  viz.,  rectal  lithotomy,  and  the  hj'pogastric  or  high 
operation.  The  rectovesical  operation  is  now  only  used  in  this  country 
as  a  last  resource,  when  the  stone  is  too  large  to  come  through  the  ordi- 
nary incision,  and  the  operator  cannot  break  it,^  and  consists  merely  in 


A  bladder  displaying  several  large  sacculi, 
and  a  large  wound,  the  result  of  the  operation 
of  lithotomy.  One  of  the  sacculi  was  about 
half  as  large  as  the  bladder  itself. 

The  preparation  was  taken  from  a  hospital 
patient,  43  years  of  age.  He  had  for  many 
years  passed  sand  with  the  water.  He  had 
latterly  been  unable  to  retain  his  urine.  A 
stone  was  detected,  and    the  operation    of 


A  stone  of  great  size  was  found  fixed  near 
the  neck  of  the  bladder.  As  it  could  not  be 
got  out  entire,  it  was  broken  up  in  its  posi- 
tion with  strong  forceps,and  finally  extracted. 
The  fragments  of  stone  weighed  31  drachms, 
16  grains.  He  gradually  sank,  and  died  on 
the  third  day  after  the  operation. — Museum 
of  St.  George's  Hospital,  Ser.  xii,  No.  40. 


^  See  a  case  by  me  in  vol.  xxv  of  the  Path.  Trans. 


816  CALCULUS. 

extending  the  incision  into  the  rectum  as  far  as  is  judged  necessary. 
Tliis  may  sometimes  be  tlie  operator's  duty  ;  but  in  a  case  which  I  once 
saw,  and  which,  in  other  respects,  was  quite  successful,  a  fistula  was  left 
between  the  urethra  and  rectum  which  could  not  be  closed.  The  old 
rectovesical  operation  (which  was,  I  believe,  frequently  adopted  by  Mr. 
Lloyd,  of  St.  Bartholomew's  Hospital)  was  commenced  in  the  rectum. 
It  resembled  the  median  operation  to  some  extent,  but  the  surgeon,  in- 
stead of  plunging  his  knife  into  the  urethra  in  front  of  the  prostate, 
passed  it  with  his  left  forefinger  into  the  rectum,  pierced  the  wall  of  the 
rectum  and  urethra  or  neck  of  the  bladder,  and  then  cut  outwards  in  the 
middle  line,  through  the  external  sphincter  and  perineum. 

The  Hi/pogastric  Operation. — The  hypogastric  or  high  operation  is  only 
used  in  this  country  when  the  stone  is  believed  to  be  too  large  to  be  ex- 
tracted through  the  perineum,  or  when  the  pelvis  is  too  rickety.  The 
blodder  should  be  filled  with  water  in  order  to  distend  it  and  push  away 
the  peritoneum  as  mucii  as  possible.  Then  the  linea  alba  is  to  be  divided 
for  an  inch  or  more  above  the  pubes,  and  the  dissection  carried  cautiously 
down  until  the  point  of  the  staff  is  felt,  when  the  bladder  is  to  be  care- 
fully drawn  up  into  the  wound  and  opened,  the  stone  extracted,  and  the 
wound  left  to  itself.  The  main  danger  is  that  of  wounding  the  peri- 
toneum. In  one  case,  at  which  I  assisted,  the  peritoneum  came  down  so 
low,  and  the  bladder  could  be  so  little  distended,  that  it  was  only  possible 
to  avoid  that  membrane  by  incising  the  parietes  in  a  cruciform  instead 
of  mereh^  a  vertical  direction.  The  patient,  a  rickety  infant  much  ex- 
hausted by  his  sufferings,  ultimately  sank  from  exhaustion. 

Perineal  Lilhotrity. — In  cases  where  the  stone  is  too  large  to  be  ex- 
tracted, it  must  be  broken  down  by  a  kind  of  lithotrite  or  forceps  before 
its  fragments  can  be  brought  out  of  the  wound.  Various  contrivances 
have  been  invented  for  this  purpose,  and  it  is  well  to  have  an  instrument 
of  the  kind  at  hand  when  the  stone  is  suspected  to  be  very  large  ;  but 
operations  on  such  complicated  cases  are  rarely  successful.  Lately  Pro- 
fessor Dolbeau,  of  Paris,  has  introduced,  as  a  substitute  for  lithotom}^ 
in  general,  an  operation  which  he  calls  "  perineal  lithotrity."  As  this 
operation  has  not  yet  obtained  a  recognized  place  in  surgery,  I  cannot 
describe  it  minutely.  It  consists  in  making  a  small  median  opening  into 
the  membranous  part  of  the  urethra,  dilating  successively  the  external 
incision — the  urethral  opening — the  deeper  part  of  the  urethra — and  the 
neck  of  the  bladder — seizing  and  breaking  the  stone — extracting  the 
pieces  and  carefully  washing  out  all  ddbris.  The  operation  requires  pecu- 
liar instruments  and  various  precautions,  for  which  I  must  refer  to  Pro- 
fessor Dolbeau 's  work.  La  Lilhotritie  Perineale.,  or  a  short  account  b}^  Dr. 
Ewart  in  the  Lancet  for  October  17, 1874. 

Lithotomy  in  the  female  is  an  operation  of  much  less  danger  than  in 
the  male,  the  parts  being  so  much  more  supeiUcial,  but  it  is  much  more 
liable  to  be  followed  by  incontinence  of  urine.  It  may  be  performed  in 
many  ways.  A  proceeding  something  like  lateral  lithotomy  may  be 
effected  by  passing  a  staff  into  the  bladder  and  making  an  incision  run- 
ning outwards  through  the  upper  wall  of  the  vagina.  Or  the  urethra  may 
be  incised  directly  upwards  to  an  extent  sufficient  to  allow  of  the  passage 
of  the  finger  and  forceps  into  the  bladder.  It  must  be  remembered  that 
the  female  urethra  is  so  distensible  that  in  the  adult,  even  without  any  in- 
cision, the  finger  can,  under  chloroform,  be  introduced,  by  dilatation  and 
gradual  pressure,  into  the  bladder.  In  fact  when  it  is  difficult  otherwise 
to  detect  a  stone,  a  foreign  body,  or  a  tumor,  this  plan  should  be  adopted. 
Vaginal  lithotomy  may  also  be  practiced,  the  lower  wall  of  the  bladder 


LITHOTPwITES. 


817 


being  laid  open,  and  the  incision  sewn  up  at  once,  and  the  case  treated 
as  a  vesico-vaginal  fistula ;  and  this  is  on  the  whole  the  most  appropriate 
operation  in  the  adult,  as  involving  less  risk  of  incontinence  than  any 
other  ;  but  most  stones  can  be  removed  from  the  female  bladder  without 
any  cutting  operation.  If  they  are  too  large  to  be  extracted  wliole,  they 
can  be  broken  with  the  litliotrite  and  removed  in  fragments,  the  uretlira 
having  been  dilated. 

Lithoirity  is  the  operation  by  which  the  stone  is  broken  to  pieces  in 
the  bladder,  and  the  pieces  either  extracted  at  the  time  through  the 
urethra,  or  allowed  to  come  away  with  the  urine. 

I  can  only  give  a  general  sketch  of  the  process,  leaving  all  minute  de- 
tails for  special  works  on  the  subject.     The  lithotrite  is  a  pair  of  forceps. 

Fig.  368. 


The  common  screw  lithotrite.  The  male  blade  is  opened  and  shut  by  the  lunated  catch  seen  on  the 
handle,  and  when  the  stone  is  firmly  caught  the  screw  is  driven  home.  The  female  blade  is  usually 
perforated  by  a  large  opening  ("  fenestrated")  in  order  to  avoid  the  jamming  of  fragments  in  the 
blades.  When  it  is  intended  to  use  the  lithotrite  as  a  scoop  and  remove  the  fragments  this  blade  is 
not  fenestrated. 

the  shape  of  a  catheter,  only  with  a  much  smaller  curved  end,  and  curving 
more  abruptly,  one  blade  of  the  foi-ceps  (the  male)  being  received  into 
the  lower  or  female  blade,  moving  in  a  groove  by  means  of  a  handle,  and 
shutting  down  by  a  screw. 

The  object  of  lithotrity  is  to  catch  the  stone  between  the  two  blades  of 
the  lithotrite,  without  injuring  the  walls  of  the  bladder,  and  then,  by 
forcing  the  male  blade  througli  it,  to  fracture  or  crush  the  stone,  and  by 


Civiale's  lithotrite.  By  turning  the  two  little  buttons  on  the  handle  horizontal,  the  male  blade  is 
detached  from  the  screw,  and  made  movable.  When  the  stone  is  caught,  the  buttons  are  turned 
vertical  and  then  the  screw  will  act  on  them. 

repeating  this  operation  break  it  down  into  pieces  small  enough  to  pass 
througli  the  urethra. 

The  urethra  should  be  pi'eviously   dilated,  if  necessary,  until  it  will 


Fig.  370. 


V. 


Thompson's  lithotrite.  The  fluted  cylindrical  handle  affords  an  easy  hold  for  the  surgeon.  Pressure 
on  the  l)utton  in  the  handle  disengages  the  screw.  The  object  of  these  newer  forms  of  lithotrite  is  to 
enable  the  surgeon  to  grasp  the  stone  and  set  the  screw  in  motion,  with  less  manipulation,  i.  e.,  less 
change  of  position  of  the  hands,  than  in  the  common  screw  lithotrite. 

52 


818 


CALCULUS. 


easily  admit  a  large  instrument,  and  it  is  better  to  ascertain  beforehand 
that  the  passage  of  instruments  is  well  borne  by  the  i)atient.  Then,  the 
general  health  being  ascertained  to  be  good,  and  all  other  indications 
being  favorable  (see  p.  809),  the  process  should  be  commenced.  It  was 
always  usual  to  inject  a  certain  quantit}'  (say  6  oz.)  of  water  into  the 
bladder.  This  is  now  often  omitted  as  superfluous  ;  but  if  it  is  not  done 
the  surgeon  ought  at  any  rate  to  ascertain  that  his  patient's  bladder  is 
full,  i.  t".,  that  he  has  not  passed  water  for  three  or  four  hours  previously. 

Fig.  371. 


The  English,  or  Brodie's,  method  of  lithotrity.    The   lithotrite  has  been  passed  to  the  base  of  the 
bladder  and  the  stone  allowed  to  fall  into  its  grasp.— After  Sir  H.  Thompson. 


The  lithotrite  is  to  be  passed  fully  into  the  bladder  before  it  is  opened. 
Then  there  are  two  ditierent  methods  of  catching  the  stone.  Both  are  in 
use  b}'  most  eminent  and  successful  operators,  and  it  seems  clear  to  me 
that  they  are  about  equal  in  value.  The  most  important  matter  is  to 
acquire  dexterity  l)y  constant  practice  in  the  method  selected.  The  one 
which  is  commonly  called  the  Knglisli  or  Sir  B.  Brodie's  method,  consists 
in  sinking  the  closed  lithotrite  to  the  base  of  the  bladder,  when  if  the 
instrument  be  opened  to  its  full  extent  the  stone  will  usually  fall  within 
its  blades,  especiall}'  if  the  patient's  i)elvis  be  moved  or  slightly  sliaken. 
The  other  method — the  French  or  Civiale's — consists  in  feeling  the  stone 


LITHOTRITES. 


819 


with  the  lithotrite,  as  with  a  sound,  and  then  geutl}^  inclining  the  instru- 
ment a\va_y  from  the  stone  sufliciently  to  open  the  blades,  which  are  then 
to  be  applied  to  the  stone.  This  may  be  necessary  when  the  stone  lies 
partly  or  entirely  behind  the  prostate.  When  the  stone  is  grasped,  and 
the  male  blade  securely  screwed  down  on  it,  the  lithotrite  shouhl  be  moved 
a  little  way  so  as  to  make  sure  that  it  is  free  of  the  wall  of  the  Ijladder, 
and  then  the  instrument  is  closed  and  the  stone  crushed.     When  this  has 


Fig.  372. 


The  French  or  Civiale's  method  of  lithotrity.    The  lithotrite  is  reversed  to  seize  a  large  stone. — After 

Sir  H.  Thompson. 


been  once  done,  there  is  generall}^  no  difficulty  in  picking  up  and  crush- 
ing other  fragments  ;  but  it  is  not  prudent  at  first  to  proceed  too  far.  As 
a  general  rule  about  three  actions  of  the  lithotrite  will  be  enougli  at  first. 
If  the  patient  bears  the  operation  well,  more  may  be  done  at  subsequent 
sittings.  The  administration  of  chloroform  or  ether  is  not,  ordinarily, 
necessary,  since  the  operation,  if  dexterously  done,  does  not  give  much 
pain  ;  but  if  the  patient  be  nervous  there  is  no  objection  to  it.  Some 
surgeons,  and  especially  Sir  W.  Fergusson,  have  recommended  the  with- 
dravval  of  such  fragments  as  can  be  extracted  by  means  of  a  scoop  ;  but 
the  general  opinion  is  that  it  is  on  the  whole  better  to  allow  the  fragments 
to  pass  of  themselves,  and  to  avoid  all  manipulation  which  is  not  abso- 
lutely necessary.  If  the  bladder  is  paralyzed,  or  if  the  surgeon  from  any 
cause  is  anxious  to  hasten  the  process,  the  ingenious  apparatus  devised 
by  Mr.  Clover  ma}'  be  employed  to  remove  the  fragments  from  the  bladder. 
It  is  figured  and  its  action  explained  on  p.  820  (Fig.  373).     The  sittings 


820 


CALCULUS. 


may  be  repeated  at  intervals  of  five  or  six  days  if  there  liave  been  no  bad 
symptoms. 

In  cases  which  do  well  the  patient  passes  the  stone  in  small  fragments 
with  little  or  no  inconvenience,  nntil  ultimately  the  nucleus  comes  away, 
and  his  symptoms  are  relieved;  but  there  is  often  a  good  deal  of  trouble 
in  deciding  whether  there  is  a  small  fragment  left  in  the  bladder  or  not, 
and  it  is  obvious  that  there  ma}'  be  cases  in  which  the  detection  of  a 

Fir..  373. 


Clover's  syringe.  The  india-rubber  ball  is  filled  with  water.  This  is  injected  into  the  bladder  with 
the  instrument  vertical.  Then  the  ball  is  allowed  to  expand,  drawing  the  water  and  fragments  of 
stone  up  to  the  eye  of  the  instrument.  The  fragments  fall  into  the  glass  receptacle  by  their  own 
weight,  and  the  process  can  be  repeated  several  times  without  any  risk.  If  a  fragment  too  large  to  pass 
should  full  into  the  eye  of  the  catheter  itmust  be  dislodged  before  withdrawing  the  instrument.  This 
is  accomplished  by  passing  the  stem  figured  below  the  catheter. 

single  fragment  may  be  well-nigh  impossible.  Thus  the  bladder  may  be 
fasciculated  as  in  Fig.  374,  and  it  will  be  easy  for  a  fragment  to  slip  into 
one  of  the  pouches  between  its  muscular  fibres,  where  it  will  be  very 
difficult  to  strike  it.  For  the  purpose  of  disengaging  such  fragments, 
the  bladder  is  to  be  filled  with  a  large  quantit}'  of  water  before  searching 
in  a  doubtful  case. 

Or  it  may  even  happen  that  there  is  a  definite  pouch  in  the  bladder,  as 
in  Fig.  375,  when  the  surgeon  will  naturally  believe  that  he  has  removed 


Fig.  374. 


Fig.  375. 


'^&k^^'^'^ '  f 


Fig.  374.— a  fasciculat(;d  bladder,  having  in  the  interstices  of  the  muscular  coat  a  number  of  lithic 
acid  calculi,  some  of  which  appear  ti>  be  partly  adherent  to  the  coats  of  the  bladder.  From  a  prepara- 
tion pre-sented  by  Sir  li.  Brodie  to  the  Museum  of  St.  George's  Hospital,  Ser.  xii,  No.  30. 

Fig.  37.5.— Impaction  of  frai-'ments  of  calculus  in  a  pouch  of  the  bladder  after  lithotrity.— St.  George's 
Hospital  Museum,  Ser.  xii,  No.  34. 

all  the  fragments,  and  the  patient  will  suflTer  from  no  symptoms  except 
when  the  sloiie  happens  to  (!scai)e  from  the  pouch.  Such  cases  are  very 
difficult  to  treat,  but  they  are  rare  ;  and  in  ordinary  instances  there  is  no 


LITHOTRITY, 


821 


difficulty  either  in  determining  the  presence  of  a  fragment,  or  in  detect- 
ing and  crushing  it. 

Sir  PI.  Tliompson  says — "  As  long  as  an}-  remain,  there  will  almost  in- 
varialily  he  pain  in  passing  water,  especially  at  the  close  of  the  act,  wliile 
the  urine  ma}'  be  cloud}'  and  often  tinged  with  blood,  and  quick  movements 
of  the  body  give  pain.  As  long  as  these  symptoms  persist  we  may  be 
assured  some  portions  still  remain  behind,  and  these  must  be  found." 

GompJications. — The  bad  s^ymptoms  which  sometimes  follow  lithotritj'- 
are  as  follows : 

1.  Inflammation  of  the  bladder  may  be  produced  by  unskilful  manipula- 
tion, or  even  when  all  possible  skill 

has  been  exercised,  the  cystitis 
previously  existing  may  be  ag- 
gravated either  by  the  necessary 
operation,  or  by  the  sharp  edges 
of  fragments.  This  may  run  the 
usual  course  of  CN'stitis  and  sub- 
side, leaving  the  patient  in  a  con- 
dition to  continue  the  treatment, 
or  perhaps  in  the  surgeon's  judg- 
ment rendering  a  resort  to  lithot- 
omy prefei'able. 

2.  Enlargement  of  the  prostate 
gland  may  cause  much  difficulty 
in  passing  the  fragments,  which 
will  be  detained  in  the  bladder, 
irritating  it  and  propagating  in- 
flammation to  the  kidney's.  In 
rarer  cases  the  same  effect  is  pro- 
duced by  partial  paralysis,  or  by 
atony  of  the  bladder. 

3.  The  plexus  of  veins  which 
surround  the  neck  of  the  bladder 
may  be  irritated  and  inflamed, 
and  this  may  prove  the  starting- 
point  of  general  pyaemia.  I  have 
seen  pyaemia  prove  fatal  in  a 
chronic  form,  ca'cu  in  a  case 
where  the  stone  had  been  very 
small  and  had  been  entirely 
crushed  and  removed.  A  small 
ulcerated  surface  existed  in  the 
bladder,  which  had  doubtless 
been  produced  by  the  stone  it- 
self, as  the  patient  had  com- 
plained of  acute  pain  for  a  long 
time  before  the  operation,  espe- 
cially after  making  water.  But 
I  have  also  seen  pyoemia  come 
on  in  the  acutest  form  and  prove 
fatal  in  a  week. 

4.  The  impaction  of  fragments  kidneys  were  inflamed,  large,  and  soft  in  texture,  the 
is  one  of  the  most  dreaded  sequelae  Pe'^is  of  the  right  being  covered  with  lymph,  and  con- 
^f  li'f  K/^f  ..If  XT        ^^  ;^  4-1,^  ^,,?,,;^.,  ^e    taining  a  quantity  of  puriform  fluid.    On  the  external 

oi  iitnotrity.     it  is  tne  opinion  ot       <•   ^ ,,  ■  ,  /  ,,      .       ^  ■  ■ 

■^  i  surface  of  this  kidney  were  some  small  cysts  containing 

some  01  the  best  authors  that  this    pus.-St.  George's  Hospital  Museum,  Ser.  xii,  No.  35. 


Hypertrophy  of  the  prostate  gland,  the  middle  lobe 
of  which  projects  into  the  cavity  of  the  bladder.  The 
bladder  is  thickened  and  fasciculated,  and  its  mucous 
membrane  was  in  astate  of  chronic  inflammation.  In 
the  bladder  was  a  stone,  for  which  the  patient,  an 
elderly  person,  underwent  the  operation  of  lithotrity. 
The  first  operation  passed  off'  well,  but  at  the  second, 
which  was  seven  days  after  the  first,  he  had  a  severe 
rigor,  from  which  he  never  rallied,  and  died  ten  days 
afterwards.  Some  fragments  of  calculus,  seen  at  the 
bottom  of  the  figure,  were  found  in  the  bladder,  which 
had  not  been  in  the  least  injured  by  the  operation  ;  the 


822  CALCULUS. 

impaction  hardly  ever  happens  unless  the  urethra  has  been  lacerated, 
i.  c,  that  a  fragment  which  is  small  enouo-li  to  pass  into  the  urethra  will 
be  passed  on  by  the  walls  of  the  canal  if  they  remain  perfect,  however 
sharp  its  edges  or  angles  may  be.  This  does  not  of  course  apply  to  the 
meatus,  which  is  much  smaller  than  the  rest  of  the  urethra.  It  often 
happens  that  the  nucleus  or  last  fragment  of  the  calculus  lodges  there, 
but  this  merely  requires  that  the  meatus  should  be  incised  and  the  frag- 
ment removed.  The  fact  that  impaction  is  far  more  frequent  when  the 
urethra  has  been  lacerated  constitutes  a  grave  objection  to  the  proposal 
to  remove  the  debris  in  the  lithotrite  scoop  immediately  after  crushing.^ 

When  a  fragment  is  impacted  retention  of  urine  and  pain  will  be  pro- 
duced. Retention,  however,  occurs,  sometimes  without  any  impaction. 
Sometimes  the  fragment  comes  so  far  forwards  as  to  be  felt  from  the  sur- 
face, more  commonly  it  is  buried  in  the  perineum.  In  the  latter  case,  if 
the  symptoms  are  not  very  urgent  the  warm  bath  and  opium  will  some- 
times enable  the  patient  to  make  water  and  bring  the  fragment  forwards, 
when  possibly  it  will  pass  without  further  trouble.  If  the  fragment  is 
lodged  near  the  neck  of  the  bladder,  it  may  be  gently  pressed  back  with 
the  lithotrite  and  crushed  at  once.  If-  further  forward  than  the  scrotum 
it  may  be  extracted  by  means  of  the  urethra  forceps — an  operation  re- 
quiring great  care,  delicacy,  and  slowness  of  manipulation.  In  a  very 
few  cases  it  is  necessary  to  cut  down  in  the  middle  line  of  the  perineum, 
when  the  surgeon  will  naturally  consider  whether  he  ought  not  to  per- 
form lithotomy  at  once,  and  in  still  rarer  cases  he  may  have  to  cut  into 
the  urethra  in  the  penis. 

5.  The  other  complications  are  of  minor  importance.  Some  amount 
of  retention  not  unusuall}^  follows  a  first  sitting;  orchitis,  or  epidid^'m- 
itis,  is  not  uncommon  fi'om  irritation  of  the  ui'ethra  after  the  passage  of 
fragments.  Rigors  and  "urethral  fever"  occur  after  this,  as  after  all 
other  operations  on  the  urethra,  but  all  these  complications  are  to  be 
treated  on  general  principles. 

It  will  perhaps  be  best  to  close  the  section  with  the  following  "  prac- 
tical hints"  from  Sir  H.  Thompson's  work  on  Lithotrity. 

1.  It  is  occasionally  desirable  that  the  urethra  be  accustomed  to  in- 
struments before  operating,  so  that  the  lithotrite,  which  it  is  necessary 
to  employ,  can  be  passed  without  causing  much  uneasiness,  or  any 
bleeding. 

2.  Always  operate,  whenever  this  is  possible,  without  previously  dis- 
turbing the  bladder  by  injecting  or  sounding. 

3.  Having  determined  the  position  of  the  patient  according  to  the  ne- 
cessities of  the  case,  slowly  introduce  the  lithotrite,  and  take  care  that  the 
blades  reach  or  pass  beyond  the  centre  of  the  bladder  before  the  male 
blade  is  withdrawn. 

4.  Execute  every  movement  deliberately ;  open  and  close,  incline,  or 
rotate,  slowly,  without  any  jerk  whatever ;  and  all  without  bringing  the 
blades  into  contact,  as  far  as  it  is  possible,  with  the  walls  of  the  bladder. 

'  Sir  B.  Brodie  writes  on  this  subject  as  follows  :  "  'Ihere  are,  however,  some  very 
grave  objections  to  this  mode  of  proceeding.  The  withdrawing  of  the  forceps,  if 
much  loaded  with  calculous  matter,  stretches  the  urethra  beyond  its  natural  diameter, 
and,  in  so  doing,  not  only  gives  the  patient  much  pain  at  tiie  time,  but  renders  him 
liable  to  rigors  afterwards;  secondly,  in  four  instances  in  which  1  had  adopted  this 
practice  the  urethra  was  torn,  and  an  infiltration  of  urine  into  the  surrounding  tissues 
followed  by  urinary  abscess,  was  the  consequence  Two  of  these  patients  in  whom 
the  mischief  ])roduced  was  deep  in  the  perineum,  died,  notwitlistanding  the  abscesses 
having  been  freely  opcn(;d  as  soon  as  they  were  detected." — Med.-Chir.  Trans  ,  vol. 
xxxviii,  p.  175.     Sir  H.  Thompson  speaks  also  to  the  same  eflect. 


REMOVAL    OF    FOREIGN    BODIES.  823 

5.  Maintain  the  long  axis  of  the  instrument  in  tlie  median  line  of  the 
body  and  the  blades  at  or  near  the  centre  of  the  bladder,  tliis  being  the 
area  for  operating  mostly  to  be  chosen.  In  screwing  home  the  male 
blade  to  crush,  it  is  especially  necessary  to  keep  the  instrument  stead}', 
to  avoid  much  vibration  of  it  or  much  lateral  movement  of  the  blades 
from  its  axis  at  each  turn  ;  a  small  deviation  at  the  handle  produces  a 
large  one  at  the  blades. 

6.  The  position  of  a  large  stone  is  often  very  near  the  neck  of  the 
bladder.  But  the  position  of  the  stone  varies  much  in  different  cases. 
When  it  is  difficult  to  find  or  seize  it,  the  reason  usually  is  that  the  stone 
lies  close  to  the  neck  of  the  bladder,  so  that  the  male  blade,  when  drawn 
out,  impinges  upon  the  stone,  instead  of  including  it  within  the  grasp  of 
the  instrument.  It  is  necessary  then  to  insinuate  carefully,  l)y  a  lateral 
movement,  the  male  blade  between  the  stone  and  the  neck  of  the  bladder. 

7.  When  the  stone  is  caught,  especially  if  in  the  fenestrated  lithotrite, 
rotate  it  a  fourth  of  a  turn  on  its  axis  before  screwing  up  firmly  or  crush- 
ing, to  make  certain  that  nothing  is  included  besides  the  stone. 

8.  Having  broken  a  stone  or  a  large  fragment,  the  operator  may  pick 
up  and  crush  piece  after  piece  consecutively,  without  further  searching, 
if  he  is  only  careful  to  work  the  lithotrite  exactly  at  the  same  spot— the 
patient  of  course  not  shifting  his  position — since  fragments  fall  imme- 
diately beneath  the  blades  of  the  instrument,  and  rest  there. 

9.  Never  witlidraw  a  lithotrite  loaded  with  calculous  debris  ;  a  moderate 
quantity  will  come  away  between  the  plain  blades;  but  if  an  impediment 
is  felt  at  the  neck  of  the  bladder  on  withdrawing,  return  to  the  centre  of 
the  cavity  and  unload  them.  This  can  always  be  done  with  a  properly 
constructed  lithotrite. 

10.  No  sitting  should  exceed  five  minutes  in  duration,  except  under 
very  peculiar  circumstances.  The  large  majority  of  sittings  should  oc- 
cupy onlj'  three  minutes,  some  less.  The  mere  sojourn  of  a  litliotrite, 
without  any  movement,  for  three  minutes  in  the  bladder,  causes  uneasi- 
ness, and  often  subsequent  irritability,  which  may  be  considerable  if  the 
time  is  prolonged. 

11.  If  the  patient  experiences  an  unusual  amount  of  pain  at  the  com- 
mencement of  any  sitting,  it  is  wise  to  postpone  it  until  another  day,  or 
make  it  very  short.  Such  unlooked-for  pain  is  a  useful  intimation  that 
the  urinary  passages  are  not  at  this  time  in  fit  condition  for  our  purpose, 
and  by  acting  upon  it,  we  may  avoid  serious  mischief. 

12.  After  the  first  sitting  it  is  generally  desirable  that  the  patient 
should  have  hot  fomentations  to  the  hypogastrium  and  perineum,  remain 
in  the  horizontal  position,  and  pass  liis  water  in  that  position  if  he  can. 
He  should  remain  tolerably  quiet  until  the  debris  has  passed,  which 
usually  happens  within  three  days  of  the  sitting. 

13.  The  removal  of  debris  by  injecting  and  washing  out  the  bladder  is 
to  be  considered  the  exception  to,  and  not  the  rule  of,  practice. 

Removal  of  Foreign  Bodies. — The  lithotrite,  or  lithotrite  scoop,  or  some 
analogous  instruments,  may  often  be  employed  with  signal  success  in  the 
removal  or  foreign  bodies  from  the  bladder.  The  most  common  case  is 
where  the  fragment  of  a  bougie  has  been  broken  into  the  bladder.  If  the 
surgeon  is  called  in  at  once,  he  may  pick  up  the  foreign  substance,  and 
generally  with  ease,  and  should  the  piece  be  small  it  may  come  away 
without  any  trouble.  If  large  it  may  be  cut  into  pieces,  which  will  pass 
of  themselves.  If  the  case  has  been  put  off  till  a  crust  of  phosphate  has 
been  deposited  on  the  fragment,  it  must  be  treated  like  any  other  case  of 
stone. 


824 


CALCULUS. 


More  complicated  foreign  bodies  generally  require  lithotom^r,  for,  even 
if  they  could  be  caught  and  crushed,  the  fragments  would  be  very  danger- 
ous to  the  urinary  apparatus.  Such  cases  are,  as  a  general  rule,  very 
favorable  for  lithotomy,  since  there  is  no  disease  of  the  bladder  or  kid- 
neys (see  page  249). 

Prostatic  calculi  have  been  spoken  of  incidentall}^  on  previous  pages. 

They     form     small     and     often 
Fig.  377.  Very  numerous  concretions,  con- 

taining a  good  deal  of  animal 
matter,  but  consisting  generally 
of  phosphate  and  carbonate  of 
lime,^  sometimes  almost  entirely 
of  the  latter  salt.  These  small 
concretions  grow  into  the  urethra, 
and  often  (I  believe  usually)  do 
not  cause  any  special  symptoms, 
but  they  may  occasion  pain  and 
irritation  in  making  water,  fre- 
quent erections  and  discharges  of 
semen.  In  such  cases  tliey  might 
be  detected  hy  careful  exploration 
wilh  the  sound  and  finger.  Cal- 
culi   also    ma}'    pass    out   of  the 

A  stone  impacted  in  the  neck  of  the  bladder  of  a  bladder  and  lodge  in  the  prostatic 

child  aged  three.   The  stone  seems  to  fill  the  prostat-  nrethra,  producing  total  Or  partial 
ic  urethra,  but  there  is  no  history  of  complete  reten-  .        ,•  -,  ,1 

tion  of  urine,  tbonsh  there  had'boen  great  difficulty  I'eteutlOn,     and     a      Calculus      may 

in  passing  water  for  about  eight  weeks.     The  child  grOW    fl'Om     the    bladder    iutO    the 

was  brought  to  the  hospital  to  be  operated  on,  when  urethra  (vesico-prostatic  Calculus), 

thus  dilatino:  the  neck  of  the  blad- 


der and  causing  more  or  less  in- 
continence. It  often  happens, 
however,  that  the  urine  can  be  re- 
tained, though  not  for  any  long 


symptoms  of  scarlet  fever  showed  themselves  and  he 
died  in  a  few  days.  The  bladder  is  small  and  thick- 
ened, the  ureters  are  dilated.  There  is  some  malfor- 
mation of  tlie  bladder,  one  side  of  it  being  much 
larger  than  the  other,  and  from  its  apex  projected  a 
small  elongated  cyst  (through  which  a  bristle  passes), 
which  had  every  appearance  of  being  a  pervious  por- 
tion of  the  urachus— From  a  specin)en  in  the  Mu-  period,  although  a  CalculuS  is  pi'O- 
seum  of  St.  George's  Hospital,  Ser.  xii,  No.  87.  jecting  OUt  of  the  bladder.     In  the 

female,  also,  I  have  known  a  stone 
grow  out  of  the  bladder  into  the  urethra,  and  produce  incontinence  of 
urine.  Removal  of  calculi  from  the  prostatic  urethra  by  means  of  for- 
ceps is  spoken  of,  and  in  the  case  of  the  small  prostatic  concretions  it 
seems  piiysically  possible,  and  the  attempt  may  be  justifiable  ;  but  in  all 
cases  in  wiiicli  the  stone  is  known  or  believed  to  have  a  vesical  origin  it 
should,  if  possible,  be  pushed  back  into  the  bladder  with  a  lithotrite, 
and  crushed.     If  this  is  not  possible,  median  lithotomy  is  indicated. 

Slonc  in  the  urethra  is  a  common  cause  of  retention  in  boys.  It  is  in 
all  ordinary  cases  carried  down  from  the  bladder,  though  it  is  said  that 
stone  has  formed  in  a  pouch  or  diverticulum  behind  a  stricture.  The  im- 
paction of  a  calculus  does  not  necessarily  cause  retention,  in  fact,  a  smooth 
and  small  calculus  may  produce  very  few  symptoms,  its  impaction  being 
due  merely  to  its  being  turned  with  its  longest  diameter  across  the 
urethra,  and  when  it  happens  to  turn  the  other  way  it  will  come  out.  But 
large  and  sharp  stones  or  fragments  of  stone  give  rise  to  much  suffering, 
and  unless  removed  early  much  mischief  will  follow  from  abscess,  extrav- 
asation of   urine,  urinary   fistula,  etc.      In  some  cases  the  obstacle  to 


1  Their  chomiciil  composition,  at'cnrdinif  to   Dr.   WoUaston,  is  phosphato  of  lime 
84.5,  carbonsitc  of  iinio  .5,  iinimal  iiuiIUt  15.0. 


EETAINED    TESTIS.  826 

the  passage  of  the  stone  depends  on  spasm  of  the  urethra,  and  relaxa- 
tion of  this  spasm  by  opium  and  the  warm  bath  will  prove  successful. 
The  patient  should  be  directed  to  hold  his  urethra  in  front  of  the  stone 
as  long  as  possible  while  passing  his  water,  in  order  to  increase  the 
force  of  the  jet.  If  the  stone  be  lodged  far  forwards  patient  and  gentle 
attempts  at  extraction  with  the  forceps  will  often  succeed,  especially 
if  the  stone  can  be  manipulated  so  as  to  turn  its  long  axis  along  the 
urethra.  If  they  ilo  not,  and  the  stone  is  near  the  scrotum,  it  may  be 
better  to  push  it  into  the  perineum  and  cut  down  on  it  there,  though  I 
must  say  that  I  have  not  seen  the  harm  which  some  surgeons  describe  as 
resulting  from  cutting  into  the  urethra  in  the  penis.  If  a  catheter  is 
passed  into  the  bladder,  tied  in  and  left  open,  the  wound  is  pretty  sure 
to  heal.  Stones  impacted  far  back  will  not,  probably,  be  extracted  by  the 
forceps.  A  free  incision  should  be  made  on  them,  keeping  the  left  thumb 
or  forefinger  pressed  on  the  urethra  behind,  to  prevent  them  from  slipping 
into  the  bladder. 


CHAPTER   XXXIX. 

DISEASES  OF  THE  MALE  ORGANS  OF  GENERATION. 
AFFECTIONS    OF    THE    TESTICLE    AND    ITS    APPENDAGES. 

Congenital  Molformah'mis. — The  congenital  malformations  of  the  tes- 
ticle with  which  we  are  concerned  in  practice  relate  chiefly  to  irregular- 
ities in  the  descent  of  the  gland.  The  cases  reported  of  multiple  testi- 
cles seem  to  be  apocryphal :  cysts  in  contact  with  the  testicle  having  been 
mistaken  for  additional  testicles. 

There  are  cases  in  which  the  testicles  are  imperfectly  developed  or  even 
entirely  absent,  though  the  patient  retains  sexual  feeling  and  power.  Such 
persons,  however,  are  probably  sterile.  Their  possession  of  sexual  power 
is  accounted  for  by  the  fact  that  the  vesiculse  seminales  are  present,  being 
developed  along  with  the  vas  deferens  and  epididymis  from  a  different 
source. 

Retained  Testis. — More  common,  however,  and  in  a  surgical  point  of 
view  more  important,  is  the  retention  of  the  testicle  either  in  the  abdo- 
men or  in  the  inguinal  ring.  Such  retained  testicles  do  not,  in  the  opin- 
ion of  most  pathologists  of  the  present  day,  secrete  seminal  fluid,  i.  e.^ 
fluid  containing  spermatozoa,  so  that  the  patient  is  sterile,  if  both  testes 
be  retained,  though  there  is  no  reason  why  he  should  be  in  any  respect 
deficient  in  sexual  power. 

When  a  testicle  has  only  descended  into  the  inguinal  ring,  or  when  it 
descends  very  late  into  the  scrotum,'  a  portion  of  bowel  very  often  ad- 
heres to  it,  and  may  easily  become  strangulated,  especially,  as  in  these 
cases,  the  internal  ring  is  often  very  deep  and  narrow.  And  in  other 
cases,  though  the  testicle  does  not  descend,  the  gut  may  come  down  into 

1  Sir  A,  Cooper  relates  tliat  he  has  seen  the  testicle  descend  as  late  as  seventeen 
years  of  age,  and  Dr.  Humphry  speaks  of  a  case  as  late  as  forty. 


826  DISEASES    OF    MALE    ORGANS. 

the  scrotum,  and,  of  course,  may  be  strangulated  there  (see  Fig.  296,  p. 
641).  In  all  cases  of  hernia  with  retained  testis,  the  first  care  of  the  sur- 
geon is  to  replace  the  hernia  if  possible.  If  the  testicle  adheres  to  the 
hernia  and  tlie  latter  is  reducible,  so  that  the  replacement  of  the  bowel 
involves  the  reduction  of  the  testis  also  into  the  abdomen,  or  into  the 
groin,  this  is  a  matter  of  but  little  importance,  provided  a  truss  can  be 
worn  and  the  risks  of  hernia  obviated.  Even  if  the  pressure  of  the  truss 
were  to  cause  atrophy  of  the  testis,  this  is  not  an  objection  to  the  prac- 
tice, since  the  testicle  is  probabl}^  useless  from  the  beginning.  But  very 
often  the  hernia  will  be  found  irreducible,  or  the  truss  cannot  be  borne. 
In  such  cases  a  bag  truss  must  be  fitted.  If  an  operation  becomes 
necessary  the  surgeon  will  probably  embrace  the  opportunity  to  remove 
the  testicle,  which  is  useless  and  in  the  way. 

Such  retained  testicles  have  not  unfrequently  been  known  to  be  the  seat 
of  cancer,^  and  in  other  cases  of  hydrocele.  Gonorrhoeal  orchitis  is  pe- 
culiarly painful  when  the  testicle  is  retained  in  the  canal. 

There  are  also  instances  in  which  the  testicle  instead  of  descending  into 
the  scrotum  has  passed  into  the  perineum,  or  even  through  the  saphe- 
nous opening  into  the  groin.  The  knowledge  of  these  rare  anomalies  will 
be  useful  to  the  surgeon  in  examining  cases  of  supposed  hernia  or  peri- 
neal abs(;ess. 

In  other  cases  the  testicle  is  inverted  in  its  descent,  so  that  the  cord 
lies  in  front  of  it,  and  the  tunica  vaginalis  behind.  This  fact  has  its  im- 
portance, as  we  shall  see,  in  the  practical  surgery  of  hydrocele. 

The  persistence  of  the  funicular  canal  is  a  fact  of  as  much  importance 
in  hydrocele  as  in  hernia. 

The  malformations  of  the  penis  derive  their  practical  importance  from 
the  condition  of  the  ui'ethra  and  bladder,  and  have  been  spoken  of  on  pp. 
t68,  781. 

The  diseases  of  the  male  organs  may  be  divided  into  those  of  the  tes- 
ticles, scrotum,  and  penis.  Tlie  vesiculae  seminales  might  perhaps  be 
added,  but  their  affections  are  not  well  understood,  and  the  diseases  of 
the  prostate  are  treated  along  with  those  of  the  urinary  organs,  with 
wliich  they  have  a  nearer  connection  than  with  those  of  the  generative 
system. 

Hydrocele. — The  diseases  of  the  testicles  will  be  first  considered — of 
these  perhaps  the  commonest  is  hydrocele,  a  collection  of  fluid  in  the 
tunica  vaginalis,  the  result  of  over  secretion  or  passive  dropsy. 

No  symptoms  attend  the  formation  of  a  hydrocele,  so  that  any  swell- 
ing in  the  testicle  which  forms  painlessly  and  gives  no  inconvenience  ex- 
cept that  occasioned  b}'  its  weight  is  suspected  to  be  a  hydrocele  till 
proved  otherwise. 

The  forms  of  liydrocele  are  various,  corresponding  to  the  condition  of 
the  tunica  vaginalis  and  its  funicular  process. 

In  the  ordinary  condition  the  tunica  vaginalis  is  entirely  separated 
from  the  peritoneal  cavity  by  the  whole  extent  of  the  scrotum  and  ingui- 
nal canah  It  only  covers  the  front  and  the  sides  of  the  testis,  extending 
somewhat  under  the  epididymis  and  around  its  head,  but  is  reflected  for- 
wards from  tlie  sides  of  that  bod}^  so  as  to  leave  its  posterior  part  free. 
Consequently,  when  this  cavity  is  distended  with  fluid,  which  constitutes 
the  common  hydrocele,  the  swelling  lies  in  front  of  the  testicle  and  above 
it  (Fig.  300,  p.  643).     The  testicle  may  be  sometimes  felt  at  the  back  of 

1  Dr.  G.  Johnson,  Med.-  Chir.  Trans.,  vol.  xlii.  Mr.  Hodgson,  St.  George's  Hos- 
pital Keports,  vol.  ii. 


HYDROCELE. 


827 


the  tumor;  the  scrotal  cord  is  perfectly  free.  The  collection  of  fluid  is 
generally  too  tightly  bound  down  to  permit  of  the  feeling  of  fluctuation  ; 
it  is  commonly  transparent,  though  often  not  so,  in  consequence  of  the 
thickness  of  the  sac.  It  is  pyriform,  and  if  the  patient  is  intelligent  he 
will  have  noticed  that  it  has  begun  from  the  bottom  of  the  scrotum  and 
extended  upwards.  When  punctured  a  greenish  or  yellowish  serum  is 
drawn  off,  which  is  rich  in  albumen,  so  tliat  it  coagulates  on  the  applica- 
tion of  heat  or  nitric  acid  like  the  serum  of  the  blood.  The  causes  of 
hydrocele  are  not  well  understood.  It  is  a  common  complication  of 
chronic  inflammation  of  the  testicle  (hydrosarcocele),  and  a  certain 
amount  of  hydrocele  also  usually  accompanies  acute  orchitis.  Its  inflam- 
matory origin  is  testified  also  by  the  fact  that  it  is  not  infrequently  re- 
ferred to  an  injury.  Yet  in  most  cases  of  pure  hydrocele  nothing  of  the 
kind  can  be  traced.  It  is  spoken  of  vaguely  as  a  "•  local  drops}',"  but  cer- 
tainly has  no  connection  or  affinity  with  general  dropsy. 

Diagnosis. — The  diagnosis  of  this  form  of  hydrocele  from  hernia  is 
usually  easy — in  fact  obvious — for,  as  the  cord  is  free  between  the  tumor 
and  the  external  inguinal  ring,  no  confusion  between  hernia  and  hydro- 
cele, or  any  other  uncomplicated  tumor  of  the  testis  or  its  coverings,  is 
possible.  But  hydrocele,  or  any  other  scrotal  tumor,  ma}'  be  combined 
with  hernia,  as  shown  in  the  diagram  above  referred  to ;  and  then  in  the 
part  caused  by  the  hj'drocele  transparency  will  be  found  without  impulse 
or  reducibility,  and  in  the  hernia  opacity  with  impulse  and  probably  with 
reducibility.  If  tlie  hernia  is  strangulated,  the  characteristic  symptoms 
of  that  condition  will  demand  the  reduction  of  the  bowel  either  by  taxis 
or  operation,  and  after  this  has  been  accomplished  the  nature  of  the  tu- 
mor will  become  plain.  But  old  hydroceles  with  a  thick  non-transparent 
sac  are  not  so  easily  distinguished  from  solid  tumors  of  the  testicles  ;  in 
fact,  are  sometimes  almost  indistinguishable  from  them.  I  once  assisted 
a  surgeon  of  great  experience  in 

an  operation  on  a  case  which  I  Fig.  373. 

had  not  seen  before,  where  he 
proposed  to  remove  the  testicle 
on  account  of  supposed  malig- 
nant disease,  which  on  incision 
turned  out  to  be  a  simple  hydro- 
cele; and  I  was  once  consulted 
in  a  similar  case  where,  remem- 
bering this,  I  avoided  the  same 
error  onl}^  by  a  puncture  with  a 
trocar  after  the  patient  had  been 
prepared  for  the  operation.  So 
also  with  hfematocele,  as  to 
which  tlie  reader  is  referred  to 
the  section  on  that  disease. 

The  treatment  of  simple  hy- 
drocele may  be  palliative  or  radi- 
cal. The  latter  cannot  be  de- 
void of  pain,  and  involves  some, 
though  a  very  trifling  risk.  Con- 
sequentl}',  man}'  persons  prefer 

to  go  on  with  the  palliative  treat-  Tapping  a  hydrocele.  After  Listen.  The  probable 
ment,    or,    in     plainer    terms,    to         position  of  the  testis  is  indicated  by  a  dotted  line. 

have  the  hydrocele  tapped  from 

time  to  time  instead  of  attempting  its  cure.     Tapping  a  hydrocele  is  a  very 


828  DISEASES    OF    MALE    ORGANS. 

simple  proceeding,  though  it  is  sometimes  mismanaged.  The  back  part 
of  the  scrotum  is  to  be  drawn  backwards  so  as  to  make  its  front  surface 
tense.  A  part  of  the  skin  is  to  be  chosen  free  from  large  A'cins,  and  the 
trocar  is  to  be  plunged  in  boldl_y,  inclining  upwards,  in  order  to  avoid  the 
testicle.  This  gives,  it  may  be  said,  no  pain,  and  after  the  swelling  has 
been  emptied  the  canula  is  withdrawn  and  a  bit  of  strapping  applied. 
When  the  fluid  has  re-collected  to  such  an  extent  as  to  cause  pain  and 
dragging  on  the  loins,  this  little  operation  may  be  repeated,  or  the  radical 
cure  may  be  undertaken.  When  the  fluid  has  all  been  withdrawn,  the 
condition  of  the  testis  must  be  carefully  examined  ;  for  before  the  empty- 
ing of  the  sac  it  is  difficult,  if  not  impossible,  to  be  sure  that  the  gland 
itself  is  healthy,  and  if  it  be  not  so  it  will  be  vain  to  try  and  cure  the 
disease  by  any  measures  directed  solely  to  the  tunica  vaginalis. 

In  this,  the  common  method  of  tapping  a  hydrocele,  the  testicle  is 
supposed  to  be  behind,  as  it  is  in  ninety-nine  cases  out  of  a  hundred. 
But  there  are  rare  instances  in  which  the  position  is  reversed,  and  the 
gland  lies  in  front  of  the  fluid.  I  once  saw  such  a  case  in  which  a  trocar 
had  been  twice  thrust  into  the  testicle  in  attempts  to  empt}"  the  hydro- 
cele. This  reversal  of  the  position  depends  on  one  of  two  causes  : 
(1)  The  hydrocele  may  have  been  tapped,  and  in  this  operation  the  front 
surface  of  the  testicle  may  have  been  punctured.  In  consequence  of  this 
the  testicle  contracts  an  adhesion  to  the  front  of  the  hydrocelic  cavity, 
and  when  the  fluid  re-collects  the  testicle  lies  at  the  front  of  the  tumor 
and  the  fluid  laps  round  each  side  of  it,  so  as  to  appear  behind  it,  though 
this  is  hardly  the  case  in  strictness  of  speech  ;  or  (2)  the  hydrocele  may 
really  lie  entirely  behind  the  testicle  as  a  consequence  of  congenital 
peculiarity,  for  it  seems  that  sometimes  the  testis  gets  twisted  as  it  were 
in  its  descent  into  the  scrotum,  so  that  the  epididymis  and  cord  are  in 
front  of  the  gland  and  the  tunica  vaginalis  behind  it;  and  if  in  a  case 
like  this  hydrocele  should  occur,  it  must,  of  course,  be  altogether  behind 
the  testicle.  Such  a  position  could  not  be  detected  if  the  tunica  vagi- 
nalis were  thick  and  opaque  ;  but  in  ordinary  cases  careful  exploration 
by  transmitted  light  will  distinguish  the  position  of  the  testicle,  or  the 
elasticit}^  of  the  part  will  convince  the  surgeon  where  fluid  is  to  be  found  ; 
or  palpation  may  elicit  sensations  in  the  patient  which  will  enable  him 
to  point  out  the  situation  of  the  gland.  Fortunately,  if  in  an  obscure 
case  the  testicle  is  punctured,  no  serious  mischief  usually  follows  ;  the 
error,  however,  is  a  discreditable  one  when,  as  commonly  happens,  it  is 
the  result  of  pure  negligence. 

Radical  Cure. — The  radical  cure  of  hydrocele  used  to  be  effected  by 
la3'ing  the  sac  freely  open,  and  this  is  sometimes  still  necessary  in  cases 
of  obstinate  recurrence.  I  have  had  occasion  to  perform  the  operation 
and  to  see  it  performed  by  others.  It  used  to  be  prescribed  to  stuff 
the  wound  with  lint  in  order  to  excite  suppuration,  but  this  is  painful 
and  superfluous.  It  is  only  necessary  to  keep  the  wound  open  by  gently 
separating  its  lips  when  necessary  and  the  cavit3^  will  fill  up. 

Injections, — Commonl}^,  however,  the  injection  of  the  sac  suftices.  The 
old  plan  was  after  withdrawing  the  fluid  to  fill  the  sac  with  port  wine  and 
water  in  equal  parts  (the  French  use  alcohol  and  water  in  various  propor- 
tions), and  keep  it  in  the  sac  till  the  patient  felt  a  good  deal  of  pain  and 
began  to  feel  sick  and  faint.  Then  the  canula  was  opened  and  as  much 
of  the  fluid  as  would  run  out  was  allowed  to  escape.  The  modern  plan 
(introduced  bj"  the  late  Sir  R.Martin)  is  less  troublesome  to  the  patient, 
and  is  usually  effective,  though,  I  think,  less  certain  to  cure  the  disease 
than  the  port-wine  injection.    Two  drachms  of  an  equal  mixture  of  Tinct. 


HYDROCELE.  829 

lodi  and  water  are  passed  into  tlie  emptied  sac  and  left  there.  Tlie 
effect  of  the  injection  of  a  liydrocele  is  always  a  smart  attack  of  inflam- 
mation, the  sac  usually  filling  to  the  same  size  as  before,  and  witli  a  good 
deal  of  redness  of  the  skin  and  pain.  But  as  this  subsides  the  part  re- 
sumes and  retains  its  natural  size,  at  least  if  tlie  operation  is  successful. 
The  tunica  vaginalis  is  sometimes  ol)literated  by  adhesions ;  but  this  is 
not  necessary  for  cure,  and  is  believed  not  to  be  the  usual  result;  though 
precise  information  on  this  head  can  hardly  be  obtained,  since  such 
operations  never  prove  fatal  and  have  been  forgotten  before  the  patient's 
death,  even  if  his  body  is  examined.  Should  the  hydrocele  recur  after 
the  iodine  injection,  as  it  sometimes  does,  the  best  plan  is  to  inject  it 
with  port-wine  or  with  sulphate  of  zinc  lotion  (gr.  iv  to  3J)  used  in  the 
same  way  as  the  port-wine  injection,  and  if  it  still  recurs  to  lay  it  open; 
but  in  these  cases  very  careful  examination  of  the  testicle  should  be 
made,  to  ascertain  whether  it  really  is  a  case  of  simple  hydrocele. 

Seions  are  also  used  in  the  cure  of  liydrocele,  but  the  silk  seton  seems 
to  me  a  more  severe  measure  than  incision,  and  the  silver  seton  is  very 
uncertain  in  its  action.  I  have  seen  it  in  some  cases  produce  too  little 
inflammation  to  cure  the  disease,  and  in  others  such  violent  symptoms 
as  are  out  of  proportion  to  the  gravity  of  the  disease,  ending  in  fact  in 
one  unlucky  case  in  death. 

The  other  forms  of  hydrocele  depend  on  the  condition  of  tlie  tunica 
vaginalis  and  its  funicular  process  in  respect  of  their  obliteration. 

Congenital  Hydrocele. — When  the  whole  funicular  process  remains 
open  and  the  communication  is  not  large  enough  to  admit  a  piece  of 
bowel,  the  serous  secretion  of  the  peritoneum  ma}'  distend  the  scrotal 
pouch  and  form  a  congenital  hydrocele^  (Fig.  295,  p.  641).  Congenital 
is  distinguished  from  common  hydrocele  by  its  shape  and  extent,  and 
by  the  fact  that  the  fluid  can  be  returned,  though  often  only  slowly  and 
with  much  difficulty,  into  the  belly,  and  from  hernia  by  its  transparency^ 
(which,  I  believe,  is  almost,  if  not  quite  always  present),  and  by  the 
different  sensation  which  the  surgeon  feels  in  reducing  it. 

The  treatment  of  congenital  hydrocele  consists  in  evacuating  the  fluid 
with  a  fine  trocar  and  endeavoring  to  procure  the  obliteration  of  the 
patent  canal  by  making  continuous  pressure  on  it  near  the  external  in- 
guinal ring  by  means  of  a  truss,  which  should  be  worn  night  and  day  if 
possible;  and  as  fast  as  the  fluid  reaccumulates  the  puncture  should  be 
repeated.  Most  cases,  I  believe,  ultimately  recover.  If  not,  the  commu- 
nication will  probably  enlarge  and  hernia  will  ensue.  In  France  it  seems 
common  to  treat  congenital  hydrocele  by  injection  with  alcohol,  pressure 
being  maintained  on  the  ring  while  the  sac  is  being  injected  ;  but  the 
gravity  of  the  disease  seems  hardly  sutticient  to  warrant  a  measure  which 
cannot  be  free  from  considerable  risk. 

Infantile  hydrocele  is  vei\y  common.  The  tunica  vaginalis  and  its 
funicular  prolongation  are  distended  with  clear  serum,  but  they  are 
separated  from  each  other  by  a  septum  at  the  external  ring  (Fig.  298,  p. 
643),  so  that  the  fluid  will  not  pass  into  the  peritoneal  cavity  whatever 

'  It  must  be  recollected  that  this  is  not  a  necessary  consequence  of  the  persistence 
of  the  communication  if  it  be  very  small,  as  shown  by  the  case  of  Sir  A.  Cooper, 
quoted  on  p.  640. 

^  It  must  be  remembered  that  a  hernia  cannot  under  ordinary  circumstances  be 
transparent,  since  botli  the  viscera  and  the  omentum,  which  form  its  contents,  are 
themselves  perfectly  opaque.  In  very  rare  cases  the  hernial  sac  is  dropsical  or  dis- 
tended with  clear  serum — "  liydrocele  of  the  hernial  ssic."  Such  cases  could  only  be 
distinguished  from  hydrocele  by  the  impulse  of  the  bowel  in  the  tumor. 


830  DISEASES    OF    MALE    ORGANS. 

force  be  used  ami  however  the  canal  may  be  straightened  out;  but  very 
careful  examination  in  this  respect  is  necessary  before  the  hydrocele  can 
be  confidently  said  not  to  communicate  with  the  peritoneum,  so  easy  is 
it  to  close  a  small  communication  by  any  folding  over  of  tiie  parts  ;  and 
then  what  is  really  a  congenital  maN^  easih'  be  mistaken  for  an  infantile 
hydrocele.  Infantile  hydrocele  generally  disappears  spontaneously  or 
after  the  application  of  a  stimulating  lotion  of  arnica  or  hydrochlorate  of 
ammonia  or  tincture  of  iodine  to  the  skin  ;  or  it  may  be  punctured  sub- 
cutaneously  or  otherwise.  There  is  no  objection  to  injecting  such  a 
hydrocele,  but  it  is  rarely  necessary. 

Hiidrocele  of  the  cord  proceeds  from  the  effusion  of  serum  into  an  un- 
obliterated  portion  of  the  funicular  process  (Fig.  301,  p.  643),  or  perhaps 
from  the  growth  of  an  independent  cyst  in  the  cellular  tissue  of  the  cord. 
It  is  commonly  met  with  in  children  or  boys  about  puberty,  and  causes  a 
small,  round,  tense  SMelling  in  the  course  of  the  cord,  separate  from  the 
testicle,  and  therefore  easy  to  distinguish  from  common  hydrocele  or  any 
tumor  of  the  testis,  and  if  also  distinctl3-  separable  from  the  external  in- 
guinal ring,  equally  eas}-  to  distinguish  from  hernia,  and  therefore  unmis- 
takable. But  as  the  cyst  may  extend  up  to  or  beyond  the  ring  there  is 
in  such  a  case  a  very  great  resemblance  to  hernia ;  so  that  I  have  seen  a 
case  of  the  kind  treated  for  hernia  at  one  of  our  truss  societies.  Careful 
examination,  however,  will  show  that  the  supposed  hernia  cannot  be  made 
to  return  into  the  bell}',  though  there  is  no  strangulation  ;  that  the  impulse 
it  receives  is  much  less  than  a  hernia  would  have  ;  and  that  it  forms  a 
small  rounded  swelling  instead  of  a  long  tubular  one  ;  and  if  the  child  be 
taken  into  a  dark  room,  and  the  candle  be  dexterously  arranged,  trans- 
parency can  usually  be  detected  in  spite  of  the  smallness  of  the  cyst  and 
fatness  of  the  part.  There  is  then  no  further  doubt.  But  if  with  a  cyst 
situated  so  high  up  there  should  be  any  symptoms  of  strangulation,  it 
would  be  right  to  cut  down  on  the  tumor  and  open  it ;  and,  in  fact, 
whenever  there  is  any  considerable  doubt  the  same  course  may  be  justifi- 
able, rather  than  expose  the  child  to  the  annoyance  of  wearing  a  truss 
unnecessarily. 

These  cysts  are  easily  curable  by  injection  with  a  small  quantity  of 
tincture  of  iodine,  say  5J  of  a  mixture  of  equal  parts  of  the  tincture  and 
water,  or  5ss.  of  the  pure  tincture.  I  have  also  cured  them  by  a  silver 
seton,  but  with  more  inflammation  and  distress,  and  once  by  cutting  the 
cyst  across  and  strapping  it. 

Besides  these  encysted  hydroceles  of  the  cord,  which  are  common 
enough,  diffused  hydrocele  of  the  cord  is  spoken  of,  forming  a  long, 
sausage-shaped  tumor  around  the  whole  cord ;  but  if  it  occurs  it  is  ex- 
ceedingly rare.  Dr.  Humphry  saj's  that  no  such  case  is  known  to  have 
presented  itself  in  modern  times,  and  refers  to  the  works  of  Pott  and 
Scarpa  for  all  that  is  known  about  it. 

Enci/Hted  hydrocele  of  the  testicle  consists  in  the  formation  of  a  cyst  in 
contact  with  the  testicle  itself  and  not  with  the  cord.  The  usual  position 
of  these  cysts  is  in  the  head  of  the  epididymis,  and  they  generally  con- 
tain spermatic  fluid.  But  they  are  found  in  other  situations,  as  between 
the  tunica  vaginalis  and  albuginea ;  and  they  may  contain,  not  the  milky 
fluid  which  results  from  the  admixture  of  semen,  and  which  i)resents  sper- 
matozoa under  the  microscope,  but  the  same  nearl}^  watery  secretion  as 
is  contained  in  the  cysts  of  the  cord.  Their  diagnosis  from  common 
hydrocele  is  formed  either  from  their  position,  for  they  do  not  envelop 
the  testicle  like  common  hydrocele,  but  lie  behind  or  at  the  side  of  it, 
like  a  double  testis  ;  or  from  the  milky  or  watery  nature  of  their  contents, 


HEMATOCELE.  831 

which  contrasts  forcibly  with  the  albuminous  serum  of  ordinary  hydrocele. 
The  way  in  which  semen  gets  into  these  cysts  is  not,  perhaps,  fully  under- 
stood ;  but  there  is  no  question  that  in  many  cases  a  distinct  communi- 
cation has  been  seen  between  the  cyst  and  the  tubes  of  the  epididymis; 
and  even  if  we  allow  that  in  the  cases  where  no  such  opening  has  been 
found  there  was  really  no  opening,  still  it  might  have  been  present  at 
one  time,  and  then  have  become  obliterated.  In  the  watery  cysts,  how- 
ever, no  such  communication  can  at  any  time  have  existed.  It  seems  on 
the  whole  most  probable  that  these  cysts  originate  in  different  ways, 
either  as  outgrowths  (or  buds  as  it  were)  from  the  tubes  of  the  epididy- 
mis, the  opening  of  which  may  or  may  not  become  obliterated,  or  as  in- 
dependent formations  in  the  cellular  tissue  of  the  cord,  which  afterwards 
may  or  ma}'  not  form  a  communication  with  its  seminiferous  tul)es.  It 
has  also  been  suggested,  but  on  pure  hypothesis,  that  they  ma}'  be  over- 
developed remains  of  the  Wollffian  body  which  have  not  become  con- 
nected with  the  testicle.  A  much  more  probable  hypothesis  is  that  put 
forward  in  a  very  interesting  paper  by  Mr.  S.  Osborn  in  the  St.  Thomases 
Hospital  Reports  for  the  present  year.  He  traces  the  development  of 
these  cysts  to  the  "  hydatid  of  Morgagni,"  a  small  C3'stic  body  which  is 
always  found  between  the  testis  and  the  globus  major,  and  is  the  remnant 
of  the  Miillerian  duct.  The  paper  and  the  preparations  depicted  in  it 
are  well  worth  studying. 

The  treatment  is  the  same  as  that  of  common  hydrocele ;  but  as  the 
tumor  is  usually  smaller  and  fills  more  slowly  than  in  hj'drocele  of  the 
tunica  vaginalis,  there  is  less  motive  for  undertaking  the  radical  cure. 

Loose  Bodies  in  the  Tunica  Vaginalis. — The  cavity  of  a  hydrocele 
sometimes  contains  a  loose  body.  These,  as  Mr.  Osborn  points  out,  may 
be  formed  by  the  hydatid  of  Morgagni  becoming  degenerated  into  a  solid 
tumor,  much  as  an  enlarged  bursa  does,  and  then  dropping  off  its  pedun- 
cle;  and  Dr.  Humphry  (op.  cit..,  p.  106)  has  pointed  out  a  similar  process 
for  the  development  of  these  movable  bodies,  and  has  given  an  interest- 
ing example  of  the  recognition  and  removal  of  one  of  them  during  life  by 
incision.  In  a  case  by  Sir  B.  Brodie  a  patient  who  had  one  of  these  loose 
bodies  used  to  complain  of  intolerable  pain  after  the  operation  for  tapping; 
and  they  often  set  up  a  certain  amount  of  irritation,  and  no  doubt  either 
produce  or  keep  up  the  eftiision  of  fluid  into  the  tunica  vaginalis.  They 
should,  therefore,  always  be  removed  when  they  can  be  recognized.  I 
have  no  doubt  that  they  ma}'  arise  from  various  causes,  just  as  loose  car- 
tilages do ;  and  their  structure  bears  much  analogy  to  that  of  the  loose 
bodies  in  the  joints.  In  Dr.  Humphry's  case  the  loose  body,  which  was 
the  size  of  a  bean,  was  composed  of  "compact  fibrous  layers  encircling 
an  earthy  nucleus." 

Hsematocele. — Common  hjematocele  is  a  collection  of  blood  in  the  cavity 
of  the  tunica  vaginalis.  It  usually  follows  on  some  sprain  or  injury 
whereby  a  vessel  is  ruptured  on  the  internal  surface  of  the  membrane, 
and  this  is  often  the  case  when  hydrocele  is  already  present.  The  same 
thing  happens  sometimes  in  hydrocele  of  the  cord  and  in  encysted  hydro- 
cele, which  by  some  blow  or  injury  becomes  filled  with  blood,  or  converted 
into  hfcmatocele.  In  the  cord,  however,  this  is  so  uncommon  that  I  think 
it  not  worth  while  to  spend  more  space  upon  it.  In  the  tunica  vaginalis 
it  appears  common  enough.  Hsematocele  may  be  produced  by  a  blow  or 
a  strain  in  the  previously  sound  condition  of  the  organ,  giving  rise  to 
haemorrhage  into  the  cavity  of  the  tunica  vaginalis,  or  by  similar  injuries, 
or  the  puncture  of  the  trocar,  in  cases  of  hydrocele,  and  perhaps  by  spon- 


832  DISEASES    OF    MALE    ORGANS. 

taneous  rupture  of,  or  exhalation  from,  some  vessel  in  the  lining  of  the 
sac. 

The  tumor  has  generally  a  somewhat  more  rounded  shape  than  a 
hydrocele,  is  heavier,  less  homogeneous,  part  of  it  being  knobbv  and 
semi-solid,  is  perfectly  devoid  of  transparency,  and  often  accompanied 
by  a  dark  color  of  the  scrotum,  due  to  blood  sugillating  into  the  subcu- 
taneous tissue. 

Diag)wsi>^. — The  diagnosis  is  an3'thing  but  easy.  It  is  hardly  too  much 
to  say  (at  least  I  may  say  it  for  myself)  that  the  surgeon  can  never  be 
sure  of  the  diagnosis  of  a  hi\?matocele  till  he  has  punctured  it.  It  ma}' 
be  a  solid  tumor  of  the  testis  (perhaps  inflammatory,  but  more  probabl}^ 
malignant),  or  a  hydrocele  with  a  thick  sac.  The  diagnostic  signs  are  as 
follows:  Chronic  orchitis  is  generally  accompanied  by  a  more  definite 
history  of  its  causation  than  hematocele,  i.e.,  it  follows  directly  on  acute 
orchitis  or  as  the  result  of  a  blow-,  the  tumor  having  been  always  solid, 
and  increasing  gradually  ;  or  after  syphilis,  with  some  other  distinct 
syphilitic  symptoms.  Cancer  of  the  testicle  advances  more  rapidly',  has 
a  greater  tendency  to  spread  up  the  cord,  and  is  accompanied  with  more 
pain.  [I  do  not  speak  of  advanced  cases  of  cancer  complicated  with  en- 
larged lumbar  glands,  where  there  is  no  difficulty  in  diagnosis.]  Hydro- 
cele is  wanting  usually  in  the  history  of  injury  and  of  sudden  increase  to 
a  certain  size,  at  which  when  a  hsematocele  has  attained  it  usually  stops. 
But  the  reader  will  see  at  once  that  all  these  signs  are  dubious  ;  and  an 
experience  of  the  complexities  of  practice  and  the  uncertainties  of  pa- 
tients' histories  will  enable  him  easih'  to  judge  how^  dubious  the}^  are. 
It  is,  however,  more  especially  the  early  stage  of  cancer  which  bears  the 
strongest  resemblance  to  hematocele. 

Notwithstanding,  however,  the  difficulty  experienced  in  diagnosing 
hematocele,  there  are  many  cases  in  which  the  S3'mptoms  and  history 
point  strongly  to  the  correct  conclusion ;  and  in  any  case  w^here  there  is 
a  real  necessity  for  operative  interference  a  preliminary  incision  will 
settle  the  matter,  and  can  do  no  harm. 

Sometimes  hematocele,  if  neglected,  grows  to  an  enormous  size,  pro- 
ducing atroph}'  of  the  testis ;  at  other  times  the  blood  degenerates  into 
a  turbid,  grumous  mass,  very  like  the  contents  of  the  small  intestine.^ 

Treatment. — In  ver}'  old  cases  of  hematocele  probabl}'  the  safest  and 
best  course  is  to  remove  the  whole  tumor  with  the  testicle  ;  but  as  a  gen- 
eral rule  it  will  be  sufficient  to  lay  open  the  tumor  by  a  free  crucial  inci- 
sion, turn  out  all  the  clots,  tie  an}'  vessels  in  the  thickened  tunic  which 
bleed  freely  enough  to  require  it,  and  allow  the  cavity  to  granulate  up. 
At  the  same  time  it  should  be  remembered  that  the  operation  is  a  severe 
one,  and  in  old  or  unhealthy  persons  it  should  not  be  lightly  undertaken. 
I  have  seen  death  follow  it.  It  is  said  that  cases  of  recent  hematocele 
occur  in  which  the  absorption  of  tlie  blood  can  be  procured  b}'  rest, 
evaporating  lotions,  ice,  etc.  I  have  not  met  with  such  cases,  nor  with 
any  in  which  the  blood  is  entirely  fluid  and  can  be  evacuated  through  a 
trocar  like  hydrocele,  and  in  which  injection  might  be  tried,  but  am  quite 
willing  to  Ijelieve  in  their  occasional  occurrence. 

Acute  Orc/iitis. — Orchitis,  or  inflammation  of  the  testicle,  is  divided 
into  acute  and  chronic.  If  the  word  orchitis  were  construed  so  literally 
as  to  restrict  it  to  inflammation  of  the  body  of  the  gland,  excluding  the 


^  I  once  saw  a  surj^con  on  ojx-niiig  a  hannatocelo  of  this  kind  start  back,  fancying 
for  a  moment  that  he  had  laid  open  a  hernia. 


ORCHITIS.  833 

epiclidymis,  we  might  say  that  acute  orchitis  is  ahnost  always  caused  by 
a  blow,  or  by  metastasis  in  mumps,  since  the  familiar  acute  intlau)mation 
of  gonorrhoea  is  properly  epididymitis,  but  this  is  in  ordinary  language 
included  in  the  term  orchitis.  The  inflammation  also  wliich  follows  from 
impaction  of  calculus,  after  lithotrity,  catlieterization,  etc.,  is  originally, 
like  gonorrheal  orchitis,  situated  in  the  epididymis. 

Gonorrho'cil  orchitii^  usually  occurs  somewhat  late  in  the  disease,  and 
often  after  the  discharge  has  more  or  less  subsided;  whether  it  occurs 
from  inflammation  spreading  up  the  vas  deferens  to  the  epididymis  or 
from  some  nervous  "  sjmpath}',"  the  nature  of  which  is  obscure,  is  as  3'et 
undecided. 

It  commences  when  in  its  severest  form  with  rigors,  sickening  pain  in 
the  back  and  loins  as  well  as  in  the  testicle,  heat  and  redness  of  the  scro- 
tum, swelling  and  tenderness  of  the  epididymis,  and  distension  of  the 
tunica  vaginalis  with  serum  and  lymph.  The  body  of  the  testicle  be- 
comes more  or  less  affected  as  the  disease  progresses.  The  inflammation 
appears  to  be  at  first  seated  in  the  intertubular  connective  tissue,  after- 
wards the  tubuli  themselves  become  loaded  with  lymph. 

On  the  subsidence  of  the  disease  it  seems  not  very  uncommon  for  the 
tubuli  seminiferi,  and  probably  also  the  large  excretory  tubes  of  the  vas 
deferens,  to  be  choked  up  by  this  lymph,  so  that  the  testicle  is  left  useless, 
and  if  both  testes  have  been  affected  the  patient  is  sterile,'  though  the 
testicles  may  not  be  wasted,  nor  the  patient  deficient  in  sexual  vigor. 

Treatment. — The  treatment  of  gonorrhoeal  orchitis  is  now  far  less  severe 
than  it  used  to  be.  Yevy  many  cases  are  found  to  get  perfectly  well  with 
no  more  active  treatment  than  rest  in  bed,  with  the  testicle  wrapped  up 
in  a  warm  poultice.^  When  there  is  much  pain  opium  should  be  freely 
given.  Leeches  sometimes  also  relieve  pain  if  followed  b}^  warm  bathing. 
Free  purging  is  very  desirable,  and  if  much  inflammatory  fever  be  present 
antimony  in  moderate  doses  is  indicated.  In  the  initial  stages  when  con- 
fined to  the  epididymis  the  disease  may  sometimes  be  arrested  by  care- 
full}^  strapping  the  part,  according  to  Dr.  Humphry.  When  the  pain  is 
gone,  but  swelling  lingers,  strapping  is  most  beneficial  if  the  pressure  be 
well  and  equably  applied,  but  this  is  an  art  which  all  people  do  not  possess.'^ 
The  application,  also,  of  mercurial  ointment  below  the  strapping,  or  rub- 
bing in  a  small  quantity  of  mercury,  often  removes  the  swelling. 

I  never  saw  any  need  for  puncturing  the  testicle,  nor  have  observed 
any  relief  from  following  the  practice  in  the  ver}-  few  cases  in  which  I 
have  seen  it  tried,  nor- can  I  see  why  it  should  relieve  the  pain. 

The  orchitis  which  follows  on  injuries,  mumps,  or  other  causes,  must  be 
treated  on  the  same  general  principles,  and  Dr.  Humphry  gives  a  useful 
caution  to  examine  the  urethra  in  cases  of  recurrent  orchitis,  since  the 
recurrence  often  depends  on  the  presence  of  stricture,  and  can  only  be 
obviated  by  its  cure.  The  acute  orchitis  of  mumps  is  remarkable  as 
being  an  affection  of  the  body  of  the.  gland,  and  as  being  liable,  occasion- 

^  See  Humphry,  op.  cit.,  pp.  111-112. 

*  Dr.  Humphry  says  that  without  treatment  or  even  rest,  most  cases  would  end  in 
resolution. 

^  To  strap  a  testicle,  separate  it  from  its  fellow  and  pull  the  skin  tight,  put  the 
first  strap  round  the  scrotal  cord,  the  next  perpendicular  to  the  iirst  between  the 
testicles,  the  third  half  overlapping  the  first,  and  the  fourth  the  second,  and  so  on 
till  the  whole  gland  is  equably  covered.  The  skin  ought  not  to  be  pinched  any- 
where between  the  straps,  nor  should  the  pressure  be  painful  anywliere.  The  straps 
should  be  about  half  an  inch  wide. 

53 


834  DISEASES    OF    MALE    ORGANS. 

ally,  to  be  followed  by  total  wasting  of  the  organ  ;  but  as  far  as  recorded 
cases  go  this  unfortunate  event  does  not  seem  ever  to  occur  on  both 
sides.  Acute  (or  subacute)  orchitis  also  happens  occasionally  in  gout 
and  rheumatism. 

Chronic  oi'chitis  is  frequently  the  remains  of  the  acute  disease,  but  its 
more  usual  cause  is  syphilis. 

It  consists  in  a  knotty  enlargement  of  tlie  various  lobes  of  tlie  gland, 
proceeding  from  infiltralion  of  lymph  into  tlieir  connective  tissue,  aud 
this  knotty  infiltration  has  given  rise  to  the  name  "tubercular  testis,"  a 
somewliat  unfortunate  one,  since  it  seems  to  be  intended  to  apply  to  a 
disease  wliich  ought  carefully  to  be  distinguished  from  that  whicli  pro- 
ceeds from  scrofula,  to  wliich  the  designation  "tubercular"  would  be 
more  ai)propriate.  As  the  disease  progresses  it  involves  the  whole 
organ  in  a  common  hard  swelling,  in  which  all  distinction  between  testis 
and  epididymis  is  lost,  and  tlie  whole  becomes  uniformly  hard  and  heav3\ 
There  may  also  be  more  or  less  fluid  in  the  tunica  vaginalis,  forming  the 
"  liydrosarcocele  "  of  the  older  authors. 

The  ultimate  end  of  the  disease  is  various.  Not  unfrequently,  if  suc- 
cessfully treated,  it  seems  to  be  entii'cly  cured  with  no  resulting  mischief 
to  the  gland  whatever;  at  other  times  the  affected  portion  of  the  gland 
shrinks,  and  becomes  atrophied  as  the  liver  does  in  cirrhosis,  or  suppura- 
tion ensues,  and  then  the  abscess  may  either  heal  or  hernia  testis  may 
follow. 

Diar/nosis. — Chronic  orchitis  is  a  disease  of  slow  progress,  and  it  seldom 
attains  a  large  size.  It  is  hard  to  distinguish  it  at  first  from  scrofulous 
orchitis,  except  by  the  concomitant  affections  in  the  latter.  And  in  some 
cases  where  chronic  orchitis  has  attained  a  rather  large  size  it  is  very  diffi- 
cult to  distinguish  it  from  malignant  disease  in  its  earlier  stage.  In  fact, 
the  physical  appearance  is  nearly  identical,  and  I  have  seen  the  mistake 
made  l)y  the  greatest  masters  of  surgical  diagnosis.  The  history  and 
rate  of  progress  of  the  diseases  are  dilferent,  but  histories  are  very  often 
deceptive.  The  effect  of  a  course  of  mercury,  however,  and  the  progress 
of  the  disease  while  that  course  is  being  administered  will  enable  the 
surgeon  to  form  the  diagnosis,  though,  probably,  if  it  do  turn  out  to  be 
cancer,  the  nature  of  the  case  may  not  be  ascertained  with  certainty  be- 
fore the  patient's  health  is  broken  down  by  the  combined  effect  of  the 
disease  and  the  mercuiy.  The  presence  of  other  sj-philitic  affections  will 
be  a  material  aid  to  the  diagnosis. 

Treatment. — In  chronic  orchitis,  whether  syphrlitic  or  not,  mercury  is 
generally  successful.  The  best  plan  seems  to  be  to  keep  the  patient  in 
bed  and  l)riiig  him  under  the  influence  of  calomel  and  opium,  slowly  but 
fully,  till  the  gums  are  slightly  tender.  After  about  three  weeks  of  this 
general  mercurial  action  it  may  l)e  ke[)t  up  by  inunction  of  mercurial  oint- 
ment into  the  scrotum,  and  then  iodide  of  potassium  and  sarsaparilla 
should  be  given.  Fiiiall}',  when  the  patient  gets  up  the  testicle  should 
be  strapped. 

ScrofulouH  Orchitis. — Scrofulous  disease  of  the  testicle  consists  in  the 
deposit  of  tubercle  in  and  around  the  tulmlar  structure,  usually  of  the 
epididymis,  with  thickening  and  enlargement  of  the  vas  deferens,  but  it 
is  soinetitnes  confined  to  the  body  of  the  testis.  The  tubercle  softens 
and  makes  its  way  to  the  skin,  causing  first  adhesion  of  the  layers  of  the 
tunica  vaginalis,  then  redness  and  thinning  of  the  coverings  of  the 
scrotum,  and  finally,  bursting  as  a  chronic  abscess,  through  which  often 


CYSTIC    DISEASE    OF    TESTICLE.  835 

the  tissue  of  part  of  the  testicle  protrudes,  and  sometimes  almost  the 
whole  gland.  It  is  frequently  associated  with  genei'al  plitliisis  or  with 
some  other  tubercular  aflection,  and  very  often  both  testicles  are  diseased. 
Occasionally,  instead  of  softening,  the  tubercles  wither  and  calcify,  leaving 
the  organ  little  affected.  It  has  been  noticed  that  in  some  of  these  cases 
an  examination  by  the  rectum  will  disclose  tubercular  deposit  in  the 
vesiculjE  seminales,  and  sometimes  in  the  prostate. 

This  is  only  another  form  of  chronic  orchitis,  and  accordingl}',  it  is  not 
always  easy  to  diagnose  it  from  the  common  or  the  syphilitic  orchitis;  in 
fact,  nothing  prevents  a  strumous  patient  from  having  syphilis,  so  that 
the  two  diseases  may  well  be  mixed  together.  And  as  the  diagnosis  of 
chronic  orchitis  from  cancer  is  sometimes  difficult,  so  is  also  (but  much 
more  rarely)  that  of  strumous  orchitis.  On  this  head,  however,  enough 
has  been  said  above. 

In  the  treatment  the  general  management  of  the  constitutional  condi- 
tion is  far  more  important  than  any  local  treatment;  in  fact,  the  disease 
requires  no  local  treatment  unless  abscess  has  formed.  Such  abscesses 
may  sometimes  be  incised  with  advantage,  and  hernia  testis,  whether 
proceeding  from  strumous  or  from  ordinary  chronic  orchitis,  requires 
treatment,  which  will  be  described  immediatel}'.  Very  rarely  when  the 
testicle  seems  hopelessly  disorganized,  and  is  a  source  of  pain  and  ex- 
haustion to  the  patient,  it  may  be  removed,  though,  as  a  rule,  this  should 
be  avoided.  I  removed  a  testicle  under  these  circumstances  a  short  time 
ago,  for  a  poor  fellow  in  an  advanced  stage  of  phthisis,  though  the  other 
testicle  seemed  also  slightl}'  affected,  and  with  very  great  benefit  to  the 
general  health. 

Treatment. — Hernia  testis  requires,  in  the  first  place,  careful  attention 
to  the  general  health  ;  in  the  next  place,  strict  cleanliness  and  the  removal 
of  all  sources  of  irritation  ;  and,  finally,  some  gentle  stimulant  to  the 
granulations.  Povvdering  them  with  the  nitric  oxide  of  mercur}',  and 
slightly  repressing  them  b}'  strapping  with  an  ointment  of  the  same,  is 
the  favorite  plan  of  treatment  at  St.  George's,  and  is  very  successful 
when  combined  with  good  diet,  rest  in  the  hospital,  and  the  usual  remedies 
for  struma  when  the  disease  is  strumous,  as  is  commonly  the  case.  Under 
such  treatment  as  this,  the  sore  usually  scars  over,  and  no  further  inter- 
ference is  necessary.  Two  kinds  of  plastic  operation  are,  however,  prac- 
ticed in  hernia  testis.  Tlie  only  one  which  I  have  either  performed  or 
seen  is  that  which  consists  in  paring  the  edges  of  the  scrotum,  and 
bringing  it  over  the  exposed  gland.  In  order  that  this  may  succeed  the 
granulations  must  previously  be  brought  into  a  healthy  condition,  and 
when  this  is  the  case  I  have  obtained  a  speedy  permanent  cure  in  this 
way.  Dr.  Pagan,  of  Glasgow,  has  also  described  an  operation  in  wliich 
the  edges  of  the  opening  in  the  tunica  albuginea,  which  he  believes  to 
constrict  the  herniated  testis  as  tiie  neck  of  the  sac  constricts  a  hernia, 
are  notched  with  a  bistoury  and  the  protruding  gland  repressed  before 
the  skin  is  brought  over  it.^ 

P'inally,  in  some  extreme  cases  it  ma}'  be  better,  on  the  whole,  to  re- 
move the  exposed  gland. 

Cystic  Disease. — The  common  cj'stic  disease  of  the  testicle  is  usually 
in  fact  cancer,  with  one  or  more  cysts  in  it.  But  besides  this  malignant 
cystic  tumor,  there  are  cases  of  innocent  tumor  formed  of  a  number  of 

1  See  Dr.  Humphry's  essay,  p.  121. 


836 


DISEASES    OF    MALE    ORGANS. 


Section  of  a  specimen  of  nou-malignant  cystic  disease  of 
the  testicle. — From  a  preparation  presented  by  Mr.  Csesar 
Hawkins  to  the  Museum  of  St.  George's  Hospital. 


cysts  of  variable  size  scattered  over  the  whole  substance  of  the  organ.    Car- 

tilao;e  is  often  found  mixed 

Fit;    379.  '^ 

with  these  tumors,  as  it  is 
with  malignant  tumors  of  the 
testicle.  And  I  have  seen  a 
case  in  which  a  congenital 
tumor  was  developed  in  the 
testicle,  which  contained  nu- 
merous cysts  lined  with  cilia- 
ted epithelium,  and  in  which 
portions  of  bone  were  found. 
The  diagnosis  between  the 
innocent  cystic  tumors  of  tlie 
testicle  and  malignant  disease 
is  very  difficult  indeed,  unless 
the  history  points  clearly  to 
a  non-cancerous  formation, 
and  clear  serum  can  be  here 
and  there  evacuated  by  punc- 
ture. But  on  removal  of  the 
testicle,,  an  operation  which 
must  be  performed  if  the  size 
of  the  tumor  requires  it,  the 
distinction  will  be  made : 
and  then  the  patient  may 
safely  be  assured  that  the  cure  will  be  permanent. 

Endiondroma  of  the  testicle  is  generally  associated  with  cystic  disease  ; 
in  fact,  Mr.  Curling  teaches  that  the  deposit  occurs  in  the  dilated  tul)uli 
seminiferi,  and  that  the  cysts  are  the  dilatations  of  the  tubes.  Thus  tlie 
cartilage  is  found  in  its  initial  stage  in  the  form  of  beads  strung  together 
upon  the  tubes.  In  other  cases,  however,  the  formation  of  the  cartilage 
has  seemed  to  be  more  in  connection  with  the  lymphatics  of  the  testicle, 
as  in  the  celebrated  case  recorded  by  Sir  J.  Paget  in  the  .38th  vol.  of  the 
Med.-Chir.  Trans.,  and  to  which  reference  has  been  made  above  (page 
358),  where  the  growth  spread  up  to  the  great  veins  and  proved  fatal. 
The  purely  cartilaginous  tumors  are  of  somewhat  slow  growth  usually, 
and  of  great  consistence  and  weight.  They  undergo  calcification,  and 
sometimes  probably  cystic  transformation.  Their  removal  is  plainly 
indicated,  and  if  they  are  not  nuxed  with  cancer  (which,  however,  they 
not  uncommonly  arej,  the  prognosis  is  good. 

Innocent  tumors  other  than  inflammatory,  cartilaginous,  or  cystic,  are 
decidedly  rare  in  the  scrotum,  and  as  originating  from  tlie  testicle  still 
rarer.  A  few  scattered  instances  of  what  have  been  described  as  fibrous 
or  fibrocellular  tumors  of  the  testicle  are  recorded;  but  1  think  hardly 
with  sufficient  details  to  make  us  certain  that  those  which  grew  from  the 
testicle  itself  were  not  really  malignant  (see  Humphry,  ojj.  cit.,  p.  138). 
I  have  recorded'  an  instance  of  a  fibrous  tumor  of  the  scrotum  enveloping 
the  testicle,  but  clearly  having  no  organic  connection  with  it,  which  had 
grown  gradually  during  thirty-thiee  years.  This  might  doubtless  have 
been  removed  without  injury  to  the  testicle  at  an  early  period,  but  was 
so  implicated  with  the  cord  and  gland  at  the  time  1  saw  it,  that  they 
were  necessarily  removed  together.     As  well  as  could  be  determined  the 

1  Path.  Trans.,  vol.  xx,  p.  246. 


REMOVAL    OF    TPIE    TESTICLE.  837 

tumor  seemed  to  have  grown  in  the  tunica  vaginalis.  Several  such  in- 
stances are  recorded,  and  it  may  be  said  in  general  that  the  fibrous 
tumors  of  the  scrotum  are  developed  apart  from  the  testicle,  though  their 
removal  often  involves  that  of  the  gland. 

Cancer  of  the  testicle  is  generally  of  the  encephaloid  variety,  and  it 
usually  begins  in  the  body  of  the  gland,  expanding  the  substance  of  the 
testicle,  which  is  then  spread  out  as  a  thin  layer  over  the  tumor,  easily 
known  from  the  cancerous  mass  by  the  seminal  tubes,  which  form  the 
bulk  of  this  expanded  layer,  as  well  as  by  its  general  appearance.  There 
are  often  large  cysts  in  these  tumors,  and  masses  of  cartilage  are  often 
found  here  and  there  in  them.  The  cancer  usually  obliterates  in  great 
part  or  entirely  the  cavity  of  the  tunica  vaginalis,  but  it  rarely  bursts 
through  the  skin  of  the  scrotum.  It  tends  more  to  spread  up  the  cord 
and  into  the  lumbar  glands,  i.  e.,  the  glands  which  lie  around  the  aorta 
and  common  iliac  arteries.  The  inguinal  glands  are  also  sometimes 
affected,  and  that  not  only  when  the  skin  of  the  scrotum  is  implicated. 
As  the  disease  progresses  (and  its  progress  is  usually  rapid)  the  patient's 
health  breaks  down  rapidly,  and  death  ensues  either  from  the  pressure  of 
the  mass  in  the  abdomen,  or  from  its  interference  with  digestion,  or  from 
fungation,  whether  of  the  secondary  tumor  or  the  primary. 

Diagnosis. — The  diagnosis  rests  mainly'  on  the  fact  that  cancer  is  a 
rapidly  increasing  solid  enlargement  of  the  testicle  itself,  unaccompanied 
by  inflammation  ;  but  the  remarks  made  above  in  the  sections  on  hjema- 
tocele,  chronic  and  scrofulous  orchitis,  will  show  that  this  diagnosis  is 
by  no  means  easy  in  the  early  stage  ;  for  at  this  period  there  is  no  can- 
cerous cachexia  (on  the  contrary,  cancer  comparatively  often  occurs  in 
florid  healthy  young  menV  nor  any  perceptible  enlargement  of  the  glands. 
There  is  no  difficulty  in  forming  a  correct  opinion  in  the  latter  stage  of 
cancer,  but  then  the  time  for  surgical  interference  will  probably  have 
passed.  However,  with  a  rapidly  increasing  solid  swelling  an  exploratory 
incision  is  justifiable,  all  the  necessary  arrangements  for  castration  having 
been  made. 

Castration. — The  operation  of  removing  the  testicle  is  a  very  simple 
one,  and  free  from  danger,  at  least  I  cannot  recollect  a  single  case  of 
death  after  the  numerous  operations  of  the  kind  which  I  have  performed 
and  witnessed,  though  these  operations  have  been  performed  chiefly  on 
patients  exhausted  by  illness  and  dissipation,  and  in  those  metropolitan 
hospitals  which  are  falsely  said  to  be  so  unhealthy. 

A  free  incision  is  to  be  made  from  the  situation  of  the  external  inguinal 
ring  down  to  the  bottom  of  the  scrotum.  The  cord  is  then  exposed  and 
the  skin  peeled  oflE"  it  with  the  fingers.  If  it  should  be  diseased  up  to  the 
external  ring  a  director  must  be  passed  into  the  spermatic  canal,  the 
aponeurosis  of  the  external  oblique  divided,  and  the  cord  followed  higher 
up ;  but  this  is  very  seldom  required  in  any  case  which  the  surgeon  has 
selected  for  operation.  The  healthy  part  of  the  cord  is  to  be  caught  in 
a  clamp,  such  as  is  figured  on  page  605,  and  when  it  has  been  entirely 
secured  it  is  divided  above  the  disease,  and  as  far  from  the  clamp  as  cir- 
cumstances permit.  Then  the  tumor  is  rapidly  shelled  out  of  the  scrotum, 
and  if  it  adheres  to  the  skin  all  the  adherent  portion  of  the  latter  is 
removed  as  well  as  a  good  part  of  the  skin  in  the  neighborhood.     The 

1  "  Cancer  of  the  testicle  makes  its  appearance  at  all  periods  of  life,  from  the  earliest 
infancy  to  old  age,  but  is  most  frequent  from  twenty  to  forty.  It  is  rare  after  sixty." 
— Humphry. 


838  DISEASES    OF    MALE    ORGANS. 

cutaneous  vessels  which  are  large  enough  to  give  any  trouble  are  tied, 
anil  then  the  ends  of  the  cut  vessels  in  the  cord  are  picked  up  and  tied. 
If  this  is  done  with  the  carbolized  gut,  and  the  ends  of  the  ligatures  cut 
short,  the  wound  will  often  heal  almost  or  altogetiier  by  first  intention. 

If  a  clamp  is  not  at  hand,  the  cord,  if  it  be  healthy  for  a  considerable 
distance  below  the  ring,  may  be  held  between  the  thumb  and  finger  of 
an  assistant  with  a  piece  of  rag ;  but  this  is  a  very  inferior  method  of 
securing  it.  Or  the  old  plan  of  passing  a  stout  ligature  through  it  to 
hold  it  by  may  be  adopted,  and,  in  fact,  must  be,  if  there  is  not  room  to 
hold  it  otherwise.  I  have  often  seen  the  cord  on  its  division  slip  from 
between  the  assistant's  fingers  up  into  the  spermatic  canal,  and  then  there 
is  very  profuse  bleeding,  and  the  surgeon  has  to  slit  up  the  canal  and 
follow  and  bring  down  the  bleeding  stump  of  the  cord  with  hooked  for- 
ceps. This  danger  is  avoided  by  the  clamp,  provided  the  division  of  the 
cord  is  not  made  too  close  to  it,  in  which  case  the  clamp  also  is  very 
likely  to  slip  off.  I  have  frequently  followed  the  old  plan  of  tying  the 
whole  cord  with  a  strong  double  ligature,  and  have  not  found  any  of  the 
evils,  such  as  pain,  tetanus,  etc.,  which  are  said  sometimes  to  result  from 
it;  but  it  is  a  tedious  method,  as  it  delays  the  patient's  convalescence, 
and  condemns  him  to  suppuration  and  confinement  to  bed  during  the 
long  i)eriod  of  separation  of  the  ligature. 

Before  the  operation  the  patient  should  be  carefully  examined  as  to 
the  presence  or  absence  of  hernia.  Unfortunately  the  immunity  from 
disease  which  this  operation  procures  in  cases  of  cancer  can  only  be 
expected  to  be  short.  The  disease  will  recur  in  the  stump  of  the  cord, 
or  in  the  lumbar  glands,  or  in  some  cases  in  the  opposite  testicle,  or  in 
remote  parts  of  the  body.  Still  the  respite  is  one  usually  of  complete 
health,  and  it  amply  justifies  the  operation,  even  if  we  believe  that  life  is 
not  prolonged  by  it.  No  doubt  also  in  some  cases  the  recurrence  is  long 
delayed.  Mr.  Curling  has  given  four  cases  in  which  the  patients  were 
well  four,  nine,  ten,  and  twelve  years  after  the  operation. 

Dermal  and  other  Fcetal  Tumors  — I  have  spoken  above  (page  353)  of 
the  occasional  occurrence  in  the  scrotum  of  congenital  tumors  containing 
bone,  teeth,  hair,  and  other  structures.  The}'  are  sometimes,  as  it  seems, 
at  first  included  in  the  testicle  itself,  out  of  which  they  grow;  but  at 
other  times  they  have  been  proved  to  be  separable  from  the  gland.  The 
diagnosis  is  usually  obscure  until  suppuration  sets  in  around  the  mass 
and  exposes  a  part  of  it,  or  till  the  whole  tumor  has  been  removed.  This 
should  be  done  in  all  cases,  for  though  they  have  been  spontaneously 
extruded,  yet  operative  removal  is  far  less  dangerous  and  distressing. 
In  the  operation,  it  is  reasonable  to  make  an  attempt  to  preserve  the 
testicle,  thougli  it  will  probably  be  found  impossible  to  do  so. 

Spermatorrluea. — The  consequences  of  masturbation,  the  apprehen- 
sions of  spermatorrluea  and  loss  of  sexual  power,  form  a  highly  un- 
pleasant sul)ject,  which  has  become  still  more  disgusting  as  afibrding  a 
field  for  the  practices  of  some  of  those  unscrupulous  and  degraded  char- 
latans wiio  infest  the  profession,  or  who  falsely  assume  a  connection  with 
it.  These  men  make  money  out  of  the  fears  of  unfortunate  youths,  some 
of  whom  are  merely  nervous  and  are  frightened  at  the  natural  emissions 
by  which  the  testicles  relieve  themselves  from  distension  in  persons  who 
are  not  in  the  habit  of  sexual  intercourse.  The  majority,  however,  of  the 
victims  of  such  fears  are  conscious  of  having  indulged  either  in  solitary 
abuse  or  in  immoderate  sexual  intercourse.     A  judicious  and  honorable 


V  A  R I  C  O  O  E  L  E.  839 

surgeon  cannot  be  better  emi)loyed  than  in  deliverina:  such  patients  from 
the  consequences  of  unfounded  apprehensions, andincnlcatingthe  strength 
of  mind  and  manliness  necessary  to  give  up  vicious  liabits  which  liave  been 
once  contracted.  In  a  work  of  this  kind  it  is  fortunately  unnecessary  to 
dwell  on  this  unsavory  subject.  So  long  as  the  power  of  complete  erec- 
tion continues  and  the  patient  does  not  lose  semen  involuntarily  or  un- 
consciously (which  is  very  rare)  the  genital  organs  will  recover  them- 
selves under  proper  treatment.  Very  frequently  what  is  mistaken  for 
spermatorrhcra  is  some  slight  mucous  discharge,  the  result  of  irritation 
of  the  urethra.  Proper  treatment,  however,  involves  as  its  most  essen- 
tial feature  the  renouncement  of  the  habit  of  self-abuse,  and  either  absti- 
nence or  only  moderate  indulgence  in  sexual  intercourse.  If  the  patient 
cannot  be  persuaded  to  put  this  restraint  on  himself  he  deserves  the  ruin 
that  will  fall  on  him.  With  this,  and  with  tonic  regimen  and  active  exer- 
cise of  body  and  mind,  recovery  will  be  regular  and  permanent.  Real 
impotence  may,  of  course,  occur;  but  it  is  very  rare.  The  cauterization 
of  the  prostatic  urethra,  which  is  so  highly  recommended,  seems  to  me 
often  useful,  less  perhaps  from  its  direct  action  tiian  indirectly,  by  making 
masturbation  or  venereal  excitement  painful. 

On  the  whole  of  this  subject,  and  especially  on  the  morbid  fears  of 
impotence  and  other  horrors  which  haunt  the  unfortunate  victims  of 
"sexual  hypochondriasis,"  I  cannot  do  better  than  refer  the  reader  to 
Dr.  Humpiu'y's  remarks  on  Functional  Disorders  of  the  Testicle^  op.  cit., 
p.  151  et  8(^9.,  and  to  Sir  J.  Paget's  excellent  essay  on  Sexual  Hyjjochon- 
driasis,  in  his  recently  published  Clinical  Lectures. 

AFFECTIONS    OF   THE    CORD. 

Varicocele  is  a  very  common  affection,  at  least  in  its  minor  degrees. 
It  consists,  as  its  name  implies,  in  a  varicose  condition  of  the  pampini- 
form plexus  of  veins  which  return  the  blood  from  the  testicle  into  the 
spermatic  vein.  The  enlarged  veins  are  easil}'  felt  in  the  cord,  "  feeling 
like  a  bag  of  worms,"  as  it  is  always  described,  and  the  description  is  very 
accurate  as  applied  to  the  extreme  instances  of  the  affection.  When  the 
varicose  veins  are  at  all  large  they  can  be  seen  and  the  disease  at  once 
recognized  without  even  touching  the  skin.  Varicocele  may  be  compli- 
cated with  any  other  affection  of  the  testicle  or  with  hernia;  but  it  can 
hardly,  as  far  as  I  can  see,  be  confounded  with  any  of  them,  at  least  by 
any  one  who  has  ever  seen  it  before.  The  swelling,  of  course,  subsides  to 
some  extent  in  the  recumbent  and  increases  in  the  erect  posture  ;  but 
this  is  utterly  unlike  the  disappearance  and  return  of  a  hernia. 

The  enlarged  veins  are  often  the  seat  of  some  amount  of  real  pain  on 
prolonged  standing,  and  still  more  often  of  a  considerable  amount  of 
nervous  pain.  The  testicle  on  that  side  is  often  smaller  than  the  other, 
and  the  patient  is  often  worried  (especially  if  he  has  fallen  into  dishonest 
hands)  by  apprehensions  of  impotence.  As  a  general  rule,  however, 
nothing  can  be  more  unfounded.'  Sir  A.  Cooper  said  with  much  truth  : 
"  Varicocele  should  scarcely  receive  the  title  of  a  disease,  for  it  produces 
in  the  greater  number  of  cases  no  pain,  no  inconvenience,  and  no  dimin- 
ution of  the  virile  powers."  It  follows  incontestably,  if  we  believe  this 
— and  there  are  few  surgeons  of  experience  who  would  question  it — that 
the  number  of  cases  of  varicocele  which  require  serious  treatment  are 

1  Sir  J.  Paget  goes  so  far  as  to  say  of  varicocele  :  "  I  do  not  believe  that  it  ever 
produced  wasting  of  a  testicle,  or  impotence,  or  any  such  thing." — Clin.  Lee.  p.  '274. 


840  DISEASES    OF    MALE    ORGANS. 

very  few  indeed,  and  that  any  snrgeon  who  operates  ver\'  frequently  for 
varicocele  must  operate  on  many  cases  which  he  would  have  done  better 
to  let  alone.  I  do  not  deny  that  such  operations  may  sometimes  be  re- 
quired, under  circumstances  which  1  will  immediately  point  out;  but  the 
great  majority  require  nothing  but  a  bag-truss.  If  the  enlarged  veins 
should  intlame,  rest  in  the  recumbent  posture,  with  the  testicles  raised  by 
a  small  pillow,  fomentation,  and  leeches  are  indicated.  There  are  cases 
(probably  those  in  wliich  the  upper  part  of  the  vein  is  varicose,  and  where 
the  enlargement  of  tlie  lower  veins  depends  on  the  pressure  of  the  column 
above)  in  which  a  light  truss  applied  on  the  ring  gives  relief.  Mr.  Wor- 
raald's  plan  of  drawing  a  part  of  the  scrotum  through  a  ring  of  soft 
metal  coated  with  leather,  the  ring  to  be  pinclied  together  when  the  skin 
has  been  drawn  through  it,  ma}'  be  tried  ;  and  some  surgeons  still  have 
confidence  in  Sir  A.  Cooper's  method  of  removing  all  redundant  scrotum 
and  sewing  it  up,  so  as  to  give  support  to  the  testicle,  which,  however, 
must  still  be  also  supported  by  a  bag-truss.  Nervous  pain  may  be  much 
relieved  by  convincing  the  patient  of  the  trivial  character  of  the  disease. 

Operations  for  Varicocele. — There  will  remain  cases  in  which  the  pa- 
tient will  wish  for  an  operation,  and  that  mainly  for  three  reasons — 
either  that  he  wishes  to  get  into  some  employment,  as  the  array,  from 
which  the  state  of  the  veins  excludes  him  (though  I  believe  army  sur- 
geons do  not  reject  recruits  for  the  slighter  degrees  of  varicocele),  or  he 
suffers  real  and  considerable  pain,  or  the  testicle  is  wasting.  As  to  the 
latter  point,  however,  I  do  not  think  that  any  slight  diff"erence  between 
the  size  of  the  testicles  is  necessaril}^  a  motive  for  operation.  Several 
years  ago  I  was  consulted  by  a  young  man  with  varicocele,  who  was  very 
anxious  to  be  operated  on,  the  varicocele  being  rather  large  and  the  tes- 
ticle much  smaller  than  the  other.  With  difficulty  I  persuaded  him  to 
wait,  and  then,  as  the  testicle  did  not  continue  to  waste,  I  advised  him 
to  give  up  the  idea,  telling  him  that  he  might  safely  marry  Tas  he  wished 
to  do),  and  might  rel_y  on  it  that  he  had  the  same  chance  of  off'spring  as 
anyone  else.  He  is  now  the  fatherof  a  large  family,  and  suff'ers  nothing 
from  his  varicocele,  which  has  remained  stationary.  And  we  must  recol- 
lect that  such  operations  are  by  no  means  free  from  danger  to  life,  and 
that  if  they  sometimes  cure  the  atrophy  of  the  testicle,  on  the  other  hand 
they  sometimes  produce  it.  The  celebrated  instance  of  Delpech  is  in 
point.  He  was  assassinated  by  a  man  on  whom  he  had  operated  for  vari- 
cocele on  both  sides,  and  who  had  lost  sexual  power  in  consequence  of 
the  operation.  The  assassin  was  executed,  and  on  examination  of  his 
body  after  death  both  testicles  were  found  flaccid  and  wasted.  This  un- 
toward result  arose  doubtless  from  obliterating  the  greater  part  of  the 
spermatic  artery  along  with  the  veins.  Usually  the  trunk  of  the  spermatic 
artery  adheres  so  closely  to  the  vas  deferens  that  as  the  latter  is  drawn 
out  of  the  way  of  injury  the  artery  follows  it  and  escapes  also  ;  but  often 
in  dividing  tlie  veins  a  large  artery  is  severed,  and  the  distribution  of 
the  spermatic  artery  is  b}'  no  means  uniform.  Numerous  cases  of  death 
after  the  operation  are  known  to  have  occurred  ;  and  in  cases  which  ulti- 
mately recovered  I  have  seen  so  much  suppuration,  sloughing,  and  other 
evil  consequences,  that  I  have  thought  the  remedy  has  been  much  worse 
than  the  disease.  I  would  therefore  recommend  the  surgeon  to  let  his 
patient  urge  the  operation  upon  him,  and  even  then  only  to  consent  when 
his  judgment  goes  along  with  the  request.' 

The  only  operation  I  have  ever  practiced  for  varicocele  is  that  recom- 

'  See  also  on  this  subject  Paget,  op.  cit.,  p.  68. 


ELEPHANTIASIS    OF    SCROTUM.  841 

mended  by  Mr.  TI.  Lee,  and  which  is  the  same  as  that  which  he  employs 
in  varicose  veins  of  the  leg.  The  vas  deferens  is  to  be  carefully  isolated 
and  held  aside,  then  two  needles  are  to  be  driven  in  beneath  the  enlarged 
veins  and  above  the  vas  deferens  at  a  distance  of  about  an  inch  from  each 
other.  The  veins  are  to  be  compressed  between  these  needles  and  the 
skin  by  a  figure-of-8  ligature  wound  pretty  tightly  over  the  needles,  or  l)y 
an  india-rul)ber  band.  In  the  latter  case  the  needle  is  introduced  with 
the  hand  strung  on  it,  and  the  band  tlien  passed  over  its  point.  When 
the  veins  are  tlius  secured  the.y  are  divided  subcutaneously  in  the  interval 
between  the  needles.  In  doing  this  a  good  deal  of  bleeding  often  takes 
place.  This  is  judged  to  be  arterial  when  it  comes  from  the  upper  or 
cardiac  end,  and  venous  from  the  lower.  If  it  is  too  great  to  be  stopped 
by  the  circular  band  of  strapping  which  is  applied  between  the  needles 
another  needle  must  be  driven  in  more  deeply  either  above  or  below  the 
former  (as  the  hiiemorrhage  is  arterial  or  venous),  so  as  to  command  tlie 
vessel  which  has  escaped  the  needle  previously  put  in.  The  needles  are 
to  be  withdrawn  in  about  four  days.  If  matter  forms  in  the  scrotum  it 
must  have  early  exit. 

Tumors  in  the  Spermatic  Canal. — Fatty  tumors  are  occasionally,  though 
very  rarely,  found  in  the  tissue  of  the  spermatic  cord,  which  very  closely 
simulate  omental  hernia.  The  diagnosis  can  only  be  formed  by  very 
careful  examination,  showing  that  the  tumor  is  movable  by  traction  on 
the  cord,  and  that  the  fingers  can  be  made  to  meet  round  its  base  ;  but  I 
am  not  aware  that  these  tumors  have  ever  been  made  the  subject  of  oper- 
ation. Dr.  Humphry  refers  to  a  few  cases  from  Mr.  Curling's  ex[)erience 
and  his  own,  and  to  some  preparations  of  fatty  and  flbrocellular  tumors 
of  the  cord  in  the  Museum  of  the  College  of  Surgeons. 


AFFECTIONS    OF   THE   SCROTUM. 

(Edema  and  Inflammation. — The  scrotum  is  very  liable  to  passive 
oedema  both  from  general  and  local  causes.  The  chief  point  in  tlie  man- 
agement of  such  affections  is  to  see  that  gangrene  is  averted  by  timely 
punctures  and  fomentation.  Inflammatory  a?dema  also  tolerably  often 
occurs  from  erysipelas,  from  the  contact  of  urine,  and  from  other  causes ; 
and  sometimes  an  abscess  forms  in  the  cellular  tissue  of  the  scrotum  and 
produces  swelling  quite  out  of  proportion  to  the  amount  of  matter  in  it. 
An  abscess  containing  only  a  few  drops  of  pus  will  often  form  a  large 
swelling  which  gives  the  patient  very  grave  uneasiness,  aud  which  I  have 
even  known  mistaken  by  the  inexperienced  for  a  tumor.  Nothing  is  re- 
quired but  a  poultice  and  a  timely  puncture,  after  which  the  swelling  will 
rapidly  subside. 

Ulephautiasis  of  the  scrotum  is  a  disease  of  tropical  countries,  which 
is  only  seen  here,  as  far  as  I  know,  in  those  who  have  contracted  it 
abroad.  There  it  extends  to  an  enormous  size,  making  the  patient's  life 
intolerable,  in  consequence  of  its  weight  preventing  him  from  any  of  the 
necessary  exertions  of  dail}'  life,  and  rendering  any  operation,  however 
desperate,  justifiable. 

Tlie  opportunity  of  seeing  these  cases  in  their  early  stages,  when  the}' 
might  be  amenable  to  pressure  or  to  astringent  applications,  is  hardly 
ever  granted.  In  the  more  moderate  condition,  the  surgeon  would  prob- 
aV)ly  think  it  better  to  dissect  out  all  the  hypertrophied  skin  and  remove 
it  from  the  penis  and  testicles,  even  if  these  organs  were  exposed.  Gran- 
ulation would  cover  them,  and  the  patient  would  in  all  probability  be 


842  DISEASES    OF    MALE    ORGANS. 

restored  to  perfect  health.^  But  wlien  the  disease  has  attained  an  enor- 
mous size,  and  it  is  nevertheless  thought  right  to  remove  it,  no  dissec- 
tion is  possible,  on  account  of  the  excessive  hieinorriiage.  Tiie  mass 
must  be  embraced  in  a  temporary  ligature,  or  in  a  clamp,  in  order  to  re- 
strain the  bleeding  as  far  as  possible,  and  the  whole  mass  be  removed  as 
quickly  as  may  be,  without  regard  to  tlie  genital  organs. 

Such  operations,  however,  are  very  fatal. 

Cancer  of  (he  sci'otinn,  soot-cancer  or  chimney-sweep's  cancer,  is  an 
epithelioma  which  arises  from  the  irritating  properties  of  coal-soot. 
Wood-soot  is  not  so  irritating,  and  therefore  will  not  usually  excite  the 
disease.  Hence  it  is  nearly  unknown  in  countries  where  fires  are  mostly 
made  of  wood  ;  and  on  the  other  hand  it  is  not  entirely  confined  to 
chimney-sweeps  in  this  country,  Init  afiects  also  people  who  deal  much  in 
soot,  as  gardeners — witness  the  well-known  instance  recorded  by  Earle 
of  the  gardener  who  habitually  carried  a  bag  of  soot  over  his  arm  to 
dress  his  beds  with,  and  was  affected  with  soot-cancer  on  that  arm.  No 
doubt  the  development  of  this  epithelioma  is  due  mainly  to  the  continu- 
ance of  the  irritation,  so  that  constant  removal  of  the  soot  will  hinder  it. 
And  therefore  in  the  present  day,  when  people  know  more  of  the  value  of 
cleanliness,  and  when  even  chimney-sweeps  wash  themselves,  this  disease 
has  become  rarer  than  it  used  to  be.  In  fiict,  it  might  proliably  be  banished 
by  the  sweep  using  always  a  clean  or  fi'eshl}'  brushed  suit,  and  thoroughly 
washing  himself  whenever  he  comes  home. 

As  usually  seen  it  forms  a  foul  epitheliomatous  ulcer  on  one  side  or 
sometimes  on  both  sides  of  the  scrotum,  with  hard,  prominent  granula- 
tions and  raised,  irritable  edge,  very  frequentl}^  complicated  with  enlarge- 
ment of  the  inguinal  glands,  and  in  some  cases  (but  rarely)  spreading 
inwards  to  aflect  the  coverings  or  even  the  bod_v  of  the  testicle.  The 
diseased  tissues  must  be  freely  removed,  and  it  is  justifiable  to  do  this  at 
any  period  of  the  disease,  provided  the  whole  of  the  morbid  tissue  can  be 
comprised  in  the  incision,  even  though  the  testicles  should  be  entirely 
denuded,  or  though  it  should  be  necessary  to  remove  them  as  well  as  the 
diseased  skin.  The  enlargement  of  the  inguinal  glands,  if  not  excessive, 
constitutes  no  bar  to  the  operation,  nor  does  it  even  necessitate  the  re- 
moval of  the  glands  themselves.  Constant  experience  sliows  that  on  the 
removal  of  the  epitheliomatous  ulcer  the  enlarged  glands  will  subside. 
But  if  the  glands  are  unusualh' large  and  hard  it  is  better  to  excise  them 
at  the  same  time. 

If  after  tlie  removal  of  the  scrotum  the  flaps  of  skin  can  meet  over  the 
testicles  without  much  traction,  the  wound  should  be  united.  But  if  not, 
granulations  will  cover  the  testicles,  and  the  cicatrix  will  form  an  excel- 
lent substitute  for  the  scrotum. 

AFFECTIONS   OF   THE    PENIS. 

Cancer  of  the  penis  is  also  usually  epithelial,  and  like  cancer  of  the 
scrotum,  is  usually  excited  by  some  irritation,  of  which  the  secretion 
retained  behind  a  congenitall}'  phimosed  prepuce  is  a  well-known  instance. 
This  liability  of  persons  with  congenital  phimosis  to  cancer  of  the  penis 


^  Two  interestine;  casps  wern  latoly  reported  by  Dr.  Lloyd,  of  the  Indian  Army, 
in  which  tumors  65  pounds  and  61  ])ounds  in  wciiijht  respectively  were  removed  with 
success,  and  the  penis  and  testes  dissected  out  of  the  mass.  In  one  of  these  cases  the 
exposed  testes  hunp  down  nearly  as  low  as  the  ankles  afti-r  the  operation,  yet  on 
convalescence  they  had  completely  retracted  to  the  normal  level. — Lancet,  Aug.  29, 
1874. 


AFFECTIONS    OF    THE    PENIP.  843 

forms  one  motive  for  circumcision  in  such  cases,  tlioiioli  ordinary  consid- 
erations of  cleanliness  would  be  quite  snflicient  vvitliout  any  such  motive.^ 

The  only  special  point  in  the  surgery  of  cancer  of  the  penis  is  to  dis- 
tinguish it  from  secondary  or  tertiary  syphilitic  ulceration  of  the  glans 
penis.  And  there  can  be  no  doubt  that  in  many  cases  the  ))enis  has  t)een 
amputated  for  supposed  cancer,  which  has  been  only  this  form  of  ulcera- 
tion, and  that  many  of  the  cases  of  permanent  recovery  after  am})utation 
for  supi^osed  epithelioma,  have  been  of  this  nature.  In  some  cases,  again, 
a  confusion  may  have  been  made  with  common  warty  growth,  tliough  this 
is  less  likely.  The  characteristic  hardness  around  the  sore  and  tiie  hard 
surface,  indurated  edge,  and  prominent  granulations  of  tlie  epitheliom- 
atous  ulcer  will  distinguish  it  from  tlie  syphilitic;  or  if  any  doubt  re- 
mains, in  consequence  of  the  history  or  the  coexistence  of  teitiary  syph- 
ilis, a  gentle  and  prolonged  course  of  mercury  will  settle  the  question, 
and  this  is  best  administered  in  the  form  of  vapor.  Sometimes  melan- 
otic deposit  is  mixed  with  the  cancer  of  the  penis,  as  in  a  remarkable  case 
which  I  communicated  to  the  Pathological  Society  a  few  years  ago,  and 
which  is  figured  above  on  p.  372. 

When  the  diagnosis  of  cancer  is  clear,  the  removal  of  the  whole  penis 
at  a  level  well  behind  that  of  the  disease  is  imperative. 

Amjjutation  of  the  Penis. — The  old  rough  plan  of  simply  rutting  the 
organ  off  with  the  loss  of  a  large  quantity  of  blood  from  artci'ies  which  the 
surgeon  proceeded  afterwards  to  tie,  leaving  his  patient  exhausted  l)y 
hjemorrhage,  would  now  be  unjustifiable.  The  penis  is  to  be  constricted 
by  a  clamp  (see  p.  605),  by  means  of  which  it  can  be  removed  without  the 
loss  of  a  single  drop  of  blood,  and  all  the  vessels  whose  mouths  can  be 
discerned  are  to  be  tied.  Then  the  clamp  should  be  slightly  relaxed,  and 
new  vessels,  will,  perhaps,  be  found  which  require  ligature.  P'inally  the 
affair  is  completed  without  any  haemorrhage  or  witli  very  triflinii  loss,  and 
the  patient  generally  recovers  without  any  serious  symptom.  IJut  unless 
some  care  is  taken  to  prevent  the  cicatrization  of  the  cut  end  of  tlie  ure- 
thra, a  most  painful  stricture  will  result,  and  I  have  seen  the  oi'ifice  of 
the  urethra  contracted  to  the  size  of  a  pinhole.  This,  however,  is  the 
result  of  unpardonable  negligence.  Always  after  the  amputation  of  tlie 
penis,  as  soon  as  the  bleeding  is  suppressed,  a  director  should  be  i)assed 
down  the  urethra,  and  the  tube  should  be  slit  down  with  scissors  on  its 
lower  aspect  for  about  half  an  inch.  Then  the  flaps  of  mucous  meml>rane 
should  be  picked  up  and  attached  to  the  skin,  whereby  a  large  valvular 
opening  will  be  left  that  will  show  no  tendency  to  contract.  The  old  p\an 
of  passing  bougies  constantly  to  keep  the  end  of  the  urethra  from  con- 
tracting, is  painful  and  far  less  eflicient. 

Congenital  phimosis  should  always  be  treated  by  circumcision.  It  is 
a  malformation  which  often  leads  to  considerable  irritation,  causing  many 
of  the  symptoms  of  stone  in  the  bladder,  and,  as  stated  before,  it  un- 
doubtedly predisposes  to  epithelioma. 

Ci7-cumcision. — The  operation  of  circumcision  is  a  very  easy  one  and 
requires  no  special  apparatus.  A  director  is  passed  up  between  the  glans 
and  prepuce  on  the  dorsal  aspect,  and  the  knife  thrust  through  the  skin 
and  made  to  cut  out.  The  mucous,  or  internal,  layer  is  never  sufiiciently 
divided  by  this  cut,  but  should  be  afterwards  incised  to  the  same  extent 
as  the  outer  skin.     Any  adhesions  between  the  i)repuce  and  glans  must 

1  Sir  J.  Paget  has,  however,  pointed  out  that  in  many  cases  the  orifice  of  the  pre- 
puce may  be  so  stretched  by  constant  gentle  traction  that  the  glans  can  ultimately  be 
exposed,  and  the  operation  avoided. 


844  SURGICAL    DISEASES    OF    WOMEN. 

be  divided.  Then  the  two  la^'ers  should  be  removed  with  sharp  scissors 
by  a  cut  ruunino-  parallel  to  the  corona  glaiulis  evenly  all  round  the  organ, 
leaving  just  enough  of  the  inner  layer  to  hold  the  stitches.  This  is  now 
to  be  united  to  the  skin  by  a  few  points  of  fine  suture.  Sometimes  the 
artery  of  the  fn^num  requires  twisting  or  tying.  The  wound  is  to  be 
covered  with  oiled  lint  and  the  penis  raised  by  a  pad  between  the  thighs 
and  a  bandage.     The  sutures  may  be  removed  on  the  third  day. 

When  the  opening  is  merely  narrowed,  but  the  prepuce  is  not  inordi- 
nately long,  it  is  surticient  to  slit  up  both  its  la3'ers  thoroughly  and  unite 
the  lips  of  the  little  wound  with  sutures. 

A  few  cases  of  persistent  priapism  have  been  recorded  from  obscure 
causes,  wliich  are  best  treated  by  low  diet,  tartar  emetic,  or  bromide  of 
potassium.  In  other  cases  priapism  results  from  disease  or  injury  of  the 
nervous  centres,  from  irritation  of  the  urethra  or  prostate,  or  from  injury 
during  connection.  The  treatment,  in  these  cases,  must  be  directed  to 
the  cause. 

Gangrene  has  been  known  as  one  of  the  sequelae  of  typhus  fever,  or 
from  paraplegia,  and  a  remarkable  case  of  spontaneous  gangrene  of  the 
penis  foUovved  by  recovery  is  recorded  by  Mr.  Partridge  in  the  twentieth 
volume  of  the  Medical  Times  and  Gazette. 


CHAPTER    XL. 

SURGICAL  DISEASES  OF  THE  FEMALE    ORGANS  OF    GENERATION. 

The  diseases  of  the  female  organs  of  generation  which  come  within  the 
province  of  the  surgeon  are  as  follows: 

MalformaHonH. — 'I'lie  commonest  malformation  (if  it  deserve  so  grave 
a  name)  is  tiie  closure  or  adhesion  of  ttie  labia,  which  is  often  seen  in  in- 
fants and  sometimes  passes  undetected  so  as  to  be  presented  to  the  notice 
of  the  surgeon  in  later  childhood.  Very  rarely  it  is  allowed  to  persist  till 
puberty.  It  is  not  unfrequently  confounded  with  imperforate  hymen  ; 
but  the  mistake  ought  not  to  be  committed  ;  for  the  adhesion  is  between 
the  laliia  majora  quite  in  front  of  the  hymen,  and  it  is  not,  at  least  in  the 
early  years  of  life,  in  any  sense  membranous.  After  years  of  neglect  it 
may  become  tougher  and  require  division  with  a  knife  and  director;  but 
usually  all  tliat  is  necessary  is  to  pull  the  parts  asunder  forcibly,  and  pre- 
vent readhesion  V)y  keeping  the  labia  sei^arated  with  a  piece  of  oiled  lint. 

Imperforate  hymen,  is  a  much  graver  malformation,  especially  if  (as  is 
almost  always  tiie  case)  it  escapes  detection  in  infancy,  and  the  patient 
first  applies  for  advice  wiien  the  collection  of  the  menstrual  fluid  has  con- 
sideral)ly  dilated  the  cavity  of  tlie  uterus.  Under  these  circumstances 
any  slight  operation,  thougli  it  is  indispensable,  involves  serious  danger. 
Hence  tiie  advice  usually  given  in  such  cases  to  wait  for  operation  till 
after  puberty,  seems  quite  erroneous.     If  the  condition  of  parts  is  dis- 


TUMOR    OF    THE    URETHRA.  845 

covered  in  childhood,  it  is  easy  and  perfectly  safe  to  remove  a  small  por- 
tion of  the  hymen,  so  as  to  make  an  opening  into  the  vagina.  But  when 
the  nterine  cavity  becomes  distended  with  menstrual  fluid,  or  with  the 
treacly  inspissated  remains  of  sucli  fluid,  it  is  often  noticed  that  after 
an  opening  has  been  made  in  the  hymen^  the  uterus  is  thrown  into  spas- 
modic action,  and  the  Fallopian  tube,  which  is  dilated  as  well  as  the 
uterus,  often  gives  way  under  this  action,  causing  extravasation  of  the 
fluid  into  the  peritoneal  cavity,  and  fatal  peritonitis.' 

Im-perforak'.  Vagina. — 'IMie  point  of  chief  importance  in  these  cases  is 
to  decide  whether  the  case  is  merely  one  of  imperforate  hymen,  or  whether 
the  vagina  is  itself  imperforate,  and  if  so,  whether  the  uterus  is  present  or 
absent.  Mr.  Jonathan  Hutchinson  speaks  on  this  head  as  follows:  ''When 
there  is  evidence  of  the  retention  of  menstrual  fluid,  and  therefore  of  the 
presence  of  a  uterus,  and  probably  of  a  vaginal  cavity  above  the  occlusion, 
the  case  will  come  fairly  under  surgical  treatment.  In  the  first  place,  the 
character  of  the  obstructing  medium  must  be  determined.  If  the  obstruc- 
tion be  found  within  an  inch  or  two  inches  of  the  vulva,  and  if  it  be  con- 
stituted by  a  membrane,  stretched  across  an  otherwise  well-formed  vagina, 
the  case  is  probably  one  of  imperforate  hymen.  In  some  of  these  during 
coughing,  the  propulsion  of  the  fluid  downwards  may  easily  be  felt,  or  the 
distended  membrane  may  even  be  forced  as  low  as  the  vulva  itself." 

When  the  obstruction  is  of  only  slight  thickness  there  is  no  diflficulty 
about  the  treatment.  The  patient  being  secured  in  the  lithotomy  posi- 
tion a  puncture  is  made  into  the  collection  of  fluid  and  this  is  enlarged 
with  the  fingers,  director,  and  forceps.  It  seems  that  a  free  opening  is 
safer  than  a  small  one,  as  rendering  the  forcing  action  of  the  uterus  less 
likel}'  to  act  on  the  Fallopian  tubes.  If  the  obstruction  be  of  consider- 
able extent,  a  very  careful  dissection  in  the  direction  of  the  supposed 
upper  part  of  the  vagina  must  be  undertaken,  assisted  by  the  finger  in 
the  rectum  and  by  a  staff  in  the  bladder.  If  this  has  to  be  done  deeply, 
the  deeper  incisions  are  more  safely  made  horizontally- ;  but  in  such  cases 
the  operation  is  doubtless  both  embarrassing  and  dangerous. 

1  do  not  speak  here  of  cases  of  doubtful  sex,  since  it  is  only  in  the 
rarest  possible  circumstauces  that  any  surgical  treatment  is  required, 
and  advice  as  to  the  sexual  relations  lies  more  in  the  province  of  the 
accoucheur. 

Vascular  Tumor  of  Urethra. — A  very  troublesome  affection,  and  one 
which  is  sometimes  very  difllcult  to  treat,  is  the  small  vascular  tumor,  or 
urethral  hsemorrhoid,  which  is  sometimes  found  surrounding  the  meatus 
of  the  female  urethra.  In  structure  it  much  resemljles  a  nrevus.  It  oc- 
casions a  good  deal  of  pain  and  irritation  ;  leads  to  troublesome  fre- 
quency in  micturition;  renders  sexual  intercourse  very  paiiiful,  some- 
times impossible,  and  often  bleeds  a  good  deal.  Though  the  disease 
appears  trifling,  it  is  often  very  troublesome  in  its  treatment,  recurring 
again  and  again,  even  after  apparently  com|)lete  removal.  Three  methods 
of  treatment  are  in  use, — caustics,  the  ligature,  and  excision.  Tlie  first 
are  often  successful  if  freely  used  and  if  suflKciently  strong.     The  pure 

1  Let  nie  in  passing  just  call  the  reader's  attention  to  this  amongst  other  facts 
which  prove  that  the  assertion  ordinarily  made  in  anatomical  works  tluit  tiie  Fal- 
lopian tube  opens  into  the  peritoneal  cavity  cannot  be  true,  at  least  in  its  literal  sense. 
There  is  no  membrane  separating  the  two  cavities,  and  the  one  can  be  made  to  open 
into  the  other  by  passing  a  probe;  but  that  they  do  not  communicate  during  life  is 
proved  by  the  fact  that  no  interchange  of  fluid  ever  takes  jilace,  however  much  the 
peritoneum  may  be  distended  by  dropsy  or  the  Fallopian  tube  by  retained  menses. 


846  SURGICAL    DISEASES    OF    WOxMEN. 

nitric  afid,  repeatedly  applied,  will  often  ultimately  eradicate  the  growth, 
with  little  pain  and  no  risk  or  confinement  to  bed;  but  it  often  fails, 
The  actual  or  t)alvanic  cautery  is  perhaps  more  efficient,  but  requires 
aniesthesia  for  its  a|)|)lication.  If  only  a  portion  of  the  circumference  of 
the  meatus  is  involved  in  the  growth,  the  latter  may  be  encircled  in  a 
ligature  passed  deeply  under  its  base,  through  healthy  tissues,  care 
being  taken  to  keep  the  urethra  open  while  passing  the  ligature,  so  that 
the  opposite  wall  of  the  canal  may  not  be  included  in  it.  But  the  most 
etticient  plan  is  to  dissect  the  growth  out  completed  with  the  knife  or 
scissors,  taking  care  to  carry  the  incisions  through  healthy  tissues.  No 
formidable  bleeding  need  be  apprehended  ;  but  even  after  this  operation, 
I  have  seen  the  growth  return,  and  if  it  be  necessary  to  cut  deeply,  there 
is  often  i)artial  incontinence  of  urine,  i.e.,  the  patient  is  obliged  to  attend 
to  the  first  desire  to  empt}'  the  bladder,  otherwise  the  nrine  will  very 
soon  pass  in  spite  of  her. 

Tumors  of  (he  Labium. — Cj'stic  and  other  innocent  tumors  are  not 
uncommon  in  the  tissue  of  the  labium.  The  cysts  are  probably  always, 
and  certainly  they  usually  are,  formed  by  the  obliteration  of  the  duct  of 
a  mucous  follicle,  as  is  often  seen  in  the  mouth.  This  is  sometimes  the 
result  of  irritation,  so  that  they  are  not  unfrequently  developed  soon 
after  marriage.  They  contain  a  glairy  mucus,  and  they  are  only  trouble- 
some if  the  patient  is  in  the  habit  of  sexual  intercourse,  or  if  they  inflame 
and  suppurate,  which  will  occur  occasionally.  Thej^  may  be  dissected 
out  entirely,  or  they  may  often  be  cured  by  laying  thera  freely  open  and 
stuffing  the  orifice  with  lint;  or  still  more  certainly  by  clearing  away  all 
the  secretion  and  rubbing  the  interior  with  caustic.  The  recommenda- 
tion of  the  treatment  by  laying  the  cyst  open  is  that  it  does  not  render 
the  employment  of  chloroform  necessar}',  nor  are  any  assistants  re- 
quired, '['he  removal  of  tlie  entire  cyst  is,  of  course,  more  certainly 
successful. 

Fil>rous  tumors  also  form  in  the  labium,  and  are  frequently  allowed 
to  attain  an  enormous  size.  They  then  become  pendulous,  and  greatl}'' 
interfere  with  all  movements,  as  well  as  with  the  functions  of  the  parts. 
Their  removal  is  sometimes  attended  with  ranch  hfemorrhage,  and  when 
this  is  apprehended,  in  consequence  of  the  size  of  the  mass,  or  its  vascular 
appearance,  it  is  prudent  to  control  the  bleeding  by  a  temporary  ligature 
or  clamp  passed  round  the  base  of  the  tumor  beyond  the  part  at  which  it 
is  removed. 

With  regard  to  condylomata,  raucous  tubercle,  and  other  syphilitic 
affections  of  the  labium,  I  do  not  know  that  I  need  add  anything  to  what 
has  been  said  in  other  parts  of  the  work. 

Hi/pcr trophy  of  /he  Labia  and  Clitoris. — The  tissues  of  the  labia  and 
clitoris  are  sometimes  so  much  hypertrophied  liy  the  constant  recurrence 
of  inflammation  (whether  sy[)hilitic  or  not),  or  by  elephantiasis,  that  it 
becomes  iiecessaiy  to  remove  the  diseased  part.  In  such  a  case  the  sur- 
geon should  be  prepared  for  free  lucmorrhage,  and  as  the  base  of  the 
growth  is  usually  too  extensive  to  be  included  in  a  clamp,  the  best  plan 
is  to  pass  a  numi)er  of  stout  harelip  pins  through  it,  and  having  removed 
the  diseased  tissue  pretty  close  to  these  pins,  and  tied  any  large  vessels, 
to  pass  the  twisted  suture  round  the  pins  tightly  enough  to  restrain  any 
further  oozing. 

Cancer  of  the  external  parts  is  almost  always  epithelial.  It  ma}- occur 
as  a  primary  disease,  and  then  usually  in  later  life,  or  it  may  be  devel- 
oped on  a  venereal   ulcer.     It  rapidly  affects  the  inguinal  glands.     Its 


RUrTURED    PERINEUM.  847 

diagnosis  from  tertiary  syphilitic  affection  rests  on  the  cliff'nsed  hardness 
and  irregular  surface  of  the  ulcer,  and  on  the  affection  of  the  glands,  as 
well  as  on  the  history.  From  rodent  ulcer,  which  is  sometimes,  tiiough 
rare!}',  found  in  the  same  situation,  it  is  distinguished  by  the  distinct 
deposit  which  is  found  in  ei)ilhelioma  ;  but  the  diagnosis  is  not  of  very 
great  importance,  since  both  require  the  same  treatment.  Early  and 
complete  excision  is  urgently  demanded  ;  although  there  is  great  prob- 
ability of  return,  much  more  so  than  in  the  analogous  disease  of  the 
scrotum.  The  enlarged  glands  should  be  removed  at  the  same  time,  if 
they  are  decidedly  indurated.  When  the  patient  will  not  submit  to  the 
removal  by  the  knife,  the  use  of  caustics  must  be  substituted,  but  is  de- 
cidedly inferior. 

Rupture  of  the  perineum  is  an  accident  following  on  parturition,  and 
in  its  highest  grades  constitutes  a  serious  infirmity  which  imperatively 
calls  for  a  surgical  operation.  The  slighter  ruptures  can  often  be  brought 
to  heal  at  once,  by  bringing  the  parts  together  with  a  stitch  and  keeping 
the  legs  together  for  some  time  after  parturition,  the  strictest  cleanliness 
being  enforced.  But  when  the  whole  tissue  of  the  perineum,  including 
the  si)liincter,  has  been  lacerated,  so  that  there  is  little  or  nothing  to 
separate  the  vagina  and  rectum,  this  will  probal)ly  not  succeed,  though 
even  in  such  cases  the  attempt  should  be  made.  When  the  rupture  is 
extensive  the  patient  has  very  imperfect  control  over  the  f?eces,  and  often 
can  hardly  walk  about  from  a  sense  as  if  the  uterus  were  coming  down. 
Frequently  there  is  a  considerable  amount  of  prolapsus.  The  operation 
for  the  restoration  of  the  perineum  relieves  the  prolapsus,  at  any  rate  for 
a  time;  and  in  some  cases  of  the  prolapsus  where  the  vagina  is  very 
wide,  an  operation  exactly  similar  may  be  performed  with  advantage, 
even  if  there  has  been  no  rupture  of  the  perineum. 

The  operation  is  thus  performed.  The  patient  is  narcotized,  and  se- 
cured in  the  lithotomy  position  ;  the  hair  is  removed  from  the  labia  as 
far  forward  as  is  necessary ;  the  vagina  is  well  opened  by  means  of  a 
duckbill  speculum.  The  two  flaps  are  marked  out  with  the  knife  of  a 
quadrangular  form  by  two  lines  running  parallel  to  each  other  along  the 
labia  about  three-quarters  of  an  inch  from  the  orifice  of  the  vulva.  These 
are  joined  b\^  a  transverse  incision  just  in  front  of  the  anus.  Another  in- 
cision is  drawn  in  the  middle  line  from  the  centre  of  this  last  to  about 
three-quarters  of  an  inch  inside  the  vagina,  and  from  this  the  base  of  the 
flap  extends  in  a  slanting  direction  forwards  and  outwards  to  join  the 
incision  on  the  labium  as  far  forwards  as  the  surgeon  thinks  fit.  The 
further  forward  the  dissection  is  carried  the  more  firm  and  resisting  will 
the  new  perineum  be  ;  !»ut  it  is,  of  course,  undesirable  to  narrow  the  ori- 
fice too  much.  After  marking  out  the  flaps,  the  surgeon  proceeds  to  care- 
fully dissect  up  the  mucous  membrane  and  skin  from  the  whole  of  the 
part  so  marked  out.  On  the  rectovaginal  septum  this  is  facilitated  by 
an  assistant  putting  his  forefinger  in  the  bowel.  Great  care  must  be 
taken  to  remove  every  vestige  of  the  mucous  membrane.  Mr.  J.  Hutch- 
inson inclines  to  the  practice  of  preserving  the  fla[)s,  leaving  them  at- 
tached by  their  base  in  the  vagina,  paring  them  down  as  much  as  is  nec- 
essary^, and  sewing  them  together  in  order  to  form  a  covering  for  the 
wound.  I  have  not  found  much  advantage  from  this  proceeding  in  the 
cases  in  which  I  have  tried  it.  When  the  denudation  is  complete,  and 
the  bleeding  (which  is  often  free)  has  been  checked  by  torsion  of  the 
vessels  and  the  free  application  of  iced  water,  the  parts  are  to  be  brought 
together  with  the  quilled  suture.     For  this  purpose  three  or  four  loops  of 


848  SURGICAL    DISEASES    OF    WOMEN. 

Strong"  silk  or  whipcord  (according  to  the  depth  of  the  new  perineum) 
are  i)assed  througli  the  whole  thickness  of  the  tissues.  This  is  most 
readily  etiected  by  means  of  a  long  and  very  strong  deeply  curved  needle 
on  a  handle — called  Baker  Brown's  needle.  The  point  of  this  is  entered 
just  inside  the  left  tuber  ischii  and  the  ligature  is  cari'ied  to  the  very 
bottom  of  the  denuded  part,  and  the  point  brought  out  near  the  right 
tuberosity.  The  posterior  suture  should  not  cross  the  cleft  at  all,  but 
should  be  buried  in  the  rectovaginal  septum,  when  that  septum  exists. 
If  such  a  needle  is  not  at  hand,  the  loops  can  easily  be  passed  with  a 
common  ciirved  needle,  exactl}-  as  in  fissure  of  the  palate  (p.  576),  draw- 
ing the  ligature  across  from  one  side  to  the  other  by  passing  one  loop 
inside  the  other.  There  are  now  a  series  of  loops  on  the  right  side  of 
the  perineum,  and  a  series  of  double  ends  on  the  other.  A  piece  of  bou- 
gie is  passed  througli  all  the  loops,  another  is  laid  between  the  double 
ends,  the  patient's  thighs  are  brought  together,  and  these  deep  sutures 
are  tied  very  firmly.  The  pressure  on  the  deep  parts  forces  the  cutaneous 
edges  in  the  middle  outwards.  These  must,  therefore,  be  attached  to- 
gether with  silver  sutures.  Finally,  if  the  vaginal  flaps  of  mucous  mem- 
brane have  been  preserved,  the}^  must  be  attached  to  the  front  of  the 
wound.  In  some  cases  where  the  rectum  has  been  much  lacerated,  and 
there  is  tension  on  the  parts,  it  is  necessary  to  make  free  lateral  incisions 
through  the  sphincter  on  either  side,  sloping  towards  the  tuberosities  of 
the  ischium  ;  but  this  is  not  required  in  ordinary  cases,  and  should 
always  be  avoided  if  possible.  Ice  may  be  applied  in  the  vagina  if  oozing 
of  blood  occurs  after  the  operation.  Before  the  operation  the  patient 
should  be  freely  purged,  so  that  there  ma}^  be  no  call  to  pass  motions  for 
some  time,  and  artificial  constipation  is  to  be  kept  up  for  about  a  fort- 
night by  the  administration  of  about  ten  droi)s  of  laudanum  twice  a  day. 
The  water  must  be  drawn  off  careful!}'  b}'  the  surgeon  or  a  dexterous 
attendant  twice  or  three  times  a  day,  as  may  be  necessary.  On  no  ac- 
count should  the  patient  be  allowed  to  pass  any  urine  for  about  ten  dajs. 
Then  she  may  pass  it  in  the  prone  position.  She  should  be  fed  as  well 
as  her  appetite  permits.  It  is  scarcely  necessary  to  say  that  the  period 
immediately  succeeding  menstruation  should  be  selected  ;  but  in  spite  of 
this  the  operation  may  provoke  premature  recurrence  of  the  flow,  and 
this  may  prevent  the  healing  of  the  wound.  There  is  usuall.y  a  great 
deal  of  foul  discharge,  which  should  be  carefully  syringed  away  with 
Condy's  fluid.  The  operation  is  a  very  successful  one.  In  some  cases 
fistulous  oi)enings  are  left  in  the  new  perineum  after  union,  but  they  can 
generally  be  easily  united  again.  In  one  unfortunate  case  I  have  seen 
death  from  pliletiitis  and  pyjemia,  but  such  a  disaster  is  purely  excep- 
tional. 'I'he  worst  which  is  to  be  apprehended  is  that  union  may  not 
occur,  and  this  will  not  generally  preclude  success  in  another  attempt. 

Frola}).'<i(.s  Uteri. — As  I  ha\e  said  above,  the  same  opei'ation — viz.,  to 
bring  the  lower  part  of  the  vagina  together  so  as  to  narrow  its  orifice 
and  thicken  the  peiineum,  is  sometimes  advisable  in  prolapsus  uteri ;  but 
as  the  weakness  which  leads  to  prolai)sus  is  more  in  the  parts  al)ove  the 
uterus  than  in  those  below,  it  can  only  be  looked  on  as  an  accessory 
measure.  The  most  important  part  of  the  treatment  of  extreme  prolap- 
sus is  rest  in  the  horizontal  position  with  the  uterus  completely  reduced. 
If  this  can  be  insisted  on  for  a  sufficient  lime,  most  cases  of  prolai)sus 
will  be  fcnind  to  be  manageable — «.  (^.,  though  not  cured,  the  patient  will 
be  restored  to  fair  con) fort  and  a  certain  amount  of  activity  by  the  use  of 
the  pessary.  If  the  orifice  of  the  vagina  is  very  wide,  no  doubt  the  opera- 
tion above  described  will  assist  in  maintaining  the  position  of  the  uterus  ; 


VESICOVAGINAL    FISTULA.  849 

but  unless  care  is  taken  afterwards,  the  external  pnrts  will  certainly 
yield  to  the  pressure  of  the  uterus,  and  the  patient  will  be  as  bad  as  ever 
again. 

Vofiinal  GijHtocele. — The  stretching  of  the  vagina  in  parturition  or  some 
accidental  inii)erfection  of  its  niusculai-  structure  may  so  weaken  its  walls 
that  a  kind  of  partial  hernia  of  the  bladder  throngii  them  is  produced. 
This  is  called  ''vaginal  c3stocele" — a  bulging  tunior  in  the  roof  of  the 
vagina,  whi(^h  disappears  when  the  catheter  is  used,  and  pressure  on 
which  may  cause  the  escape  of  urine.  The  patient  often  suffers  from 
some  difficulty  in  making  water  and  irritation  of  the  bladder.  The 
remed}'  consists  in  reducing  the  projecting  bladder  entirely,  then  paring 
a  lunated  edge  of  the  vagina  on  each  side,  bringing  the  edges  together 
in  the  median  line,  and  keeping  the  bladder  em{)ty  by  means  of  the 
catheter  retained  in  the  urethra  till  the  vaginal  wound  is  soundly  healed. 

Vaginal  Fidulse.. — Vesicovaginal  and  rectovaginal  fistulas  are  lesions 
which  are  caused  by  parturition,  and  generally  l»y  the  prolonged  pressure 
of  the  foetal  head,  though  in  some  cases  bj'  direct  laceration,  either  in  the 
passage  of  the  fretus  or  by  instruments.'  As  most  of  these  injuries  are 
accomi)anied  b}'  loss  of  substance,  cicatrization  has  often  taken  place 
around  the  seat  of  perforation,  and  the  vagina  is  narrowed  and  puckered 
by  scars.  In  such  cases  the  first  step  towards  cure  is  to  divide  such 
cicatrices  and  keep  the  vagina  dilated  until  the  parts  have  healed.  Yesi- 
covaginal  fistula  is,  on  the  whole,  easier  to  cure  than  rectovaginal,  at 
least  in  uncomplicated  cases ;  but  it  is  sometimes  complicated  with  in- 
jury to  the  uterus  or  the  urethra,  which  hardly  permits  of  entire  re- 
covery. Thus  the  sloughing  may  have  implicated  the  os  uteri  so  that 
the  bladder  and  uterus  form  almost  one  cavity,  or  the  urethra  may  be 
entirely  separated  from  the  bladder  or  even  altogether  destroyed.  In 
such  very  severe  cases  it  may,  perhaps,  be  better  to  al)stain  from  opera- 
tion altogether,  and  merely  provide  the  patient  with  a  urinal,  giving  her 
instructions  to  wash  the  parts  well  out  with  dilute  mineral  acid  as  often 
as  is  necessary  to  prevent  the  formation  of  sabulous  concretions.  In 
other  cases  an  imperfect  cure  may  be  effected  by  uniting  the  back  wall 
of  the  vagina  to  the  anterior  lip  of  the  fissure,  so  that  the  uterus  and 
bladder  fall  into  one  cavity  and  the  patient  menstruates  through  the 
urethra.  I  have  seen  cases  in  which  tliis  obliteration  of  the  vagina  has 
taken  place  spontaneously,  so  that  the  os  uteri  was  completely  hidden. 
But  in  the  common  cases,  in  which  there  is  no  great  loss  of  sul)stance 
and  the  fistula  does  not  involve  the  uterus,  a  cure  may  generally  be  ob- 
tained, though  it  is  often  necessary  to  repeat  the  operation  several  times. 
The  operation  is  thus  performed  :  Tiie  patient  is  narcotized  and  placed 
in  the  lithotom}-  position,-  the  vagina  thoroughly  exposed  by  the  duckbill 
speculum,  and  the  os  uteri  is  gently  dragged  down  as  far  as  possible 
with  a  vulsellum,  so  as  to  get  the  fistula  well  within  reach.  Then  the 
whole  of  the  mucous  membrane  of  the  vagina  is  pared  away  around  the 
opening,  the  bladder  being  interfered  with  as  little  as  possible,  and  the 
sutures  are  passed  so  as  to  take  up  only  the  tissues  in  the  vagina  and  not 
lodge  the  sutures  in  the  bladder.     The  object  is  to  bring  the  vesical  mu- 


*  In  one  very  singular  case  relatccT  in  Dr.  Emmet's  work  on  Vesicovaginal 
Fistula,  that  lesion  was  caused,  not  by  accident  of  jiarturition,  but  by  the  accidental 
explosion  of  a  pistol  which  had  fallen  on  the  ground  at  th(^  woman's  t'ect. 

2  In  America  the  prone  position  on  the  hands  and  knees  is  often  adopted,  tuid  the 
patient  is  frequently  not  under  antesthesia. 

54 


850  SURGICAL    DISEASES    OF    WOMEN. 

cons  membrane  together  as  closely  as  possible,  but  not  to  leave  anj' 
suture  in  the  cavity  which  can  conduct  the  urine  into  the  wound.  The 
fistula  is  brouglit  together  longitudinally,  transversely,  or  obliquely,  ac- 
cording to  circumstances,  so  that  tliere  may  be  as  little  tension  as  possi- 
ble on  the  sutures.  The  sutures  can  be  secured  b^-  twisting  them  with 
the  "  wire-twister,"  which  is  a  stem  carrying  a  small  cross-piece  of  metal 
having  a  hole  on  eacli  side.  Tlie  ends  of  tlie  wire  are  passed  through 
these  two  holes.  The  suture  is  run  up  as  tight  as  necessary,  and  then  by 
rotating  the  handle  tlie  ends  are  securely  twisted.  This  instrument  en- 
ables the  operator  to  tie  the  sutures  at  any  depth  where  the  fingers  could 
not  reach.  The  cleft  having  been  completely  closed,  if  any  tension  ex- 
ists it  may  be  possible  to  relieve  it  by  dividing  cicatricial  bands  in  the 
neighborhood,  and  tlien  an  S-shapcd  cathetei-  of  soft  metal  is  placed  in 
the  urethra,  and  will  keep  its  place  by  its  own  shape,  or  the  catheter  ma}'' 
be  tied  in  ;  a  bag  is  attaclied  to  it  and  changed  as  often  as  necessary,  or 
the  tube  is  left  opening  into  a  vessel  below  the  bed.  This  catheter  must 
be  gently  clianged  twice  a  day  at  first,  and  tlien  every  day;  but  the  su- 
tures need  not  be  removed  for  an  unlimited  time.  After  a  fortnight  if  no 
water  has  passed  into  the  vagina  the  patient  may  be  relieved  from  the 
catlicter,  and  in  anotlier  week  the  sutures  may  be  examined,  and  if  all 
is  healed  may  be  gently  withdrawn.  If  the  opening  is  narrowed  but  not 
closed,  a  few  weeks  must  be  allowed  to  elapse,  until  all  irritation  has  long 
subsided,  before  the  operation  is  repeated. 

The  iypcration  for  rectovaginal  fiatula  is  exactly  the  same  in  principle, 
the  great  object  iDeing  to  exclude  the  sutures  from  the  rectum,  so  that  no 
air  or  matter  from  the  bowel  may  get  into  the  vaginal  wound.  The 
bowels,  as  in  ruptured  perineum,  must  be  kept  from  action  for  about  a 
fortnight,  and  if  there  is  much  tension  on  the  sutures  it  may  be  necessary 
to  divide  the  sphincter.  Careful  syringing  of  the  vagina  is  very  necessary 
to  prevent  the  accumulation  of  foul  discharge  around  the  healing  wound. 

Uterine  poli/jji  are  sometimes  quite  small  and  almost  sessile,  growing 
from  one  of  the  lips,  or  near  the  cervix  uteri,  and  consisting  of  the 
enlarged  glandulte  Nabothi,  or  of  hypertrophied  mucous  membrane,  or 
cellular  tissue.  These  tumors  bear  some  analogy  to  the  common  mucous 
polypi  of  the  nose.  They  never  attain  any  large  size  ;  but  ma}-  cause  a 
good  deal  of  inconvenience  from  hasmorrhage  at  irregular  intervals,  and 
from  leucorrhoea.  Their  removal  can  never  involve  much  difficulty  or 
danger.  The  tumor  being  well  exposed  is  to  be  twisted  off,  or,  if  more 
sessile,  removed  with  the  scissors,  bleeding  being  repressed  by  the  appli- 
cation of  perchloride  of  iron  or  the  cautery,  before  the  patient  is  allowed 
to  recover  from  anesthesia. 

The  ordinary  polypi,  however,  consist  of  filirous  tissue  mixed  with 
unstriped  muscle.  They  grow  from  the  muscular  wall  of  the  uterus,  and 
often  attain  an  enormous  size.  When  they  pass  into  the  cavit.y  so  as  to 
assume  the  form  of  [)olyi)i,  they  usually  become  detached  from  the  mus- 
cular tissue  of  the  uterus,  and  are  completely  covered  with  mucous  mem- 
brane, though  this  is  not  always  the  case.  Though  they  may  cause  very 
great  haemorrhage,  they  are  not  usually  in  themselves  very  vascular. 
They  are  peculiarly  prone  to  calcareous  degeneration,  and  preparations 
exist  showing  such  tumors  converted  almost  entirely  into  an  earthy  mass 
covered  by  the  mucous  memlirane. 

IMiere  ai-e,  again,  other  polyj)!  much  looser  and  more  vascular  than 
these,  which  are  sarcomatous  in  structure,  and  i)rone  to  obstinate  recur- 


HYSTEROTOMY.  851 

rence  after  veinoval  ;  and  malignant  disease  will  sometimes  grow  in  a 
pendnlous  form  like  })olypns  ;   hut  both  these  events  are  rare. 

The  general  suhjeot  of  fibrous  or  fibromuscular  tumor  and  polypus  of 
the  uterus  belongs  more  to  obstetrics  than  to  surgery  ;  but  a  few  words 
must  be  said  about  the  removal  of  these  tumors.  Polypi,  i.  e.,  the  pendu- 
lous tumors  attached  to  the  interior  of  the  uterus,  may  be  removed  with 
case  when  their  attachment  can  be  exposed,  and  this  is  usually  near  tlie 
OS  uteri.  And  even  if  tiie  surgeon  cannot  penetrate  to  the  seat  of  im- 
plantation of  the  polypus,  he  may  be  sure  that  any  small  remnant  of  the 
neck  of  the  polypus  which  he  may  have  been  obliged  to  leave  will  witlier 
away.  Small  polypi,  or  those  whose  neck  is  thin,  may  be  safely  removed 
by  torsion.  Tlie  patient  is  to  be  narcotized,  and  the  polypus  being  well 
exposed  is  to  be  grasped  near  its  root  with  a  vulsellum  forceps,  and 
slowly  twisted  round  till  it  is  loose.  If  the  neck  is  so  thick  that  this 
would  not  be  expedient,  the  wire  ecraseur'  may  be  used  to  divide  the 
neck,  or  the  galvanic  ecraseur  may  be  used  with  still  less  risk  of  haemor- 
rhage or  of  unhealthy  inflammation.  The  old  plan  of  passing  a  ligature 
round  the  base  with  Gooch's  double  canula,  and  leaving  the  canula  con- 
taining the  tightened  ligature  in  position,  is  now,  I  believe,  almost 
abandoned.  It  has  its  advantages,  however,  for  tumors  with  a  very 
thick  neck,  since  the  tension  of  the  ligature  can  be  gradually  increased 
as  it  cuts  into  the  base  of  the  tumor. 

Enncleo.tion  of  Fibrous  Tumor. — Imbedded  fibrous  tumors  may  be 
removed  by  enucleation,  but  as  this  is  a  very  dangerous  and  uncertain 
operation,  it  should  only  be  used  when  the  patient  is  in  great  danger 
otherwise  of  dying  from  hremorrliage.  The  os  and  cervix  uteri  must  be 
previously  dilated  with  tents,  and  the  uterus  dragged  down  by  gradual 
traction  as  near  the  external  parts  as  possible,  so  as  to  bring  the  tumor 
well  into  view.  If  the  latter  is  covered  by  uterine  tissue,  this  must  be 
divided  b}'  the  knife,  and  then  the  tissue  of  the  tumor  must  be  separated 
from  that  of  the  uterus  with  the  finger,  or  any  convenient  blunt  instru- 
ment, suflBciently  to  allow  of  the  imi)lantation  of  a  strong  pair  of  vul- 
sellum forceps  in  its  substance.  Then  the  tumor  is  to  be  gradually 
dragged  outwards,  the  uterus  being  pulled  down  and  everted  more  or 
less  until  the  whole  growth  can  be  separated,  when  the  uterus  is  to  be 
returned. 

Hysterotomy. — Again,  fibrous  tumors  of  the  uterus  may  grow  upwards 
towards  the  peritoneal  cavity,  and  these  sometimes  soften  and  simulate 
ovarian  tumors,  as  will  be  afterwards  pointed  out.  In  other  cases,  without 
any  softening,  the  growth  proceeds  to  such  an  extent  as  to  become  dan- 
gerous to  life  from  its  pressure,  or  to  render  it  impossible  for  the  patient 
to  perform  any  of  the  ordinary  duties  of  life.  Under  such  circumstances 
the  operation  of  removing  the  tumor  together  with  a  portion  or  the  whole 
uterus,  or  even  the  ovaries  also,  has  been  performed  and  with  some  success, 
though  I  need  not  say  that  the  gravest  consideration  of  the  symptoms 
and  probable  danger  of  the  case  if  left  to  itself  is  ne  .'ssary  before  so 
very  dangerous  an  operation  is  undertaken.  In  the  o  ly  case  in  which 
I  have  myself  operated,  tlie  operation  was  undertaker  in  the  mistaken 
belief  that  tiie  tumor  was  ovarian,  and  it  proved  imme<    ately  fatal. 

The  operation  resembles  ovariotomy  in  its  early  steps.  Tlie  tumor 
having  been  completely  exposed,  and  freed  from  adhesions,  if  it  has  any, 

1  This  is  an  ecraseur  in  which  the  chain  shown  in  Fig.  21Z,  p.  606,  is  replaced  l)y 
a  noose  of  stout  wire;  in  using  this,  or  the  galvanic  ecraseur,  it  is  essential  to  divide 
the  tissues  very  sh>wly. 


852  SURGICAL    DISEASES    OF    WOMEN. 

is  to  be  tapped,  if  it  has  softened  in  an_y  part,  in  order  to  facilitate  its 
extraction,  or  if  lobnlated,  portions  may  be  removed  with  the  ecrasenr  to 
diminish  its  bullv.  Wlien  the  base  is  reached  it  may,  in  some  cases,  be 
secured  with  a  strong  clanij),  in  otliers  divided  by  means  of  the  ecrasenr. 
The  operation  is  one  wdiicli  is  not  often  practiced  at  present,  and  more 
definite  information  as  to  tlie  indications  before  operation  is  required  be- 
fore we  can  say  how  lar  it  lias  been  justifiable  in  those  cases  in  which  it 
has  been  performed. 

Ujccision  of  Os  Uteri  for  Cancer. — Cancer  of  the  uterus  commences 
not  uncommonly  at  the  os,  and  in  some  cases  it  is  detected  at  a  period 
when  it  has  not  spread  too  far  for  removal.  In  such  cases  much  benefit 
has,  no  doubt,  sometimes  been  produced  by  the  excision  of  the  diseased 
structures.  The  operation  is,  however,  a  dangerous  one,  and  in  most 
cases  the  relief  is  only  temporary.  Still,  if  the  surgeon  can  be  sure  of 
the  diagnosis,'  if  the  disease  has  not  spread  to  the  vagina,  and  if  the 
general  health  is  still  good,  it  is  his  duty  to  make  the  attempt. 

The  parts  may  be  removed  with  the  knife  or  the  whipcord  or  galvanic 
ecrasenr,  and  the  preference  for  one  over  the  other  method  depends  in  a 
great  measure  on  the  shape  of  the  mass.  The  uterus  must  be  gently 
drawn  down  as  far  as  possible.  If  the  knife  or  scissors  is  to  be  used, 
the  uterus  must  be  commanded  by  a  ligature  of  stout  wire  driven  through 
both  its  lips,  and  the  part  in  front  of  the  wire  cut  away  in  a  conical  shape, 
the  wound  being  bevelled  towards  the  uterus.  The  actual  cautery  and 
perchloride  of  iron  must  be  at  hand  to  repress  haemorrhage,  and  the  wire 
can  be  made  use  of  to  tie  a  compress  of  lint  steeped  in  the  perchloride 
over  the  wound  if  necessary. 

The  application  of  the  ecrasenr  is  facilitated  by  passing  needles  through 
the  uterus  just  behind  the  part  to  be  removed  and  slipping  the  chain  over 
these  needles. 

Ovarian  Tumors. — The  ovary  is  liable  to  tumors  of  all  kinds.  The 
solid  tumors  are  fibroid  or  malignant.  The  fibroid  tumors  are  difficult  of 
diagnosis  from  similar  tumors  of  the  uterus,  which  are  sometimes  pedun- 
culated, and  attain  a  very  large  size.  The  fibroid  tumors  also  are  at  first 
difficult  to  distinguish  from  the  cancerous,  but  the  different  rate  of  growth 
will  settle  the  question  ultimately.  No  surgical  interference  is  advisable 
in  solid  tumors  of  the  ovary.  Those  which  are  innocent  will  probably 
cease  to  grow,  and  the  patient  will  ultimately  become  accustomed  to  their 
presence,  while  in  malignant  disease  an  operation  would  do  nothing  but 
harm. 

Cy^ta  of  the  Broad  Ligament. — 13ut  the  ovarian  tumors  with  which  sur- 
geons are  most  concerned  are  cystic.  These  cysts  are  serous,  colloid, 
or  dermal.  The  serous  cysts  are  unilocular  or  multilocular.  The  uniloc- 
ular cysts  are  occasionally  situated,  not  in  the  ovary  itself  but  in  the 
broad  ligament,  and  result,  it  is  believed,  from  degeneration  of  the  re- 
mains of  tlie  Wolffian  body  or  of  the  duct  of  Miiller.^     They  seldom  attain 

'  Mr.  Hutchinson  says:  "It  is  not  by  any  means  an  easy  matter  in  many  cases  to 
make  a  contidenl  differential  diagnosis  between  a  simple  or  venereal  ulceration  of  the 
OS  uteri  and  one  ot  a  malignantnatiire  in  an  early  slJige.  The  tendency  of  tiie  latter 
to  bleed,  its  warty  and  thickened  edges  and  fetid  disehargo,  are  the  chief  symptoms 
on  which  to  rely.  The  surgeon  must  notice  especially  whc;ther  there  be  any  tendency 
to  new  growth,  and  if  practicable  a  small  portion  of  the  e(lg(i  sliould  be  removed  for 
microscopic  examination.     Pain,  if  severe,  is  a  very  suspicious  sign." 

^  bee  Osborn,  in  St.  Thomas's  Ilosjjiial  Reports,  1875. 


OVARIAN    TUMORS. 


853 


Fig.  380. 


a  size  large  enough  to  call  for  surgical  operation,  though  one  containing 
eighteen  pints  was  successfully'  removed  by  Mr.  Ctesar  Hawkins,  and  is 
preserved  in  the  nuiseum  of 
St.  George's  Hospital.  In  the 
ovary  cystic  tumors  attain  an 
enormous  size.  Like  c^ystic  tu- 
mors in  other  organs  tliey  are 
either  simple  single  cysts,  or 
proliferous  ;  and  the  latter  are 
eitlier  merely  cystigerous  (mul- 
tilocular  cysts)  or  with  a  solid 
intracystic  growtli,  whicli  may 
be  of  a  sarcomatous  nature. 
Otlier  compound  cysts  contain 
colloid  matter,  and  are  some- 
time spoken  of  as  instances  of 
"  alveolar  cancer."  Mr.  Hut- 
chinson, however,  points  out 
that  tliere  is  no  proof  that  any 
of  the  forms  of  ovarian  tumor 
are  really  cancerous  except  the 
encephaloid,  althougii  the  more 
compound  the  tumor  is,  and 
the  more  active  the  intracystic 
growth,  the  more  does  it  ap- 
proacli  in  clinical  characters  to 
malignancy.  Dermal  cysts  (p. 
353)  occur  here  more  frequently 
than  in  any  other  situation,  but 
are  indistinguishable  from  the 

other    forms    before   operation,        a  watery  eystiu  the  broad  ligament  of  the  uterus,  which 
unless  tiiere  is  a  history  of  con-    '^  perfectly  separate,  both  from  that  viscus  and  from  the 

genital  origin.  * 

Tlie  cliaracter  of  the  fluid 
contained  in  ovarian  cysts  va- 
ries greatly.  Tlie  cysts  in  the 
broad  ligament  usually  contain 
nearly  watery  fluid,  as  the  en- 
cysted hydroceles  of  the  testis  sometimes  do,  but  the  true  ovarian  cysts 
contain  a  fluid  rich  in  albumen,  which  is  generally  less  serous  than  the 
fluid  c)f  peritoneal  dropsy,  and  is  very  commonly  thick  and  glutinous, 
like  thick  gum.  It  also  often  contains  a  good  deal  of  cholesterin.  Often 
it  is  very  deep  in  color.  Sometimes  it  is  seropurulent,  and  occasionally 
is  unmixed  pus.  Suppuration  in  an  ovarian  cyst  is  accompanied  in  some 
cases  by  definite  symptoms,  constant  pain,  acute  tenderness,  some  fever, 
and  daily  rise  of  temperature,  but  it  occurs  also  vvithout  any  such  symp- 
toms. I  have  recorded  one  such  case  in  tlie  Medico- (Jhirnrgical  Tra))s- 
actions,  vol.  Iv,  and  a  very  short  time  since  I  assisted  at  the  removal  of 
a  dermal  cyst  of  the  ovary  which  contained  pure  pus,  and  in  which  there 
had  been  no  suspicious  symptoms  whatever.  ' 

Tlie  gradual  growth  of  an  ovarian  C3^st  produces  what  is  called  ovarian 
dropsy,  i.  e.,  a  distension  of  the  belly  with  a  very  large  quantity  of  fluid, 
which  occasions  much  the  same  symptoms  as  peritoneal  dropsy,  viz., 
shortness  of  breath,  inability  to  take  exercise,  cedema  of  the  lower  limbs 


ovary,  a  shows  the  sharp  edge  of  the  cyst,  formed  appar- 
ently by  the  round  ligament  of  the  uterus ;  b,  the  os  uteri  ; 
c,  the  P'allopian  tube,  between  which  and  the  round  liga- 
ment a  bristle  is  stretched;  d  is  placed  on  the  ovary,  which 
is  not  very  distinctly  seen  in  this  view  of  the  preparation, 
but  Is  quite  separate  from  the  cyst. — St.  George's  Hospital 
Museuin,  Ser.  xiv,  No.  13L 


854  SURGICAL    DISEASES    OF    WOMEN. 

from  pressure  on  the  large  veins,  and  sometimes  pressure  on  tlie  bladder, 
causing-  irritation,  or  in  rare  cases  difficulty  in  making  water. 

Tcrniinalions  of  Orarian  Dropsij. — If  the  disease  is  allowed  to  run  its 
natural  course  it  may  i)rove  fatal  from  the  effects  of  its  pressure,  causing 
ditlicuUy  in  taking  food,  and  wasting  in  consequence  of  the  loss  of  albu- 
minous material  into  the  cyst ;  or  it  may  burst  into  the  pei-itoneal  cavity, 
and  then  usually  causes  death,  though  a  few  instances  have  been  recorded 
in  which  the  tluid  was  absorbed  again  from  the  i)eritoneum  ;  and  it  is  even 
possible  that  spontaneous  cure  may  thus  take  place.  In  rarer  cases  the 
tumor  may  ulcerate  into  the  bowel,  bladder,  or  vagina,  and  this  also  is 
almost  sure  to  produce  death.  In  some  rare  cases,  as  it  seems,  the  tumor 
may  cease  to  secrete,  and  the  fluid  even  may  be  to  a  certain  extent  re- 
absorbed. Tiie  suppuration  of  the  tumor  will  probably  lead  to  its  ulcera- 
tion, and  this  must  almost  necessarily  be  fatal. 

Tlius  we  see  that  the  progress  of  ovarian  dropsy  is,  speaking  generally, 
to  death,  though  its  rate  of  progress  varies  greatly. 

Diagtiosis. — The  diagnosis  of  ovarian  droi)sy  is  not  by  any  means  easy 
in  all  cases,  as  is  seen  b}'  the  mistakes  which  are  known  to  occur  in  the 
practice  of  even  experienced  ovariotomists.  The  first  question  is  as  to 
peritoneal  dropsy.  Peritoneal  dropsy  depends  on  disease  of  the  kidneys, 
heart,  or  liver,  so  that  it  is  necessary  in  first  taking  charge  of  a  case  of 
supposed  ovarian  tumor  to  ascertain  that  these  viscera  are  healthy.^  Then 
the  ph3'sical  examination  of  the  abdomen  differs  in  peritoneal  and  ovarian 
dropsy.  In  the  former  tlie  whole  abdomen  is  uniformly  dnll,  unless  the 
abdomen  is  so  little  distended  that  the  transverse  colon  floats  to  the  sur- 
face and  its  resonance  is  perceptible.  In  the  latter  the  transverse  colon 
is  quite  buried,  but  the  flanks  are  resonant,  and  the  line  of  the  c^st  can 
often  be  traced  by  making  the  patient  turn  from  side  to  side,  and  ob- 
serving hovv  the  resonance  to  percussion  advances  or  recedes.  The  tumor 
can  also  in  many  cases  be  felt  in  the  pelvis  by  examination  from  the  vagina 
or  from  the  rectum;  and  very  frequently  the  surrounding  cysts  can  be  felt 
as  hard  masses  in  the  wall  of  the  principal  tumor.  In  cases  of  doubt  de- 
cisive information  may,  very  likely,  be  obtained  by  tapping,  for  the  ap- 
pearance of  the  dense,  sticky,  gumlike,  and  often  deeply  colored  fluid 
which  is  often  found  in  ovarian  cysts  is  quite  different  from  the  greenish 
serum  of  dropsy. 

Another  source  of  error  is  mistaking  a  softened  fibroid  tumor  of  tlie 
uterus  for  an  ovarian  cyst.  In  a  case  of  this  kind  which  happened  to 
myself  as  much  as  a  gallon  of  fluid  was  contained  in  the  softened  fibroid, 
and  the  mobility  and  relations  of  the  tumor  exactly  resembled  one  of  the 
ovar}-.  But  if  an  accurate  history  can  be  obtained  it  will  be  found  that 
there  has  been  flooding,  the  uterine  sound  will  probably  discover  that  tlie 
cavity  of  the  uterus  is  elongated,  and  the  tumor  is  not  fluid,  but  semi- 
fluid, so  that,  though  a  good  deal  of  fluid  can  be  obtained  from  it  by 
taj)ping,  it  does  not  run  out  freely  as  from  a  cyst. 

Large  cysts  are  also  found  in  the  kidney,  and  these  have  been  operated 
upon  by  mistake  for  ovarian  dropsy.  Such  tumors,  however,  generally 
present  more  towards  one  flank  than  ovarian  tumors  do,  their  contents 
are  more  or  less  urinous,  and  if  the  hand  can  be  got  into  the  rectum 
(page  616,  footnote)  the  difference  in  tiieir  relations  may  probably  be 
perceived. 


1  It  is  true  thnt  disease  of  the  viscera  does  not  necessarily  preclude  the  occurrence 
of  ovarian  drupisy,  but  it  would  at  any  rate  contraindicate  any  attempt  at  removal  of 
the  ovary. 


OVARIOTOMY.  855 

Pregnancy  has  been  mistaken  for  ovarian  dropsy,  but  in  most  cases 
from  haste  or  carelessness.  Whenever  the  patient  is  of  chihll»earing 
age  tlie  possil)ility  of  pregnancy  siioukl  not  be  overlooked,  and  careful 
examination  should  be  made  for  its  usual  signs.  It  is  more  common 
and  less  discreditable  to  overlook  pregnancy  vviien  it  complicates  ovarian 
dropsy,  but  even  in  cases  of  decided  ovarian  tumor,  if  tlie  patient  is 
married  or  likely  to  be  pregnant — L  e.^  if  the  menses  have  not  appeared 
for  some  time — the  breasts  should  be  inspected,  the  abdomen  carefull}'- 
auscultated,  the  os  uteri  examined,  and  "  ballottement "  searched  for. 

Lastly,  tumors  of  various  kinds,  chiefly  those  in  the  omentum,  and 
even  phantom  tumors,  have  l)een  mistaken  for  ovarian  cysts;  but  a  care- 
ful surgical  examination  will  prevent  any  such  error.  Phantom  tumors 
very  commonly  disai)pear  under  anaesthesia. 

Treatment. — When  the  diagnosis  is  settled  the  question  of  treatment 
occurs.  There  are,  in  the  present  day,  for  ordinary  cases  of  ovarian 
tumor,  only  two  methods  of  treatinent  worth  discussing,  viz.,  tapping 
and  excision.  The  injection  of  iodine  has,  I  think,  been  satisfactorily 
proved  to  be  more  dangerous  than  ovariotomy,  as  well  as  being  very 
uncertain  ;  and  the  establishment  of  a  permanent  opening  into  the  tumor 
is  reserved  for  cases  in  which,  from  extensive  adhesions,  the  attempt  to 
remove  the  tumor  is  unsuccessful. 

In  selecting  between  these  two  plans  of  treatment  a  great  considera- 
tion is  the  age  of  the  patient.  Ovarian  cysts  are  sometimes  detected  in 
early  life;  the  dermal  tumors  are  probably  always  congenital,  though 
they  do  not  usually  show  till  later  in  life  ;  and  other  cysts  may  be  de- 
veloped in  childhood.  It  would  be  impossible  to  expect  prolonged  life 
in  such  cases,  except  after  ovariotomy.  When,  on  the  other  hand, 
ovarian  disease  appears  late  in  life,  which  is  rare,  the  patient  is  probably 
better  advised  in  avoiding  ovariotomy  if  possible.  But  much  will  depend 
on  the  sequelae  of  a  first  tapping,  and  I  am  myself  disposed  to  think  that, 
as  a  general  rule,  ovariotomy  ought  not  to  be  performed  except  after  a 
preliminary  and  exneriraental  paracentesis.  This  is  useful  in  many  ways, 
and  hardly  ever  causes  any  bad  symptoms.  Afterwards,  if  the  tumor 
refills  only  slowly,  the  patient  may  be  better  advised  in  having  it  tapped 
repeatedly  rather  than  running  the  risk  of  the  radical  operation.  But 
repeated  tapping  is  by  no  means  devoid  of  danger,  and  in  cases  of  young 
healthy  women  ovariotomy  is  on  the  whole  far  preferable. 

Ovariotomy  is  thus  performed.  The  patient  should  have  been  well 
purged,  and  should  have  her  legs  covered  with  a  pair  of  warm  drawers. 
The  room  should  be  warm— nearly  70°.  A  large  band  is  to  be  passed 
round  the  belly,  of  waterproof  cloth,  with  a  hiatus  for  the  incision.  She 
should  be  in  a  semi-recurabent  position  at  the  edge  of  a  firm  table,  with 
her  feet  supported  by  assistants.  The  bladder  should  l)e  empty.  Full 
anaesthesia  liaving  l)een  produced  by  ether, ^  an  incision  is  made  in  the 
linea  alba  from  a  little  belovv  the  um'hilicus  to  a  little  above  tlie  pubes, 
and  tiiis  is  deepened  l\y  successive  strokes  of  the  knife  till  the  peritoneum 
is  exposed.  The  peritoneum  having  been  opened,  some  ascitic  fluid  very 
commonly  escapes.  The  surgeon  introduces  liis  fore  and  middle  fingers. 
and  sweeps  them  round  over  the  cyst  to  ascertain  in  the  first  place  that 
he  is  really  in  the  peritoneal  cavity,  and  secondly,  to  feel  for  adhesions.'' 

1  Mr.  Spencer  Wells,  I  believe,  uses  the  bicliloride  of  methylene;  but  ether  seems 
to  have  all  the  necessary  properties,  being  little  liable  to  cause  sickness  and  not  pro- 
ducing depression,  whilst  it  is  undeniably  safer  than  methylene. 

'^  I  know  of  no  way  of  determining  the  presence  or  absence  of  adhesions  in  most 
cases.     Sometimes  they  may  be  detected  by  a  certain  crackling  of  fluid  in  them,  and 


856  SURGICAL    DISEASES    OF    AV  O  M  E  X. 

These,  if  present,  are  gently  separated  from  the  wall  of  the  cyst,  until 
tlie  wliole  hand  is  introduced,  and  the  cyst  is  freed  from  adhesions  on  all 
sides.  Now  the  trocar  is  plunoed  into  the  cyst.  To  tlie  trocar  a  tube  is 
fixed  which  goes  into  a  pail  on  the  floor.  As  the  cyst  is  punctured  the 
surgeon  seizes  it  with  a  vulsellnni  and  draws  it  forward,  so  as  to  keep  the 
trocar  opening  as  much  as  possible  outside  of  the  vvound  in  the  belly,  and 
he  and  his  assistants  take  care  that  the  trocar  does  not  slip.  Mr.  Spencer 
Wells  has  introduced  a  trocar  the  end  of  which  is  hollow  and  can  be 
retracted  within  the  canula,  and  which  has  a  set  of  hooks  on  each  side. 
As  the  cyst-wall  collapses  with  the  escape  of  the  fluid  it  is  drawn  into  the 
grasp  of  the  hooks,  and  thus  the  caniila  is  firmly  fixed.  I  have  used  tliis 
trocar  with  good  results;  but  if  the  cyst-wall  is  thin  the  hooks  are  liable 
to  tear  it,  and  then  it  is  better  to  trust  to  gentle  traction  with  blunt  for- 
ceps. As  the  fluid  escapes  and  the  cyst  collapses  the  surgeon  passes  his 
hand  gently  round  the  sides  and  top  of  the  tumor  to  ascertain  that  there 
are  no  adhesions  behind,  to  divide  them  carefully  if  thei'e  are,  and  to 
deliver  tlie  cyst.  And  at  this  stage  of  the  operation  the  operator  may 
find  reason  to  extend  his  incision  upwards  even  as  liigh  as  the  ensiform 
cartilage.  At  the  same  time  the  assistants  (one  on  each  side)  keep  up 
guarded  pressure  on  either  side  of  the  abdomen,  so  that  the  intestines 
may  not  protrude.  When  the  first  cyst  has  been  emptied  it  may  be  nec- 
essary to  puncture  others  in  the  same  way  before  the  tumor  can  be  de- 
livered, and  in  doing  so  the  escape  of  cyst-fluid  into  the  peritoneal  cavity 
is  still  more  probal)le.  Or  the  tumor  may  be  adherent  to  the  liver  or 
omentum  above,  to  the  intestines  behind,  or  to  the  wall  of  the  abdomen 
or  pelvis.  These  posterior  adhesions  are  the  most  formidable  complica- 
tion in  ovariotomy,  especially  those  to  the  intestine.  The  omentum  con- 
tains large  vessels,  and  it  may  be  necesary  to  tie  it  with  catgut  befoi-e 
freeing  it  from  the  tumor;  otherwise  there  is  little  trouble  in  dealing 
with  omental  adhesions.  Adhesions  to  solid  viscera  are  not  generally 
very  formidable,  but  the  intestine  is  sometimes  almost  imbedded  in  the 
wall  of  the  tumor.  In  such  a  case  the  peritoneal  lining  of  the  tumor  must 
be  slowly  and  carefully  peeled  off  along  with  the  bowel.  It  is  as  well, 
perhaps,  to  have  a  clamp  like  that  figured  on  p.  656  at  hand,  so  that  any 
broad  hand  of  adhesion  may  be  securely  clamped  while  it  is  divided  and 
its  vessels  tied  with  catgut.  This  appears  preferable  to  searing  the  bleed- 
ing surface  with  the  actual  cautery,  though  this  is  a  plan  adopted  with 
success.  Finally,  the  tumor  having  been  freed  and  its  remains  delivered 
through  the  wound,  its  pedicle  must  be  secured.  Three  ways  are  in  use 
for  this  purpose.  The  best,  in  my  opinion,  and  the  one  which  has  re- 
ceived the  approval  of  Mr.  Spencer  Wells,  is  to  secure  the  pedicle  with 
a  clamp,  whenever  that  is  possible  without  much  traction  on  the  uterus. 
The  clamp,  which  consists  of  two  broad  blades  held  together  by  a  power- 
ful screw,  liaving  been  fixed  on  the  pedicle  just  outside  of  the  abdominal 
wound,  the  whole  tumor  is  cut  away  about  two  inches  beyond  it;  and 
then  the  surgeon  passes  down  his  finger  to  the  other  ovary  to  assure  him- 
self that  it  is  healthy.  If  so,  the  wouiid  is  united,  after  any  cyst-fluid 
whicli  lias  got  into  tlie  pelvis  has  been  gently  removed  witli  a  perfectly 
clean  new  sponge.  In  uniting  tiie  wound  stout  gilt  harelip  needles  are 
used.     These  are  passed  from  the  left  to  the  right  lip  of  the  wound,  about 

may  often  be  suspected  from  the  history  of  previous  psvin  or  other  symptoms  of  peri- 
tonitis. But  in  all  olr]-stiinding  casns  tliny  may  bo  expected.  Their  existence  to  fi 
moderate  extent  floos  not  seem  to  prejudice  the  patient's  prospect.  The  adhesions  in 
front,  between  the  cyst  and  the  abdominal  walls,  are  much  tnoro  easily  dealt  with 
when  the  cyst  is  full  and  tense  than  after  it  has  been  taj)pod. 


OVARIOTOMY.  857 

an  inch  from  its  edge,  and  embrace  the  whole  tissue  down  to  the  peri- 
toneum ;  and  it  is  well,  I  think,  that  the  pin  should  take  up  a  small  piece 
of  the  peritoneum  on  either  side  (p.  235).  Then  any  superfluous  part  of 
the  tumor  beyond  the  clamp  may  be  cut  awa\^,  a  broad  flannel  roller 
applied,  and  the  patient  cleaned  from  any  stains  of  the  operation,  and 
put  into  a  warmed  bed.  About  one-quarter  of  a  o-rain  of  morjihia  should 
be  injected  subcutaneousl}',  or  double  the  quantity  introduced  as  a  sup- 
pository. 

When  the  clamp  cannot  be  fixed  on  tlie  pedicle  of  the  tumor  on  ac- 
count of  its  proximity  to  the  uterus,  without  injudicious  traction  on  tliat 
oroan,  the  best  plan  is  to  perforate  the  pedicle  with  a  needle  tlireaded 
with  stout  wire,  and  tie  it  in  halves,  the  ends  of  the  ligature  liaving  been 
flattened  down  so  as  not  to  irritate  the  neighboring  parts,  and  after  cut- 
ting away  the  tumor  down  to  within  about  half  an  inch  from  the  ligature, 
drop  the  pedicle  back  into  the  belly.  In  a  case  treated  successfully  in 
this  way,  I  searched  some  time  afterwards  carefidl}-  for  the  wire  V)y  pal- 
pation from  the  abdominal  wall  and  from  the  vagina,  but  could  elicit  no 
sensation  of  its  presence. 

The  other  plan  of  treating  the  pedicle  is  with  the  clamp  and  cautery, 
returning  the  cauterized  end  into  the  belly;  but  this  is,  I  think,  more 
dangerous  than  the  former,  though  it  may  be  necessary  to  adopt  it  in 
some  cases  of  very  short  pedicle. 

The  after-treatment  of  the  case  should  be  simple.  For  about  twelve 
hours  notliing  should  be  given  by  the  mouth.  The  patient,  if  restless, 
should  be  quieted  by  subcutaneous  injections  or  suppositories  of  morphia, 
some  pieces  of  ice  should  be  given  to  suck,  and  she  may,  if  mucli  ex- 
hausted, require  stimulant  enemata;  but  as  a  general  rule  the  less  that 
is  given  in  an}'  way  at  first  the  better.  The  room  should  be  kept  warm 
but  fresh,  and  the  pulse  and  temperature  carefully  watched  ;  and  as  soon 
as  the  tendency  to  vomiting  has  passed  away,  nourishment  and  stimu- 
lants should  be  given  as  the  state  of  the  i)ulse  indicates.  The  urine  must 
be  evacuated  with  the  catheter  for  several  days  at  any  rate  after  the 
operation.  The  superfluous  part  of  the  tumor  left  outside  the  pedicle  (in 
order  to  insure  that  the  clamp  does  not  slip)  may  be  trimmed  off  next 
day,  and  the  clamp  removed  the  day  after.  The  harelip  sutures  should 
be  faken  away  on  the  fourth  or  fifth  day,  the  lips  of  the  wound  being  kept 
together  with  broad  strips  of  strapping  and  a  flannel  bandage. 

Acute  and  general  peritonitis  is  almost  always  rapidly  fatal.  Its  treat- 
ment must  be  the  same  as  after  herniotomy.  Limited  inflammation  and 
suppuration  sometimes  occur  around  the  pedicle,  and  by  no  means  pre- 
chides  the  hope  of  a  successful  issue,  though  it  will  retard  union. 

Besults. — The  success  of  ovariotomy  of  late  years  has  been  very  en- 
couraging, the  operation  in  practiced  hands  having  given  a  ratio  of  mor- 
tality not  exceeding  a  quarter,'  a  wonderful  triumph  of  surgery  in  an 
operation  so  extensive  and  so  dreadful  in  appearance;  and  considering 
the  recent  introduction  of  the  operation  there  is  good  reason  to  believe 
that  even  this  ratio  of  deaths  may  be  diminished.  The  improvement  in 
the  I'esults  of  the  operation  over  those  which  attended  it  on  its  first  in- 
troduction are  due  undoubtedly  in  the  first  place  to  ana;sthesia,  saving 
the  patient  the  horrible  shock  of  the  operation,  and  enabling  the  surgeon 
to  carry  on  the  necessarily  protracted  manipulations  in  quiet.  In  the 
next  place  they  are  due  to  the  extended  experience  of  the  operation  and 
to  the  simplification  of  operative  measures  and  after-treatment.     And  no 

1  Mr.  Spencer  Wells  has  published  500  cases,  with  a  mortality  of,  as  nearly  as  pos- 
sible, one-fourth. — Med.-Chir.  Trans.,  vol.  Ivi,  p.  120. 


858  DISEASES    OF    THE    BREAST. 

doubt  the  results  have  heeu  improved  hy  the  fact  that  a  large  number  of 
the  cases  have  fiillen  into  the  hands  of  individual  operators,  who  have 
thus  acquired  a  familiarity  with  the  details  of  the  operation  and  the 
manauenient  of  cases  whicli  can  only  be  accjuired  by  frequent  practice, 
and  who  also  probably  operate  more  freely — ?'.  e.,  on  a  larger  proportion 
of  liopeful  cases — tlian  those  do  whose  experience  is  more  limited. 

Certain  it  is  that  the  experience  of  ovariotomy  in  hospitals  and  by 
hospital  surgeons  has  presented  a  deadly  contrast  to  these  results,  and  I 
believe  I  am  not  wrong  in  saying  that  the  operation  is  not  now  practiced 
in  the  ordinary  wards  of  our  hospitals.  Some  have  separate  wards  under 
the  same  roof,  others  separate  buildings  ;  and  under  such  conditions  it 
is  performed  with  more  or  less  success. 

Several  causes  may  be  alleged  to  account  for  this  want  of  success  in 
hospital  practice.  It  is  always  said  b}'  those  who  decry  our  hospitals  that 
the  ill  success  of  ovariotom^^  in  them  proves  the  insalubrity  of  their  at- 
mosphere. Yet  the  great  success  obtained  by  Mr.  Spencer  Wells  in  a 
hospital  which  differs  from  other  hospital  buildings  only  in  being  less 
aiipropriately  constructed  renders  this  conclusion  very  suspicious,  espe- 
cially when  we  see  the  most  delicate  plastic  operations,  requiring  the 
speediest  and  most  healthy  processes  of  union,  going  on  successfully  in 
the  very  atmosphere  said  to  be  so  deadly.  Yery  probabl}^  cases  of  ovari- 
otomy involve  a  susceptibility  of  inflammation  in  the  exposed  peritoneum 
too  great  to  be  safely  treated  in  the  same  ward  with  other  suppurating 
wounds,  and  we  see  something  analogous  to  this  in  healthy  parturition. 
But  why  they  should  not  be  successfully  treated  in  separate  wards  re- 
mains still  unaccounted  for.  Possibly  the  fact  that  the  attendants  are  in 
communication  with  other  miscellaneous  cases  may  liave  a  great  deal  to 
do  with  it.  At  any  rate,  for  the  present,  we  must  recognize  the  fact;  and 
if  ovarian  operations  are  to  be  undertaken  at  hospitals  a  separate  depart- 
ment must  be  provided  for  them.  I  need  hardly  say  that  in  such  opera- 
tions the  minutest  precautions  must  be  taken  to  insure  the  perfect  clean- 
liness of  every  instrument,  sponge,  or  other  thing  which  touches  tlie 
patient,  and  to  see  that  no  one  takes  part  in  tlie  operation  except  the 
surgeon  and  his  two  immediate  assistants,  who  must  all  have  thorougldy 
washed  and  disinfected  their  hands  just  before  commencing. 

The  more  strictl}^  obstetric  operations,  viz.,  the  Caesarean  section  and 
those  for  extra-uterine  pregnancy,  are  not  treated  of  in  this  work. 


CHAPTER  XLI. 

DISEASES    OF    THE     BREAST. 

Hypertrophy. — The  female  breast  is  occasionally  affected  with  simple 
hypertrophy.  It  is  a  rare  disease  which  commences  generally  soon  after 
puiierty,  in  single  women  as  well  as  married.  It  is  distinguished  from 
tumor  of  the  breast  partly  by  its  perfectl}'  even  and  homogeneous  feel, 


LACTEAL    ABSCESS.  859 

partly  Ity  the  absence  of  all  symptoms,  and  partly  by  the  ft^et  thatjt  usu- 
ally affects  both  breasts,  which  tumors  hardly  ever  do.  The  diagnosis  is 
generally  obvious  if  careful  examination  be  made.  In  some  cases  large 
tumors  of  the  breast  have  been  carelessly  classified  as  "hypertrophy;" 
but  the  error  is  one  easily  avoided.  Nor  should  the  genuine  hypertrophy 
be  confounded  with  the  temporary  enlargement  which  sometimes  accom- 
panies amenorrhcDea.     The  differences  are  well  described  by  Mr.  Birkett. 

When  the  breasts  are  seen  to  be  enlarging  gradually,  and  to  an  incon- 
venient extent,  the  surgeon's  first  care  is  to  inquire  into  the  general  health, 
and  to  attempt  to  stop  the  progress  of  the  affection  by  correcting  any- 
thing that  may  be  amiss.  Carefully  applied  i)ressure  may  also  be  tried. 
But  it  must  be  allowed  that  little  good  is  usually  done  by  any  measure 
short  of  amputation,  and  to  this  no  surgeon  would  willingly  resort  unless 
it  is  absolutely  necessary  in  order  to  allow  the  patient  to  go  about.  It  is 
said  that  sometimes  after  the  removal  of  one  breast,  the  other  has  become 
smaller. 

At7'ophy  of  the  breast  is  natural  in  the  later  period  of  life,  though  usu- 
ally it  is  not  much  noticed,  as  the  place  of  the  gland  tissue  is  occupied 
by  fat;  but  atrophy'  also  takes  place  sometimes  without  any  known  cause, 
or  in  connection  with  tlie  growth  of  a  tumor  in  some  part  of  the  breast, 
or  from  excessive  lactation.  But  it  must  be  remembered  that  a  good  deal 
of  wasting  of  the  breast  is  quite  consistent  with  the  perfect  integrity  of 
the  gland  tissue,  as  evidenced  by  the  secretion  ;  and  it  is  noticed  that 
women  with  breasts  which  are  verj^  small,  and  have  been  supposed  to  be 
atrophied,  often  have  a  fuller  supply  of  milk  than  others.  Sometimes, 
however,  there  is  genuine  atrophy  witli  consequent  want  of  milk.  Nothing 
can  be  done  to  avert  it. 

Injlammaiion  of  the  rudimentary  breast  in  infancy  is  not  uncommon 
in  both  sexes,  perhaps  more  so  in  boys  than  girls.  It  produces  redness 
and  tenderness,  with  a  serous  or  even  milky  secretion  from  the  nipple. 
Nurses  are  in  the  habit  of  aggravating  the  mischief  by  rubbing,  to  ''rub 
away  the  milk,"  as  the}'^  phrase  it.  This  ought  never  to  be  permitted  ; 
the  irritation  will  soon  subside  under  soothing  lotions  and  cataplasms, 
with  attention  to  the  state  of  the  bowels. 

Chroyiic  Abscfss. — Inflammation  also  occurs  sometimes  at  pubert}',  and 
here  also  in  the  male  as  well  as  the  female  ;  though  in  boys  it  is  usuall}'' 
insignificant  and  transient.  In  females  it  sometimes  lays  the  foundation 
of  chronic  abscess,  an  affection  often  mistaken  for  tumor;  and,  in  fact, 
not  easy  to  distinguish  from  a  solid  tumor  by  palpation.  But  in  all  cases 
where  a  perfectly  healthy  young  woman  presents  a  rounded  elastic  lump 
in  tlie  breast,  the  idea  of  chronic  abscess  should  occur  to  the  surgeon's 
mind,  and  he  should  be  cautious  of  giving  an  opinion  without  an  explora- 
tory puncture.  I  have  seen  several  such  cases  brought  into  operating 
theatres,  a  mistake  which  indeed  involves  no  bad  consequences,  since  the 
abscess  is  opened  by  the  incision  made  to  expose  the  supposed  tumor; 
but  which,  at  any  rate,  involves  unnecessary  alarm  to  the  patient,  and  is 
as  vvell  avoided. 

I  have  heard  of  breasts  having  been  removed  for  chronic  abscess,  a 
grave  and  a  disgraceful  mistake. 

Lacteal  Abscess. — The  common  cause  of  inflammation  of  the  breast  is 
irritation  in  suckling,  and  usually  in  women  who  persist  in  doing  so  when 
in  too  weak  a  condition  to  bear  it.  Its  cause  is  often  to  be  found  in  an 
imperfect  development  of  the  nipple.  The  woman  is  generall}'  a  primi- 
para,  and  the  abscess  usually  occurs  within  about  a  month  after  delivery. 


860  DISEASES    OF    THE    BREAST. 

But  the  inflammation  sometimes  commencos  with  the  secretion  of  the  milk 
or  even  before  this,  with  tlie  vascular  excitement  preliminary^  to  the  secre- 
tion, especially  if  the  l)reast  has  been  irritated  or  injured.  Abscess  soon 
forms,  sometimes  with  much  fever  and  constitutional  disturbance.  The 
abscess  presents  in  one  of  three  situations :  over  the  breast,  in  it,  or  be- 
hind it.  Superficial  abscess  produces  generally  oidy  slight  symptoms  ; 
the  pus  lies  near  the  surface,  and  a  simple  puncture  suffices  for  its  evacua- 
tion. The  true  mammary  abscess  is  usually  accompanied  by  more  fever 
than  superficial  abscess,  and  by  much  tension,  heat,  and  pain  in  the  breast. 
As  soon  as  fluctuation  can  be  felt,  or  even  before,  if  the  symi)toms  I)e 
decided,  a  free  incision  should  be  made  into  it,  in  a  direction  radiating 
from  the  nipple.  The  evacuation  of  the  matter  gives  great  relief,  and 
prevents  the  abscess  from  burrowing  about  in  the  gland  or  behind  it. 
Cases  in  which  incisions  have  been  neglected  or  refused  are  often  seen, 
in  which  the  breast  is  riddled  with  sinuses,  indurated  in  various  parts, 
and  jn'obably  permanently  damaged  as  a  secreting  organ.  In  the  deep 
or  sulnnammary  abscess  the  whole  gland  is  raised  from  the  surface  of  the 
chest,  and  tloats  on  the  subjacent  matter  as  on  a  water-bath.  In  this  form, 
the  patient  sliould  be  brought  under  the  influence  of  chloroform,  and  an 
incision  made  under  the  breast  into  the  collection  of  matter  so  as  to  afford 
a  depending  opening  which  is  to  be  kept  patent  with  oiled  lint.  Or  it  is 
sometimes  useful  to  pass  a  drainage-tube.  It  saves  subsequent  cutting 
to  make  a  satisfactory  opening  at  first,  or  even  to  open  the  abscess  in 
several  places. 

Patients  with  abscess  after  lactation  should  give  up  suckling  entirely ; 
they  require  good  diet;  full  doses  of  quinine  are  often  very  beneficial,  and 
a  moderate  allowance  of  wine  or  porter;  care  being  taken  not  to  overload 
the  digestive  organs. 

Piecautionary  measures  may  sometimes  avert  abscess  in  parturient  or 
pregnant  women  whose  breasts  are  much  congested  with  milk  or  in  whom 
the  large  milk-ducts  are  obstructed.  These  consist  in  free  purging,  sooth- 
ing warm  applications  to  the  breast,  drawing  off'  the  superfluous  milk  with 
a  pump,  and  opening  any  ducts  which  are  found  to  be  obstructed  with 
epithelium. 

Lobular  Induration. — Hyperesthesia  of  the  breast,  with  chronic  indu- 
ration of  various  parts  of  it,  is  extremely  common,  and  is  very  liable  to 
be  mistaken  for  tumor.  In  some  cases  the  whole  breast  I'emains,  after  an 
acute  attack  of  inflammation,  hard,  heavy,  and  somewhat  tender.  These 
cases  are  not  so  difficult  of  diagnosis,  but  when  only  a  portion  of  the 
breast  is  indurated  the  hardened  part  much  resembles  a  scirrhous  or 
glandular  tumor.  The  diagnosis  can  only  be  made  by  the  fact  that 
various  separate  lobules  are  usually  affected  and  often  in  both  breasts, 
and  by  tlie  general  aspect  of  the  case,  and  of  the  patient,  to  which  Mr. 
Birkett  adds  as  diagnostic  signs  that  in  these  cases  the  pain  usually  fol- 
lows the  course  and  distribution  of  one  or  more  nerves,  and  that  if  these 
nerves  be  sought  for  and  pressed  upon  as  they  issue  from  tlie  tliorax,  the 
slightest  pressure  will  induce  acute  pain,  sometimes  confined  to  a  single 
branch  distril)uted  to  the  indurated  part  while  the  rest  are  unaffected. 
This  induced  i)ain  is,  he  says,  almost  pathognomonic  of  the  disease. 
Another  diagnostic  sign  on  which  he  also  lays  stress  is,  that  "when  the 
hand  is  pressed  gently  over  the  gland,  nothing  indicating  the  existence 
of  a  new  growth  is  felt,  which  always  happens  when  one  exists — the  indu- 
ration is  very  distinct  if  compressed  between  the  fingers  and  thumb,  but 
imperceptible  with  the  hand  placed  flatly  on  the  part." 


FUNCTIONAL    DISORDERS.  861 

In  treating  this  affection  the  first  point  is  to  improve  the  general 
health,  to  insist  on  health}'  habits  ol"  exercise,  to  cure  any  menstrual 
irregularities,  and  to  dissipate  the  apprehensions  of  tumor  and  cancer 
whicli  the  patient  probably  entertains.  Quinine,  iron,  and  mineral  acids 
often  do  good  if  the  digestion  be  attended  to,  and  iodine  internally  is 
highly  tliouglit  of  by  some  surgeons.  Local  applications  are  always 
useful  in  removing  the  part  from  the  patient's  own  constant  inspection 
and  handling,  for  which  purpose  a  belladonna  plaster  may  be  used ;  the 
breast  if  heavy  and  pendulous  must  be  supported  from  the  opposite 
shoulder.  In  some  cases,  where  pressure  can  be  tolerated,  strapping, 
applied  over  a  layer  of  mercurial  ointment,  removes  the  induration. 
Wliere  the  evidences  of  inflammation  are  more  distinct,  evaporating  and 
soothing  lotions  must  be  employed. 

Neuralgia  or  Hysterical  Fain. — In  other  cases,  even  without  any  swell- 
ing or  induration,  the  breast  is  the  seat  of  almost  intolerable  pain,  some- 
times constant,  sometimes  [)eriodic,  and  usually  accompanied  by  hyper- 
aesthesia  of  the  skin  of  the  breast,  as  well  as  by  pain  in  the  neighl)oring 
parts.  The  affection  is  more  common  in  young  girls  than  in  elderly  per- 
sons, and  in  the  unmarried  than  the  married.  It  is  usually  associated 
with  deranged  menstruation,  and  probably  with  other  disorders  of  health 
and  digestion  ;  and  those  who  sulfer  from  it  may  sometimes  be  found  to 
be  addicted  to  depraved  practices.  The  treatment  consists  in  protecting 
the  breast  from  all  contact  or  examination.  The  organ  will  often  be 
found  to  be  hard,  prominent,  and  congested  ;  and  in  this  condition,  I 
believe,  relief  will  often  be  obtained  by  tolerably  firm  strapping,  which 
ma}'  be  done  under  antx^sthesia  if  necessary.  The  bowels  and  the  state  of 
the  menstrual  secretion  must  lie  carefully  attended  to,  and  the  moral 
treatment  recommended  for  other  nervous  disorders  must  be  strictly  en- 
forced, and  it  is  unnecessary  to  say  that  any  secret  practices  which  may 
be  detected  must  be  put  a  stop  to. 

Functional  Disorders. — The  secretion  of  milk  may  be  disordered  in 
various  ways.  It  is  said  that  in  rare  cases  the  breasts  have  been  known 
to  secrete  milk  quite  independent  of  pregnane}',  in  old  women,  children, 
and  virgins.  Atrophy  of  the  breast-tissue,  causing  absence  in  the  secre- 
tion, has  been  referred  to  al)ove.  The  opposite  state,  in  which  the  secre- 
tion is  excessive  (galactorrlia'a),  or  in  which  it  does  not  cease  on  the  ces- 
sation of  suckling,  is  connected  with  derangement  of  the  general  health, 
and  will  subside  as  this  is  restored.  The  only  derangement  of  secretion 
which  constitutes  a  specific  disease  is  congestion  with  milk,  which  some- 
times leads  to  so  much  solidity  and  brawniness  of  the  organ  as  to  be 
taken  for  cancer,  especialh'  as  the  raising  of  the  gland  causes  the  nipple 
to  be  buried.  The  diagnosis  is  settled  by  observing  that  there  was  no 
tumor  before  delivery,  and  that  cancer  hardly  ever  begins  during  suck- 
ling. Abscess  is  to  be  apprehended,  yet  cases  occur,  according  to  Mr. 
Birkett,  in  which  the  congestion  subsides  and  the  breast  is  again  quite 
useful.  Only  one  breast  is  usually  affected.  The  improvement  of  general 
health,  weaning  the  child,  pressure  with  carefully  applied  strapping,  or 
the  application  of  tincture  of  iodine,  or  iodide  of  lead  ointment,  are  the 
measures  prescribed  for  the  treatment  of  this  condition. 

Tumors  of  the  Breast. — The  disease  descriljed  by  Sir  A.  Cooper  as 
"chronic  mammary  tumor,"  and  formerly  regarded  as  a  fibrous  growth,  is 
now  usually  denominated  by  some  name  such  as  adenoma,  adenoid 
tumor,  or  mammary  glandular  tumor,  in  order  to  mark  the  fact  that  in 
its  structure  tissue  is  found  which  bears  considerable  resemblance  to  that 


862  DISEASES    OF    THE    BREAST. 

of  the  gland  itself.  Simple  adenoma  forms  a  lii-ni,  lobulated  tnmor,  sur- 
ronnded  h\  a  capsule  of  librous  tissue,  in  vvliich,  on  microscopic  examin- 
ation, rudimentary  breast-tissue  is  found,  ?'.(^.,  tlic  ccecal  pouches  in  which 
the  ducts  commence,  and  in  some  cases,  according  to  Mr.  Birkett,  rudi- 
ments of  the  ducts  themselves.  He  also  describes  tumors  in  which  "the 
observer  may  detect  ducts,  sinuses,  and  even  the  secretion  peculiar  to 
this  gland." 

Adenoma  is  more  common  at  an  early  period  of  adidt  life,  the  decade 
from  twenty  to  thirty  years  of  age  forming  the  majority,  and  it  com- 
mences more  commonly  in  single  than  in  married  life. 

Scroeijsfic  Tumor. — Closely  connected  with  this  disease  is  the  form  of 
new  growth  described  bj'  Sir  B.  Brodie  as  seroci/slic.,  and  by  Mr.  Ctesar 
Hawkins  as  tuherocydic  tumor.  In  this  disease  c^ysts  are  found  into 
each  of  which  a  nevv  growth  projects.  The  cysts  contain  a  tenacious 
viscid  Huid,  often  more  or  less  dark  in  color  from  the  admixture  of  some 
of  the  elements  of  the  blood.  Ver}^  commonly  there  are  many  such 
cysts,  and  the  growth  of  the  solid  matter  into  them  gradually  tills  them 
up,  until  at  length  they  are  almost  altogetlier  obliterated;  and  then  tlie 
growth  projects  through  the  c.yst,  presses  on  the  skin,  bursts  it,  and 
fungates.  Two  views  prevail  of  the  origin  of  these  growths.  In  Sir  B. 
Brodie's  view  the  cyst  was  the  original  formation,  being  produced  either 
hy  the  obstruction  of  one  of  the  ducts  of  the  gland  (which,  however, 
seems  to  be  ver}'^  rare),  or  in  the  connective  tissue  of  the  part,  in  the 
same  way  as  cysts  form  in  any  other  part  of  the  body.  The  solid  tumor 
then  grows  from  the  tissue  which  forms  the  wall  of  the  cyst.  But  in  Mr. 
Birkett's  view  the  so-called  cyst  in  these  compound  tumors  is  a  secon- 
dary formation,  and  is  reall^'only  a  space  in  the  capsule  of  the  tumor,  the 
layers  of  which  are  separated  I)}-  fluid  which  has  accumulated  probabl}' 
in  consequence  of  the  pressure  of  the  solid  growth  below  it.  Mr.  Birkett, 
therefore,  describes  serocystic  or  tuberocystic  tumor  as  merely  a  variety 
of  the  adenoid  tumor;  and  he  separates  the  cystoid  cavities  which  form 
parts  of  such  tumors  entirely  from  the  true  cysts,  likening  them  rather 
to  "the  arrangement  of  the  capsular  ligaments  of  joints  attached  around 
the  articular  ends  of  the  long  bones  than  to  genuine  cysts."  The  solid 
matter  which  forms  the  growing  portion  of  such  tumors  consists  in  large 
proportion  of  cells,  usually  spindle-  or  awn-shaped,  and  rapidly  growing 
into  imperfect  fibrous  tissue,  constituting  the  "  libro-plastic  tumor"  of 
Lebert,  or  the  "spindle  celled  sarcoma"  of  later  i)athologists.  Tlie  im- 
perfect imitation  of  the  gland-tissue  characteristic  of  adenoma  is  also 
often  met  with  in  portions  of  these  tumors,  and  this  fact,  together  with 
the  occasional  coexistence  of  the  firm  adenoma  (or  chronic  mammary 
tumor)  with  such  seroc3stic  growths,  of  which  an  excellent  di-awiug  will 
lie  found  in  Mr.  Birkett's  essay  (Syd.  of  Surg..,  vol.  v,  p.  257),  has  led 
him  to  classify  the  sercKjstic  tumor  as  a  variety  of  adenoma. 

Opei-alionn. — At  the  same  time,  even  if  we  allow  that  the  two  are 
varieties  of  the  same  form  of  tumor,  the}'  are  vai'ieties  which  are  char- 
acterized by  the  very  important  difference  that  in  the  (irm,  hard,  lobulated 
tumor  which  Sir  A.  Cooper  described  as  chronic  mammary,  in  which 
there  are  no  cysts,  in  which  the  fibrous  tissue  forming  the  framework  of 
the  adenoid  growtli  is  well  developed,  and  the  whole  mass  free  from  juice, 
I'ccurrence  after  removal  hardly  ever  takes  place  ;  nor  is  it  necessary  to 
lemove  more  tlian  the  tumor  itself  A  free  incision  having  been  made 
tiirough  tiie  cajjsule  of  the  new  growtli,  tlie  latter  should  l)e  enucleated, 
the  l)reast  being  preserved,  and  especial  care  being  taken  not  to  interfere 
witii  the  nipple  or  the  large  ducts  converging  to  it,  particularly  if  the 


SIMPLE    CYSTS.  863 

jjatient  is  likely  to  have  children.  She  may  then  he  confidently  assured 
that  no  recurrence  is  probable. 

But  in  the  serocystic  tumors,  when  the  fibro-i)lastic  or  sarcomatous 
element  prevails  in  the  solid  growth,  the  case  must  always  be  looked  upon 
with  apprehension  ;  for  such  tumors  do  unquestionably  recur,  and  they 
are  the  more  prone  to  do  so  the  more  succulent,  loose,  and  imperfect  their 
tissue  is,  and  perhaps  the  older  the  patient  is  at  the  time  of  their  forma- 
tion. This  recurrence  takes  place  g-enerally  only  in  the  scar  itself,  and  I 
have  seen  several  cases  in  wliich  the  patient  has  i)reserved  her  general 
health  entirely  unaffected  after  the  disease  has  recurred  many  times.  In 
one  remarkable  case  in  Mr.  Cjesar  Hawkins's  i)ractice  at  St.  George's 
Hospital  it  was  not  till  after  ten  recurrences  and  eighteen  3'ears'  dura- 
tion of  the  case  that  the  patient  finally  succumbed  to  exhaustion  pro- 
duced l)y  the  sloughing  of  tlie  tumor,  which  at  lengtli  it  became  im- 
practicable to  extirpate.  But  I  have  known  one  instance  in  which  a 
serocystic  tumor  recurred  in  the  other  breast.  These  circumstances 
should  teach  caution  in  prognosis,  and  should  incline  the  surgeon  rather 
to  remove  the  whole  breast  than  merely  extirpate  the  tumor  whenever 
the  growth  is  large  and  advancing  rapidl}',  and  particularly  if  the  patient 
be_somewhat  advanced  in  years,  or  be  from  any  cause  unlikely  to  suckle. 

Diagno^U. — The  diagnosis  between  simple  adenoma  and  lobular  in- 
duration has  been  given  under  the  latter  head.  From  cancer  there  is 
usuall}'  no  difficulty  in  distinguishing  it,  if  the  case  l)e  kept  for  some 
time  under  observation,  looking  to  the  age  oH  the  patient,  the  non-im- 
plication of  the  gland  or  skin,  the  absence  of  the  stabbing  pain  of  cancer, 
the  more  lol»ulated  feeling  and  less  firm  consistence  of  the  tumor,  and  the 
almost  imperceptible  progress  of  the  disease,  though  an  incipient  cancer 
is  not  uncommonly  mistaken  for  adenoma  on  a  single  examination.  The 
diagnosis  between  the  seroc3'stic  tumors  and  the  softer  forms  of  cancer  is 
sometimes  by  no  means  easy ;  for  even  if  the  presence  of  cysts  has  been 
ascertained,  such  cysts  may  exist  in  a  mass  of  medullary  cancer.  But 
the  rate  of  growth  of  the  two  diseases  is  very  different — the  skin  is  un- 
affected in  the  serocystic  tumor,  or  if  adherent  is  not  infiltrated  and 
brawny  as  in  cancer ;  nor  are  there  the  large  superficial  veins,  and  the 
great  general  vascularity  which  are  found  in  cancer.  However,  if  the 
growth  be  advancing  rapidly,  it  is  better  to  pronounce  a  very  guarded 
diagnosis  before  removal,  and  to  insist  on  the  necessity  of  extirpating 
the  whole  breast;  and  when  the  skin  has  given  way  and  the  tumor  is 
fungating  out  of  a  large  opening,  tiie  diagnosis  is  the  more  diflicult,  and 
the  removal  of  the  entire  breast  more  obviously  necessary.  The  condi- 
tion of  tlie  surrounding  skin  is  the  cliief  element  in  diagnosis  during  this 
stage  of  a  serocystic  tumor.  Tlie  edges  of  the  ulcer  are  sharp-cut,  and 
the  neighboring  skin  thinned  ;  while  in  the  cancerous  ulcer  the  edges  are 
prominent  and  hard,  and  the  cancerous  matter  is  infiltrated  for  some 
distance  around. 

Simple  cyds  also  occur  in  the  breast,  in  which  no  solid  growth  ever 
takes  place.  Some  depend  on  obstruction  of  the  ducts  of  the  gland  and 
contain  a  tenacious  mucoid  fluid.  Such  obstructed  ducts  forming  small 
cysts  will  very  often  be  found,  on  careful  examination  of  the  breasts  of 
women  who  have  borne  children,  and  in  whom  the  cysts  have  remained 
so  small  as  never  to  occasion  any  symptoms.  At  other  times,  oftener  in 
those  who  have  borne  children,  one  or  more  of  them  increase  till  they 
project  under  the  skin  and  attract  the  patient's  attention.  Other  cysts, 
also,  sometimes  form  in  the  neighborhood  of  the  nipple,  usually  earlier 


864  DISEASES    OF    THE    BREAST. 

in  life  than  the  duct-cysts,  and  in  women  who  have  not  borne  children, 
containing  a  simple  watery  serum,  with  only  a  slight  proportion  of  albu- 
men. Tliese  simple  cysts  require  only  a  i)uncture,  with  pressure  or 
stimulating  lotion  afterwards.  The  puncture  may  be  repeated  if  the  cyst 
fills  ai>ain,"or  it  may  ))e  laid  open  and  made  to  granulate.  Sometimes 
the  tumor  bursts  of  itself,  and  then  usually  disappears. 

i)/i7A'-c!/s/.s,  or  "  galactoceles,"  are  tumors  wliich  form  during  lactation 
either  from  mere  dilatation  of  an  obstructed  duct,  or  from  its  rupture  and 
effusion  of  the  milk  into  the  neighboring  tissue.  They  may  subside  on 
the  cessation  of  suckling,  to  recur  at  each  of  the  following  pregnancies, 
of  which  Mr.  Birkett  gives  a  remarkable  instance;  and  as  the  contents 
thicken  they  may  present  a  considerable  resemblance  to  a  sold  tumor. 
The  cases  are  rare  and  the  diagnosis  will  be  difficult  unless  the  patient 
has  been  under  observation,  and  the  sudden  development  of  the  tumor 
during  suckling  has  been  noticed.  Generally  they  are  not  diagnosed  till 
after  a  puncture  has  been  made,  wlicn  the  cyst  must  be  emptied  and 
made  to  heal  by  granulation. 

Rarer  Forms. — There  are  other  forms  of  innocent  tumors  which  are 
met  with,  though  very  rarely,  in  the  female  breast.  The  expression 
"hydatid  disease"  in  the  older  authors  usually  means  cystic  or  serocystic 
tumor;  but  echinococci  are  sometimes  found  in  laying  open  what  have 
been  taken  for  common  cysts  or  abscesses.  Common  fibrous  or  fibro- 
cellular  tumors  are  also  found,  but  can  hardly  be  diagnosed  before  re- 
moval. Fatty  tumor  may  of  course  form  in  the  adipose  tissue  over  the 
breast,  though  I  cannot  remember  to  have  seen  a  case ;  and  a  few  cases 
of  enchondroma  are  on  record. 

The  main  point  in  these  cases  is  to  distinguish  them  from  cancer,  in 
order  to  preserve  the  breast  if  possible.  The  precise  anatomical  form  of 
the  tumor  is  generally  only  ascertained  after  removal. 

Cancer. — Scirrhus  is  the  form  of  cancer  most  commonly  met  with  in 
the  female  breast,  though  medullary  or  soft  cancer  is  not  very  uncommon. 
Isolated  examples  of  colloid  are  to  be  found  here  and  there,  and  have 
been  known  to  run  a  definitely  malignant  course;  but  the  nature  of  the 
disease  can  hardly  be  diagnosed  before  removal,  nor  is  the  prognosis  by 
any  means  certain.  As  usually  seen,  cancer  of  the  breast  presents  itself 
as  a  small,  hard,  stony  lump  situated  in  the  thickness  of  the  gland,  and 
the  size  of  tiie  breast  is  noticed  not  to  be  much  increased,  even  as  the 
tumor  enlarges,  since  the  tissues  around  shrink  as  they  become  adherent 
to  the  tumoi-.  This  same  shrinking  of  the  tissues  and  the  adhesion  of 
the  cellular  tissue  to  the  tumor  produce  the  dimpling  of  the  skin  and  the 
retraction  of  the  nipi)le  whicii  are  so  often  seen  in  cancer.  The  adhesion, 
however,  may  take  place  "in  the  other  direction,  causing  the  tumor  to  be- 
come attached  to  the  i)ectoi-al  muscle,  or  even  to  the  ribs.  Later  on  tiie 
cancer  infiltrates  the  skin,  and  then  ulcerates,  fungating  out  of  the  ulcer 
in  large  bleeding  masses  if  it  be  of  the  soft  kind,  or  else  producing  the 
scirrhous  ulcer.  Cancer  of  the  breast  is  accompanied  by  lancinating  pain 
in  the  chest  and  neck  and  down  the  arn),  by  wasting  and  ultimately  by 
cancerous  cachexia.  The  axillary  glands  become  enlarged,  and  some- 
times also  the  subclavian  and  other  cervical,  or  even  the  mediastinal 
glands.  The  arm  often  becomes  u?den)atous  from  the  pressure  of  these 
enlarged  glands  on  the  veins;  and  in  some  cases  the  skin  becomes  ex- 
tensively infiltrated  and  matted  to  the  deeper  parts — "hidebound  cancer." 

Cancer  in  the  breast  appears  oillier  in  the  form  of  a  detined  mass  sepa- 
rated from  the  gland  by  a  distinct  capsule,  or  infiltrated  throughout  the 


CANCER.  865 

glaiul-tissne,  or  containing  cysts  which  may  be  formed  by  the  softening 
of  its  texture,  and  according  to  Mr.  Birlvctt  by  tlie  etfiision  of  tiie  juice 
of  the  cancer  into  tlie  envelope  of  the  tumor.  It  occurs  usually  between 
the  ages  of  thirty  and  lifty.  Out  of  458  cases  tabulated  by  Mv.  Birkett, 
100  occurred  in  the  decade  between  thirt}'  and  forty,  and  198  between 
forty  and  fifty.  This  shows  that  the  occurrence  of  the  disease  is  relativel}^ 
most  common  towards  the  period  of  the  cessation  of  the  catamenia;  3et 
in  examining  the  particidars  of  100  cases,  Mr.  Birkett  failed  to  detect  any 
connection  between  the  two  events,  and  he  equally  failed  to  prove  the 
coi'rectness  of  the  common  opinion  that  cancer  is  more  frequent  in  the 
single  than  the  married,  and  in  the  sterile  than  in  those  who  have  borne 
children;  or  any  connection  between  the  growth  of  cancer  and  imperfec- 
tion in  suckling.  It  is  noticed  that  cancer  liardly  ever  begins  during 
pregnane}'  or  suckling,  though  it  is  not  rare  to  see  cancer  in  a  suckling 
woman,  the  disease  having  begun  before  pregnancy. 

Diagiiosh. — The  diagnosis  of  cancer  from  innocent  tumor  rests  on  the 
more  advanced  age  of  the  patient,  on  the  hardness  of  the  tumor  in  scir- 
rhus,  its  rapid  growth  and  great  vascularity  in  the  soft  form  of  cancer, 
the  early  implication  of  the  skin  and  cellular  tissue  around,  leading  to 
dimpling  and  retraction  of  the  nipple,'  the  affection  of  the  glands,  the 
state  of  the  general  health,  the  characteristic  pain  (which,  however,  like 
pain  of  all  other  kinds,  is  liable  to  be  simulated  by  mere  nervous  affec- 
tion), and  lastly  by  the  occasional  deposit  of  cancer  in  remoter  organs. 

Question  of  Operatioii . — When  the  diagnosis  has  been  made  the  ques- 
tion of  the  removal  of  the  disease  has  to  be  discussed.  There  is  not,  I 
think,  any  convincing  evidence  either  way  as  to  whether  the  operation 
prolongs  life,  or  shortens  it,  on  the  average  of  a  large  number  of  cases, 
l)ut  1  do  not  see  tliat  this  tells  conclusively  either  for  or  against  the 
o[)erati()n.  The  operation  frees  the  patient  for  a  time  from  the  oppres- 
sion of  a  disease  which  is  known  to  be  gradually  advancing  to  a  fatal 
issue,  it  renders  the  interval  (allowing  that  the  cancer  recurs)  one  of 
complete  health  for  the  greater  part  of  the  time  instead  of  being  a  period 
of  pain  and  anxiety,  it  gives  the  patient  a  chance,  however  slender,  of 
immunity  from- recurrence,  and  in  many  cases  the  cancer  recurring  in  an 
internal  organ,  such  as  the  liver,  terminates  life  in  a  less  painful  manner 
than  by  the  spread  and  ulceration  of  an  external  tumor.  The  operation, 
in  these  days  of  anaesthesia  and  of  rapid  healing  of  wounds,  is  not  one  of 
much  danger  or  suffering. 

The  ('ontraindications  to  the  removal  of  the  breast  for  cancer  are  either 
absolute  or  partial.  The  spreading  of  the  cancer  so  far  into  the  skin  or 
neighboring  parts  that  the  surgeon  cannot  operate  through  healthy  tissue, 
the  implication  of  the  glands  beyond  the  axilla  (in  the  subclavian  trian- 
gle, or  higher  in  the  neck)  the  deposition  of  cancer  in  other  ])arts,  or  an 
advanced  condition  of  cancerous  cachexia,  are  absolute  contraindications. 
The  infiltration  of  the  skin  to  any  extent,  however  small,  the  ulceration 
of  the  tumor,  or  an}'  implication  of  the  axillary  glands,  are  very  unfavor- 
able conditions,  though  under  certain  circumstances  the  surgeon  may  be 
justified  in  operating.  It  is  true  that  all  the  visibly  diseased  skin  may 
be  removed  with  the  breast ;  that  the  removal  of  an  ulcerated  and  bleed- 
ing mass  ma}^  produce  great  temporary  relief;  and  that  all  the  visibly  en- 
larged axillary  glands  may  possibly  be  excised.     The  latter  point,  how- 

1  Retraction  of  the  nipple  is  met  with  occHsionally  in  non-cancerous  tumors,  from 
adhesion  of  the  cellular  tissue  of  the  nipple  to  some  portion  of  the  tumor  which  bo- 
comes  drawn  in  by  the  growth  of  neighboring  portions,  but  it  is  far  more  common  in 
scirrhus- 

55 


866  DISEASES    OF    THE    BREAST. 

ever,  is  always  doubtful,  and  the  surgeon  will  often  discover  when  lie 
opens  the  axilla,  ex])ccting  only  to  find  one  or  two  small  scirrhous  glands, 
that  in  reality  the  whole  chain  of  glands  is  implicated,  and  that  he  is 
committed  to  a  deep  and  dangerous  dissection,  which  possibly  has  ulti- 
mately to  be  abandoned  without  the  whole  of  the  diseased  glands  having 
been  removed.  But  however  comi)lete  the  apparent  removal  may  have 
been,  a  speedy  return  of  the  disease  in  the  cicatrix  may  always  be  prog- 
nosticated under  the  conditions  specified,  so  that  the  operation  must  at 
the  best  be  regarded  as  only  a  palliative. 

Repetition  of  Operation. — With  regard  to  the  repetition  of  an  operation, 
the  same  considerations  exactly  apply.  Under  circumstances  which 
would  have  justified  the  original  operation  it  may  be  repeated,  and  even 
more  than  once,  in  the  cicatrix. 

t/'se  of  Caustics. — That  cancerous  breasts  ma}'  be  successfully  removed 
by  caustics  is  amply  proved  by  experience.  The  method  is  much  in- 
ferior to  removal  by  the  knife,  being  slower,  more  painful,  and  less  cer- 
tain to  expose  healthy  tissue  ;  but  the  fear  of  a  cutting  operation  renders 
the  alternative  acceptable  to  many,  and  the  cancer-curing  quacks  make 
a  livelihood  chiefly  V)y  concealing  some  of  the  common  potential  caute- 
ries— generally  chloride  of  zinc — with  some  inert  nostrum.  On  the  whole, 
the  chloride  of  zinc  is  the  best  of  these  caustics,  and  is,  I  think,  best 
used  on  the  method  of  Maisonneuve,  "cauterization  en  fleches,"  which 
will  be  found  described  in  Chap.  XLIY.  The  method  introduced  by  Fell, 
of  destroying  the  skin  by  means  of  some  strong  acid,  then  scoring  the. 
exposed  surface  and  stufhng  the  incisions  with  the  chloride  of  zinc  paste 
saves  some  time  and  pain. 

Treatment  of  Ulcerated  Cancer. — It  is,  however,  in  the  treatment  of 
cancerous  ulceration  that  the  application  of  caustics  is  most  frequently 
advisable.  When  the  ulcer  is  of  limited  extent  the  caustic  often  gives 
little  pain,  and  tiie  separation  of  the  eschar  is  sometimes  followed  by 
temporary  cicatrization.  Otherwise  nothing  can  be  done  in  ulcerated 
cancer,  except  to  keep  the  part  as  free  from  odor  as  possible  with  some 
of  the  tarry  solutions,  and  to  soothe  pain  with  morphia.  I  have  found 
nothing  better  than  tlie  carbolic  lotion  covered  with  carded  oakum.  But 
the  patient  may  get  tired  of  the  odor  of  this  dressing,  and  then  solution 
of  chloride  of  zinc,  or  Condy's  lotion,  or  solution  of  terchloride  of  carbon 
or  chloride  of  potash  may  be  used,  mixed  with  laudanum  or  belladonna. 
The  balsam  of  Gurjon,  recently  introduced,  and  the  boracic  acid  lately 
recommended  by  Prof.  Lister  for  its  deodorizing  qualities,  have  not  an- 
swered in  the  trials  I  have  made  of  them. 

Removal  of  the  Mamma. — In  amputating  the  mamma  it  is  always 
advisable,  whenever  it  can  be  done  consistently  with  removing  the  whole 
disease,  to  leave  sufficient  skin  to  cover  the  wound  without  any  tension. 
The  nipple  should  be  included  lietween  two  curvilinear  incisions,  which 
are  generally  made  to  lie  above  and  below  it,^  though  this  is  a  matter 
almost  of  indilference.  The  angle  of  junction  of  the  incisions  outwards 
can  easily  be  i}rolonged  into  tlie  axilla,  if  any  glands  are  to  be  removed 
from  thence,  and  this  better  than  to  make  a  separate  small  incision  over 
the  glands  themselves.  The  lower  flap  is  to  be  first  dissected  back,  down 
to  tiie  base  of  the  tumor  or  of  the  breast,  then  the  upper,  these  flaps  being 
made  as  thick  as  is  consistent  with  keeping  well  away  from  the  disease. 
The  breast  being  now  fully  exposed  is  to  be  forcibly  drawn  away  from 
the  pectoral  muscle,  and  the  cellular  tissue  which  unites  them  divided  by 

1  See  Fiir.  396. 


AFFECTIONS    OF    THE    NIPPLE.  867 

rapid  strokes  of  the  knife,  the  assistant  putting  his  fingers  on  tlie  bleed- 
ing vessels,  whieh  should  then  be  rapidly  secured  with  carbolized  catgut 
ligatures.  When  all  bleeding  has  been  thus  commanded,  the  wound  is 
to  be  united  by  sutures,  and  dressed  according  to  any  plan  which  the 
surgeon  prefers  as  likely  to  procure  speedy  union.  Very  often  a  large 
part,  and  in  some  rare  cases  the  whole,  of  the  wound  unites  by  primary 
union. 

DiHea.Hes  of  the  Mavimilla. — Malformations  are  common  in  the  nipple. 
It  is  sometimes  bifid,  sometimes  multi[)le,  far  more  often  deficient  or  ill- 
developed,  and  such  ill-developed  nipples  are  fruitful  causes  of  trouble  in 
suckling,  as  pointed  out  above.  It  may  be  possible,  in  some  cases,  where 
the  nipple  is  merely  short  but  otherwise  natural,  to  draw  it  out  by  con- 
stant well-directed  pressure  l)y  means  of  a  breast-pump,  and  the  attempt 
is  worth  making  in  a  married  woman  before  she  becomes  pregnant,  or 
during  pregnancy.  Inflammation  of  the  nipples  and  small  ulcers  or  cracks 
on  them  are  ver^^  common,  especially  during  a  first  suckling.  The  ulcers 
should  be  carefully  cleaned,  covered  with  fine  powder,  as  oxide  of  zinc, 
dusted  on  them  through  a  muslin  bag;  or  coated  with  collodion,  and 
protected  by  a  shield  from  direct  contact  with  the  infant's  mouth.  When 
abscess  forms  near  the  nipple  it  should  be  allowed  to  burst,  or  at  least  to 
come  close  to  the  surface,  for  fear  that  in  opening  it  the  milk  sinus  should 
be  wounded. 

The  nipple  and  areola  are  occasionally  found  to  be  the  seat  of  epithe- 
lioma. I  once  treated  a  case  of  this  kind  in  a  married  lad}',  who  from 
some  malformation  had  (as  I  was  informed)  never  been  capable  of  com- 
plete sexual  intercourse.  Tlie  nature  of  the  disease  was  indubitable,  and 
was  proved  afterwards  by  microscopic  examination.  There  was  a  small 
hard  gland  in  the  axilla,  which  was  not  removed  ;  but  the  nipple  and 
areola  were  fully  excised.  I  saw  her  five  years  afterwards  in  perfect 
health,  and  the  gland  had  quite  disappeared.  Such  a  case,  however, 
should  be  carefully  watched  ;  and  on  the  appearance  of  any  recurrence 
and  extension  of  disease  to  the  breast  the  whole  organ  should  be  removed. 

Sir  J.  Paget  has  lately  called  attention^  to  the  frequency  with  which 
an  obstinate  eruption  of  the  nipple  and  areola,  reseml)ling  eczema  or 
psoriasis,  is  the  [jrecursor  of  cancer  in  the  mammary  gland.  Tlie  erup- 
tion is  very  rebellious  to  treatment,  and  usually  persists  till  the  period 
at  which  the  cancer  appears.  He  has  noticed  lifteen  cases,  in  all  of 
which  the  cancer  showed  itself  within  two,  and  in  most  within  one  year 
after  the  eruption.  The  cancer  is  not  continuous  with  the  diseased  nipple, 
but  grows  in  a  remote  part  of  the  gland.  In  such  cases,  particularly  when 
cancer  is  known  to  have  existed  in  the  patient's  family,  he  believes  the 
diseased  skin  ought  to  be  removed  or  destroyed. 

The  nipple  is  sometimes  the  seat  of  common  sebaceous  or  cystic  tumors 
and  of  naevi,  but  their  treatment  is  the  same  as  in  other  regions.  Great 
care,  however,  must  be  taken  not  to  induce  deformity  by  an}'  operative 
measure  undertaken  for  their  cure. 

Disease)^  of  Male  Breast. — Analogous  affections  sometimes  though  rarely 
attack  the  male  breast.  The  irritation  which  in  male  infants  sometimes 
leads  to  a  secretion  of  milk  has  been  spoken  of.  In  later  life  tumors  form 
in  the  male  breast,  which  are  usually  of  a  scirrlious  nature,  sometimes 
fibrous,  and  I  have  once  seen  a  case  of  serocystic  tumor,  precisely  like 

1  St.  Bartholomew's  Hosp.  Keports,  vol.  x,  p.  87- 


868  DISEASES    OF    THE    THYROID    BODY. 

the  same  disease  in  the  female/  The  disease  occurred  in  a  man  aged 
54.  The  diagnosis  of  tliese  artections  is  mucli  the  same  in  the  male  breast 
as  in  the  female.  Any  growth  which  forms  in  this  situation  should  be 
at  once  removed. 


CHAPTER    XLII. 

DISEASES  OF  THE  THYROID  BODY. 

Endemic  Goitre. — The  tiiyroid  gland  is  liable  to  an  endemic  enlarge- 
ment, which  is  called  goitre,  and  which  prevails  extensively  in  the  val- 
leys of  many  mountain  regions  in  various  parts  of  the  globe,  from  some 
cause  which  is  not  completely  understood.  Cretinism  also  prevails  usually 
in  the  same  locality',  either  in  the  same  or  different  persons.  In  this  coun- 
try the  endemic  form  of  bronchocele  is  known  as  "  Derbyshire  neck," 
from  the  place  where  it  chiefly  prevails.  This  endemic  disease  seems  sus- 
ceptible of  little  alleviation,  either  from  prophylaxis  or  treatment,  nor 
can  it  be  till  its  cause  has  been  discovered. 

Sporadic^  or  Common  Bronchocele. — More  important  in  practical  sur- 
gery-, though  far  less  so  in  public  hygiene,  are  the  sporadic  cases  of  bron- 
chocele which  are  seen  prett}^  commonly  in  all  parts  of  the  country.  Most 
of  the  patients  are  females,  and  usually  unmarried.  There  is  very  com- 
monly some  menstrual  irregularity;  yet  the  general  health  is  often  per- 
fectl}-  good.  The  disease  consists  in  an  enlargement  of  one  or  both  sides 
of  the  thyroid  body  along  with  its  isthmus,  the  enlargement  being  gen- 
erally most  marked  on  the  right  side.  Sometimes  it  extends  behind  the 
sternum.  It  often  causes  distressing  dyspnoea  from  pressure  on  the 
trachea,  and  has  been  know^i  to  produce  death  from  this  cause.^  Some- 
times, also,  it  seems  to  cause  loss  of  voice  from  pressure  on  the  recurrent 
laryngeal  nerves,  or  even  spasm  of  the  glottis  from  irritation  of  the  same 
nerve,  and  I  have  known  a  case  wdiere  the  tumor  burst,  and  suppuration 
threatened  to  prove  fatal.  The  structure  of  the  tumor  usually  consists 
of  one  or  more  large  cysts,  surrounded  by  the  hypertrophied  gland- 
structure,  or  it  may  be  entireh'  solid. 

The  treatment  of  the  disease  which  is  most  relied  upon  is  by  the  ex- 
'ternal  and  internal  use  of  iodine,  due  attention  being  given  to  the  gen- 
eral healtli,  and  especially  the  menstrual  functions.  Dr.  Morell  Mackenzie 
has  lately''  called  attention  to  the  benefit  which  may  be  produced  in  cystic 
broncliocele  by  the  injection  of  pefchloride  of  iron.  His  plan  is  to  tap 
the  cyst,  then  to  inject  5j  or  5ij  (according  to  the  size  of  the  cyst)  of  a 
solution  of  percl)loride  of  iron  (5ij :  5J)  vvhich  is  left  in  the  cyst  for  about 
three  days,  the  canula  being  plugged  and  retained,  when  the  iron  is 


1  St.  George's  Hospital  Mugeum,  Ser.  xv,  No.  50. 

2  Sfte  a  case  related  by  Dr.  Dickinson,  Path.  Trans.,  vol.  xii,  p.  229. 

3  Clin.  Soc.  Trans.,  vol.  vii,  p.  115. 


CANCER.  869 

allowed  to  escape,  and  the  part  is  poulticed,  the  plug  being  still  retained 
until  suppuration  is  fjiirly  established,  when  it  may  be  removed.  In  fibro- 
cystic bronchoceles  after  the  cysts  have  been  thus  obliterated  the  solid 
part  is  treated  b}-  subcutaneous  injection  of  iodine,  but  this  is  undeniably 
dangerous.  These  cysts  are  often  treated  by  seton,  a  practice  which, 
though  it  is  sometimes  very  successful,  is  not  witliout  its  dangers. 

Removal  of  Bronchocele. — In  some  cases  it  seems  to  me  justifiable  to 
remove  sucli  tumors,  i.  e.,  either  where  they  threaten  to  prove  fatal  by 
great  and  increasing  pressure  on  the  windpipe  or  other  structures  in  the 
neck,  or  when  as  in  my  case  (recorded  in  the  Am.  Jour,  of  Med.  Sci., 
Jan.  1873),  the  tumor  has  burst,  and  the  suppuration  is  exhausting  the 
patient.  The  operation  is  a  formidable  one,  but  has  often  been  performed 
with  success.'  In  cases  where  the  tumor  is  so  very  large  as  it  was  in  the 
one  which  I  operated  upon  (where  it  hung  down  below  the  mamma)  flaps 
must  be  carefully  dissected  off  it,  and  its  base  must  be  commanded  by 
an  ecraseur,  or  some  form  of  clamp,  while  tlie  mass  is  removed.  In 
smaller  tumors,  the  best  plan  seems  to  be  to  lay  open  the  capsule  freely 
and  enucleate  the  mass  with  the  fingers  as  rapidly  as  possible,  without 
paying  any  attention  to  the  bleeding  till  the  tumor  is  removed. 

Exophthalmic  Goitre. — A  singular  malady  affects  the  thyroid  body 
amongst  other  parts,  which  is  generally  called  exophthalmic  bronchocele, 
from  the  protrusion  of  the  eyes,  which  is  one  of  the  prominent  symp- 
toms. There  is  palpitation  of  the  heart,  great  I'apidity  of  the  pulse, 
extreme  prominence  of  the  eyes,  and  a  large  soft  pulsating  swelling  of 
the  thyroid  body,  in  which  a  musical  brait  can  often  be  heard,  and  which 
varies  greatly  in  size.  Another  prominent  s^^mptom  is  the  jerking  pulse 
in  the  carotid  arteries.  In  one  unfortunate  case  I  saw^  both  cornene  slough 
and  the  eyeballs  wither  away  in  consequence  of  their  continued  exposure. 
This  form  of  bronchocele  is  sometimes  accompanied  by  organic  disease 
of  the  heart,  otherwise  it  is  not  very  dangerous  to  life,  and  under  proper 
treatment  there  is  a  good  chance  of  recovery.  It  often  depends  in  some 
measure  on  mental  causes,  and  is  frequently  associated  with  irregular 
menstruation.  All  concomitant  circumstances  of  this  kind  being  ascer- 
tained and  treated  as  best  may  be,  digitalis  and  iron  seem  to  be  the  most 
promising  internal  remedies,  and  ice  to  the  thyroid  tumor  the  best  local 
application.  The  reader  is  referred  to  works  on  Medicine  for  a  fuller 
account  of  this  affection,  which  falls  more  commonly  under  the  physi- 
cian's care. 

Cancer  occurs  in  the  thyroid  body;  but  it  is  very  rare.  Mr.  Holmes 
Coote  refers,  however,  to  a  few  cases  recorded  by  Mr.  Caesar  Hawkins 
and  other  authors  ;  but  the  disease  is  not  within  the  range  of  surgical 
treatment. 

1  See  especially  a  paper  by  Dr.  Greene,  of  Portland,  Maine,  in  the  Am.  Jour.  Med. 
Sci.,  Jan.  1871. 


870  SKIN    DISEASES. 


CHAPTER    XLIII. 

DISEASES  OF  THE   SKIN  AND  ITS  APPENDAGES. 

It  seems  necessary  to  give  in  this  work  a  general  idea  of  the  diseases 
of  the  skin,  although  the  subject  is  so  extensive,  and  the  practical  con- 
siderations connected  with  the  treatment  of  skin  diseases  are  so  very 
numerous  and  complicated,  that  it  is  quite  impossible  for  me  to  attempt 
anytliing  here  beyond  the  liarest  outline,  and  this  chiefly  with  the  view 
of  rendering  what  has  been  said  in  previous  pages  intelligible.  But  in 
order  to  acquire  a  useful  knowledge  of  the  matter  and  to  be  able  readily 
to  distinguish  the  various  eruptions  from  eacli  other,  it  is  absolutely 
necessary  to  stud}^  these  diseases  in  the  living  body,  comparing  the  erup- 
tions seen  in  the  out-patient  rooms  or  in  the  wards  with  the  drawings 
and  descriptions  which  are  given  in  approved  authors,  and  with  the 
models  to  be  found  in  the  Museum  of  the  College  of  Suroeons  and  else- 
where. 

Affections  of  the  cutaneous  system  are  divided  into  those  of  the  skin 
itself,  and  those  of  its  appendages,  the  hair,  nails,  and  cellular  tissue. 
We  will  speak  first  of  the  eruptions  of  the  skin  itself. 

The  anatomical  classification  of  these  eruptions  is  the  most  obvious 
and  the  most  useful  in  practice — viz.,  into  1.  Exanthemata  or  rashes;  2. 
Haemorrhages ;  3.  Vesicles  ;  4.  Parasites  :  5.  Blebs ;  6.  Pustules  ;  1. 
Papules;  8.  Scales;  9.  Tubercles;  and  10.  Stains — to  which  certain 
conditions  are  to  be  added,  named  "  Xerodermata,"  resulting  from  un- 
natural dryness  of  the  skin. 

Exanthemata — or  rashes — are  eruptions  characterized  by  the  occur- 
rence of  patches  of  skin  which  are  injected  and  red,  and  thickened  in 
consequence  of  being  injected,  but  in  which  there  is  not  necessarily  any 
inflammator}^  effusion.  The  epidermis  usually  desquamates  on  the  sub- 
sidence of  an  exanthematons  eruption. 

The  skin  eruptions  which  are  properly  classed  as  exantliemata  are 
roseola  and  erythema.  Urticaria  so  closel}^  resembles  some  varieties  of 
erythema,  that  it  is  usually  described  along  with  it,  though  it  is  not  truly 
an  exantliem.  Many  fevers  are  accompanied  by  exanthematons  erup- 
tions ;  but  they  are  not  spoken  of  here,  since  in  them  the  eruption  is  only 
a  subordinate  symptom. 

I  have  enumerated  and  described  the  varieties  of  erythema  in  a  pre- 
vious chapter  f  p.  67 )  in  connection  with  erysipelas,  so  that  the  only  trul}^ 
exanthematons  disease  left  for  description  here  is  roseola. 

Boseola. — This  arises  from  various  causes,  but  is  always  of  constitu- 
tional origin.'  It  is  characterized  by  small  rose-colored  spots,  or  a  roseate 
mottling  of  the  skin.  Some  of  its  varieties  (R.  infantilis  and  R.  testiva) 
approach  very  nearly  in  character  to  the  eruption  of  measles,  and  are  ac- 
companied by  some  fever  and  sore  throat,  but  are  not  marked  by  the 


'  "  The  eruptions  proper  to  tj'phus  fevor,  measles,  typhoid  fever,  scarlet  fever,  and 
cholera  are  in  reality  roseola." — Jenner. 


•PURPURA SCORBUTUS.  871 

coryza  of  measles.  These  varieties  sometimes  bear  the  name  of  "  mor- 
billi  nothi  " — bastard  measles.  Another  form  of  roseola  is  that  wliicli 
sometimes  precedes  the  small-pox  ernption,  and  occasionally  tliat  of  cow- 
pox.  Roseola  also  is  found  in  gout  and  rheumatism.  Another  form  of 
roseola  is  found  in  definite  rings — roseola  annulata— hardly  to  be  dis- 
tinguished from  erythema  marginatum.  This  is  merely  a  symptom  of 
deranged  digestion.  In  fact,  all  these  A'arieties  of  roseola  are  in  them- 
selves insignificant,  although  the  constitutional  condition  on  whicli  they 
depend  may  be  of  the  gravest  possil)le  import.  The  varieties  of  roseola 
which  constitute  substantive  diseases  require  only  attention  to  the  state 
of  the  digestive  organs,  and  in  infancy  to  that  of  the  dentition,  with  mode- 
rate purging  and  free  action  of  the  skin. 

Syphilitic  Roseola. — In  3'oung  persons,  especially  girls,  suflfering  for  the 
first  time  from  S3'philis,  an  eruption  is  constantly' seen  which  is  classed  by 
many  under  the  name  of  roseola,  less  red  in  color  than  the  non-syphilitic 
varieties  of  the  disease,  and  nearly  allied  to  pityriasis.  Like  tlie  latter 
eruption  its  favorite  seat  is  the  chest.  It  will  rapidl^y  disappear  under 
the  endermic  use  of  mercury. 
/%.-  Urticaria,  or  nettlerash,  is  usually  described  along  with  the  exan- 
themata, though  not  properly  belonging  to  that  class  ;  since  in  urticaria 
there  is  not  only  redness  fading  on  pressure,  as  in  tlie  exanthematous 
eruptions,  but  also  elevated  flat  patches  of  skin  called  wheals  or  "pom- 
phi."  These  wheals  are  seated  on  the  red  patch  of  skin,  and  they 
testify  to  the  effusion  of  serum  into  the  tissue  of  the  cutis,  just  as  the 
wheals  which  occur  in  insect  bites  do,  and  as  the  wheals  which  follow 
a  lash  testify  to  effusion  into  the  substance  of  the  skin.  These  wheals 
tingle  and  burn  like  the  stings  of  nettles.  Urticaria  is  excited  by  all 
sorts  of  causes  which  disturb  digestion;  errors  in  diet,  especially  the 
eating  of  sliellfish,  by  those  with  whom  it  acts  as  a  kind  of  poison, 
or  from  local  irritation  of  the  skin.  These  kinds  of  urticaria  are  acute 
and  transitory,  and  can  be  cured  by  the  witlidrawal  of  their  causes, 
an  emetic,  if  needful,  and  a  mercurial  purge.  There  are  other  varieties 
of  urticaria  which  are  chronic.  In  some  of  these  .the  individual  wheals 
disappear  while  others  come  out — U.  evanida;  in  others,  on  the  con- 
trary, they  are  persistent — U.  perstans ;  other  minuter  differences  in  the 
arrangement  and  size  of  the  wheals  are  expressed  by  the  terms  U.  con- 
ferta,  U.  tuberosa;  and  a  kind  in  which  the  causes  and  the  symptoms  of 
urticaria  are  present,  the  burning,  tingling,  etc.,  but  no  wheals  are  seen, 
is  called  U.  subcutanea.  In  these  more  obstinate  cases  of  urticaria  the 
first  care  is  to  soothe  the  irritation  of  the  skin  by  some  wash.  Lemon-juice 
or  vinegar  often  succeeds.  Mr.  Erasmus  Wilson  prescribes  Hydr.  Per- 
chlor.  gr.  v-x,  Sp.  Roris  marini,  Sp.  Vin.  Tenuior.,  aa  |j,  Emuls.  Amyg- 
dal.  amar.,  ^vj.  A  dilute  solution  of  prussic  acid  and  almond  emulsion 
is  often  very  grateful.  The  next  point  is  to  discover  and  correct  any 
error  in  diet  or  regimen,  and  to  try  the  effect  of  copious  diaphoresis, 
combined  with  change  of  air,  strong  exercise,  and  sea  bathing.  In  other 
cases,  arsenic,  quinine,  colchicum,  or  alkaline  medicines  have  acted  bene- 
ficially. 

Pii?'pura — Sco7-biitus. — The  haemorrhagic  diseases  of  the  skin  are  pur- 
pura and  scurv3\  Purpura  is  characterized  by  spots  (petechifB)  or  large 
patches  (vibices)  of  ecchymosis  under  the  skin,  which  are  easily  distin- 
guished from  every  other  form  of  spot  by  their  persistence  under  pressure, 
and  by  their  changing  their  color  with  time,  as  bruises  do.  Purpura 
hsemorrhagica  is  a  severer  form  of  the    disease,  in   which  blood  exudes 


872  SKIN     DISEASES. 

from  the  mucous  cavities,  as  in  liremophilia  (p.  105).  Purpura  is  merely 
a  symi)tom  of  some  disorder  of  tlie  healtli  or  tlie  blood,  and  its  treatment 
must  depend  on  a  thorough  knowledge  of  its  cause.  Without  this  the 
ordinary  astringents  and  hjumostatics  will  be  prescribed  in  vain. 

Scurvy  is  a  specific  disease,  and  in  no  other  sense  a  disease  of  the  skin 
than  that  one  of  its  symptoms  is  subcutaneous  haemorrhage  in  the  form 
of  vibiees  and  petechia,  just  as  the  bleeding  of  the  gums  is  another  and 
still  more  prominent  symptom. 

Vesiculse. — A  vesicle  is  a  small  elevation  of  the  epidermis,  which  is 
separated  from  the  true  skin  by  the  effusion  between  them  of  a  clear 
serum.  This  is  usually  the  result  of  inflammation,  and  accordingly  the 
neighboring  skin  is  generally  seen  to  be  red  and  congested. 

The  vesicular  eruptions  are  sudaniina,  miliaria,  eczema,  and  herpes. 

Sudamina  and  Miliaria. — The  two  first  fall  within  the  province  of  the 
physician,  sudamina  being  tlie  small  clear  vesicles  which  appear  in  the 
course  of  certain  fevers,  apparently  only  as  the  result  of  obstruction  of 
the  sweat-ducts ;  and  vanish  in  a  day  or  two.  Miliaria  are  vesicles  which 
are  found  in  acute  rheumatism,  and  in  children  or  adults  with  very 
tender  skin  in  the  summer  months,  often  mixed  wath  roseola,  and  dis- 
play more  distinct  traces  of  inflammation  than  sudamina  do,  being  sur- 
rounded b}'  a  red  halo,  and  easily  passing  on  to  suppuration.  In  some 
cases  a  fever  accompanied  b}'  miliary  vesicles  (miliary  fever)  prevails  as 
an  epidemic. 

Eczema  is  the  commonest  of  all  skin  diseases.  It  is  characterized  by 
the  eruption  on  patches  of  inflamed  skin  of  a  thick  crop  of  small  vesicles, 
together  with  scattered  vesicles  each  surrounded  by  its  halo  of  vascular- 
ity, but  unaccompanied  by  any  diffused  inflammation  of  the  skin.  The 
vesicles  burst  and  tlie  epidermis  then  may  form  scabs  or  scales  on  the 
surface,  so  that  the  erui)tion  in  this  state  may  appear  to  be  squamous; 
or,  on  the  other  hand,  the  fluid  in  the  vesicles  may  become  purulent,  and 
then  the  eruption  will  resemble  the  pustular — impetigo.  Successive 
crops  of  vesicles  may  make  their  appearance  as  the  former  die  away. 
The  fluid  is  strongly  alkaline  in  reaction,  and  often  as  it  oozes  away  it 
seems  to  scald  or  burn  the  skin,  and  a  smarting  sensation  in  the  parts 
often  accompanies  the  eruption,  and  justifies  its  appellation.  It  is  a  very 
common  eruption  on  the  leg,  and  is  often  accompanied  by  an  ulcer — the 
eczematous  ulcer  aljove  described  (p.  413).  Eczema  is  often  nearly  allied 
to  gout,  and  the  urine  accordingly  will  be  found  to  contain  lithic  acid  or 
oxalate  of  lime. 

Varieties  of  eczema  are  described  by  Hebra  without  an}^  vesicular 
eruption — i.e.,  a  diffused  inflammation  of  the  skin  resembling  eczema  in 
its  constitutional  complications  (or  rather  caus^es)  and  in  its  seat,  but 
characterized  by  the  separation  of  the  epidermis  from  the  skin  in  papules, 
scales,  or  pustules,  instead  of  vesicles.  The  papular  form  would  be 
classed  V)y  others  as  lichen  eczematodes,  the  scaly  as  pityriasis  rubra,  the 
pustular  as  impetigo  or  eczema  impetiginodes ;  but  the  difi'erences  are 
obviously  immaterial. 

The  recognized  varieties  of  eczema  are  E.  simplex,  when  the  inflam- 
mation of  tiie  neighboring  skin  is  not  severe;  E.  rubrum,  when  the  skin 
is  much  inflamed  ;  and  E.  impetiginodes,  when  the  vesicles  raj)idly  sup- 
purate or  are  mixed  with  pustules.  Hebra  describes  a  form  as  E.  margin- 
atum, wjiich  is  by  many  writers  considered  to  be  syphilitic,  and  there  is 
no  question  tiiat  eczema  may  appear  as  a  secondary  syphilitic  eruption, 
though  it  is  not  a  common  sj'mptom  of  s^'philis. 


HERPES.  873 

Eczema  appears  at  all  periods  of  life  and  in  all  parts  of  tlie  body. 
"The  face,  the  hairy  scalp,  and  the  skin  beliind  the  ears  are  all  common 
seats  of  eczema  ;  but  there  is  no  part  of  the  trunk  or  extremities  which 
it  may  not,  nay  does  not,  frequently  affect.  Befoie  and  during-  the  first 
dentition,  eczema  is  by  far  the  most  common  of  the  diseases  of  the  scalp." 
— Jenner.     It  is  never  contagious. 

Its  causes  are  constitutional  and  local;  the  latter  being  the  n)ost  easily 
cured,  by  withdrawing  the  irritation  on  which  the  disease  depends.  The 
kinds  of  eczema  wliich  depend  on  gouty,  strumous,  diabetic,  and  other 
constitutional  conditions  are  often  excessively  obstinate. 

The  treatment  will  consist  in  the  first  place  in  discovering  and,  if  })os- 
sible,  counteracting  the  causes  on  which  the  inflammation  depends,  tlien 
in  diminisliing  the  inflammation  of  tlie  skin  by  soothing  and  slightly 
astringent  lotions  or  ointments,  accompanied,  of  course,  by  suitable  posi- 
tion of  the  parts,  with  moderate  purgation  and  an  antacid  regimen  if 
the  condition  of  the  urine  indicates  it;  and  in  the  more  chronic  condi- 
tion, when  the  disease  api)roaches  more  to  the  scaly  eruptions,  by  the 
application  of  some  of  the  tarry  substances  (such  as  the  ung.  picis 
liquidae  or  the  petroleum  Barbadense)  with  a  course  of  arsenic.  If 
S3'philis  be  present  or  suspected,  a  mild  and  prolonged  course  of  mercury 
or  mercurial  fumigation  should  be  tried.  When  the  scalp  is  affected,  the 
hair  must  be  most  thoroughly  and  carefully  removed  with  scissors,  and 
the  scales  and  scabs  detached  by  a  cap  of  gruel  or  a  bread  and  milk 
poultice  or  linseed  oil ;  after  which  Sir  W.  Jenner  recommends  the  ap- 
plication of  liquid  pitch  if  there  is  not  much  inflammation.  While  the 
eruption  is  in  the  ''weeping"  stage  the  discharge  must  be  absorbed  by 
blotting-paper,  or  wet  strapping,  or  soda  lotion  (soda  snbcarbonat.  5iJ5 
aquae  Oiss.). 

Herpes  is  an  eruption  of  vesicles  situated  in  small  groups  on  slightly 
inflamed  skin.  It  diff"ers  from  eczema  in  many  respects,  chiefly  in  the 
fact  that  the  vesicles  form  a  far  more  prominent  feature  of  the  eruption 
than  in  eczema,  and  the  inflammiition  of  the  skin  is  far  less  marked. 
The  vesicles  also  are  usually  larger  than  in  eczema,  and  the  fluid  which 
they  contain  is  less  alkaline.  There  is  also  no  such  connection  witli 
chronic  constitutional  disease,  or  with  any  abiding  local  irritation  as  is 
constantly  found  in  eczema. 

The  varieties  of  herpes  are  as  follows  : 

Herpes  labialis  is  a  very  common  affection  which  occurs  sometimes 
from  cold,  but  often  with  no  affection  of  the  health  whatever.  The  ves- 
icles become  more  or  less  pustular,  then  crack,  and  the  scabs  fall  off  and 
leave  the  skin  below  a  little  irritable  for  a  few  days,  tlie  whole  affair  being 
generally  over  in  about  a  week.  The  prepuce  is  another  common  seat  of 
herpes,  and  these  little  cracks,  occurring  after  suspicious  connection, 
often  cause  the  patient  much  alarm.  Their  numbei'  and  their  perfectly 
superficial  situation  will  disclose  their  nature,  and  the  ai)i)lication  of  a 
little  mild  mercurial  ointment  will  in  a  few  days  remove  all  cause  for  ap- 
prehension. No  treatment  is  required  for  these  simple  forms  of  herpes 
beyond  a  purge,  some  care  in  diet,  and  the  use  of  citrine  ointment,  or 
an  ointment  of  gray  oxide  of  mercury,  gr.  x-xv  to  the  oz.  Lemon-juice 
is  a  favorite  application  in  herpes  labialis,  and  there  are  a  thousand  do- 
mestic remedies  for  what  is  after  all  a  spontaneously  curable  affection. 

Another  form  of  herpes  follows  the  distribution  of  one  of  the  sensory 
nerves,  and  is  often  complicated  by  severe  neuralgia  of  that  nerve.  The 
best  known  example  is  herpes  zoster  or  shingles  (cinguhim,  a  girdle) 
which  follows  the  distribution  of  one  of  the  intercostal  nerves,  extending 


874  SKIN     DISEASES. 

from  the  back  to  the  sternum/  This  is  generally  preceded  b}'^  some  fever 
and  severe  pain  in  the  part,  and  often  neuralgia  persists  in  the  part  for 
some  time  afterwards.  The  eruption  runs  its  course  in  about  a  fortnight, 
and  is  said  seldom  to  affect  the  same  individual  twice.  It  requires  in 
itself  no  treatment  beyond  a  purge  and  some  soothing  application.  The 
neuralgia  which  it  leaves  behind  may  require  prolonged  and  careful  man- 
agement. Other  forms  of  neuralgic  hei'pes  occur  in  the  face,  following 
the  distril)ution  of  the  fifth  nerve,  and  sometimes  complicated  with  iritis, 
and  iu  other  nerves  also,  but  more  rarely. 

Herpes  jihlyctenodes  is  a  variety  found  on  the  face,  in  which  the 
vesicles  are  unusually  large.  H.  iris  is  a  rare  variety  in  which  there  is  a 
ring  of  vesicles  arranged  around  a  central  one,  and  each  surrounded  by 
concentric  circles  of  various  shades  of  red.  It  is  found  usually  on  the 
back  of  the  hand. 

H.  circinnatus  is  when  the  eruption  occurs  in  a  red  ring  and  spreads 
from  the  centre.  Sometimes  the  vesicles  are  large,  and  it  runs  the  ordi- 
nary course  of  herpes  in  other  parts,  disappearing  in  about  a  fortnight. 
But  the  form  of  the  disease  in  which  the  vesicles  are  so  minute  that  they 
often  pass  unnoticed,  and  the  eruption  appears  to  be  of  a  furfuraceous 
character,  is  exceedingly  obstinate,  and  is  known  in  popular  parlance  as 
"the  ringworm."  It  occurs  on  the  face,  trunk,  and  extremities,  and  is 
contagious;  is  often  mixed  with  the  parasitic  disease — tinea  tonsurans — 
on  the  scalp ;  and  its  secretions  seem  to  afford  a  nidus  in  which  tlie  para- 
site grows.  The  eruption  spreads  centrifu gaily  ;  the  original  ring  disap- 
pearing and  giving  i)laee  to  a  larger  one,  and  so  on.  Its  causes  are  local, 
and  it  is  curable  by  local  treatment — the  ap[)lication  of  strong  astringents, 
as  sulphate  of  iron  or  gallic  acid — of  strong  acetic  acid,  nitrate  of  silver, 
or  blistering  fluid. 

Parasitae. — The  diseases  excited  on  the  skin  by  the  growth  of  a  vege- 
table parasite  are  tinea  tonsurans,  tinea  decalvans  (possibly),  tinea  favosa, 
tinea  sycosis  or  simply  sycosis  (mentagra),  and  chloasma  or  pityriasis 
versicolor. 

Tinea  tonsurans  is  exceedingl}'  like  herpes  circinnatus  ;  so  much  so 
that  by  some  they  are  classed  as  the  same  disease,  and  both  are  included 
in  the  popular  term  "  ringworm."  It  is  seated  on  the  hairy  scalp,  and  is 
only  seen  in  children,  seldom  before  two  or  after  twelve.  It  appears  in 
round  patches  covered  with  white  scales,  and  here  the  hairs  are  so  com- 
pletely I'emoved  that  the  places  seem  to  have  been  shaved;  but  on  minute 
examination,  short  thick  twisted  hairs  will  be  found  among  the  scales, 
and  the  hair-follicles  can  be  detected,  and  after  its  cure  the  hairs  will 
always  grow  again.  The  disease  is  caused  by  the  growth  in  the  hair  of  a 
vegetable  parasite — the  trichophyton  tonsurans.^  This  imbeds  itself  in 
the  secretion  of  the  hair-follicles  which  is  believed  to  be  unhealthy,  and 
as  it  grows  into  the  hair  it  causes  it  to  swell  and  become  brittle,  so  that 
it  breaks  off  and  comes  away.  The  spores  of  this  plant  may  be  found 
also  in  the  epithelium  of  tiie  patch,  which  is  heaped  up  in  opaque  white 
scales. 

The  treatment  is  directed  to  the  destruction  of  the  parasite.     Strict 

*  In  some  cases  it  is  found  in  the  course  of  the  intercosto-hunieral  branch  as  well 
as  the  intercostal  trunk. 

^  I  must  rct'or  the  reader  to  some  of  the  special  treatises — such  as  that  of  Mr. 
Nayler — for  the  microscopical  appearances  of  these  parasitic  fungi.  In  the  judgment 
of  some  dermatologists,  as  Dr.  Tilbury  Fox,  they  are  all  different  stages  of  growth 
of  the  same  plant. 


RINGWORM.  875 

cleanliness  must  be  enforced,  the  epithelium  removed  by  a  lotion  of  borax, 
and  an  ointment  rubbed  in  twice  a  day  to  destroy  all  the  spores  of  the 
fungus.  Sir  W.  Jenner  recommends  5  grains  of  the  aminonio-chloride 
of  mercury  to  tlie  drachm  of  sn][)hur  ointment  for  tliis  purpose  ;  or  2 
grains  of  the  perchloride  to  the  draclun  of  lard  ;  or  30  grains  of  nitrate 
of  copper  to  4  drachms  of  lard  ;  or  10  drops  of  creasote  to  the  drachm  of 
lard  ;  or  strong  blistering  fluid  or  strong  sulphuric  acid,  tlie  part  to  be 
washed  directly  afterwards  with  cold  water. 

Tinea  Becalvans. — In  so-called  tinea  decalvans  the  hairs  are  completely 
removed  from  the  scalp,  and  sometimes  from  other  hairy  parts  also,  in 
large  irregular  patches,  where  the  skin  is  perfectly  bald  with  no  trace  of 
the  truncated  hairs  which  are  found  in  tinea  tonsurans.  The  skin  ex- 
posed is  smooth  and  paler  than  natural.  This  is  said  to  be  due  also  to 
the  presence  of  a  parasite — the  microsporon  Audouini — which,  however, 
Sir  W.  Jenner  says  he  has  never  been  able  to  find  either  on  or  in  the  hairs 
about  to  fall  from  their  follicles,  nor  has  Mr.  Nayler  been  more  successful 
in  his  search  foi-  these  sporules.'  There  is  also  no  proof  that  the  disease 
is  contagious  as  parasitic  diseases  always  are  ;  accordingly  in  this  country 
the  disease  is  more  frequently  classed  as  "Alopecia."  The  patches  are 
bounded  by  definite  margins,  and  as  these  areas  fall  into  each  other  the 
whole  scalp  may  become  bald  ;  na}^  I  have  seen  a  case  in  which  the  whole 
body  was  so,  no  trace  of  a  hair  being  recognizable  on  any  part.  Alopecia 
is  also  a  common  symptom  of  syphilis,  especially  common  in  the  secondary 
syphilis  of  young  girls  and  in  congenital  or  acquired  syphilis  in  infants. 
The  remedies  consist  in  the  application  of  stimulants  to  the  part.  The 
bald  patches  should  be  painted  about  once  a  fortnight  with  blistering 
fluid,  and  left  alone  till  the  irritation  has  subsided,  when  a  slightly  stimu- 
lating ointment  or  lotion  is  to  be  applied  till  the  time  for  the  next  blis- 
tering arrives.  Liniments  or  lotions  of  ammonia  seem  well  suited  fortius 
purpose  (see  p.  403).  Tn  syphilitic  cases  a  mercurial  course  is  indis- 
pensable. Slight  cases,  especially  at  early  periods  of  life,  and  syphilitic 
cases  will  probably  get  well ;  in  very  extensive  alopecia,  and  in  older 
persons,  there  is  much  reason  to  fear  that  the  baldness  will  be  permanent. 

Tinea  favom,  or  favus,  is  a  very  acute  and  formidable  eruption  of  the 
scalp  in  childhood.  It  is  due  to  the  lodgment  in  the  hair-follicles  of  the 
sporules  of  a  fungus  called  the  achorion  Schonleinii.  These  give  rise  to 
an  eruption  consisting  of  brimstone-yellow  crusts,  cup-shaped,  and  each 
having  a  hair  in  its  centre.  These  dry  crusts  are  not  uncommonly  mixed 
with  pustules  of  impetigo.  As  these  crusts  increase  they  kill  the  hair  on 
which  they  form,  and  thus  favus,  unless  soon  cured,  may  induce  perma- 
nent baldness  of  the  aflTected  part.  In  some  cases  a  peculiar  and  unpleas- 
ant odor  is  perceived  (compared  to  that  of  cat's  urine)  but  not  always. 
Sir  W.  Jenner  has  noted  that  children  affected  with  herpes  circinnatus 
are  peculiarly  exposed  to  the  contagion  of  favus,  and  has  given  interesting 
examples  of  this  fact. 

The  cure  of  favus,  as  of  other  parasitic  diseases,  is  procured  by  killing 
the  parasite.  For  this  purpose  the  hairs  may  be  plucked  out.  The  huile 
de  cade  is  said  to  loosen  their  attachment,  and  the  hairs  have  less  than 
the  normal  tenacity  of  implantation  in  any  case,  so  that  when  the  disease 
is  limited  there  is  no  great  difficulty  ;  but  it  becomes  almost  impractica- 
ble when  the  scalp  is  extensively  affected.  No  doubt  drawing  out  the 
hairs  facilitates  the  application  of  the  parasiticide  remedies,  but  Mr. 
Nayler  saj^s  that  it  is  by  no  means  necessary,  and  that  after  the  usual 

1  Diseases  of  the  Skin,  2d  ed.,  p.  21G. 


876  SKIN    DISEASES. 

preparatory  cleansing,  tar  or  the  nng.  picis  liqniili\?,  answers  every  pur- 
pose. In  fact  these  applications  as  they  separate  bring  away  the  hairs 
with  them.  Then  a  saturated  solution  of  sulphurous  acid  applied  on  lint 
covered  with  oiled  silk,  or  perchloride  of  mercury  in  the  proportion  of  8 
grs  to  the  ounce  of  lard,  or  acetate  of  copper,  half  a  drachm  to  the 
ounce,  are  recommended  for  the  destruction  of  the  parasite.  Favus 
affects  the  hairs  of  other  parts  of  the  body  as  well  as  the  scalp.  It  is  a 
rare  disease,  and  only  seen  in  the  poorest  and  most  neglected  children. 
It  is  undoubtedly  contagious,  though  not  very  activel}'  so  (see  Nayler, 
op.  cil.,  p.  245). 

Si/('ox/.-<  is  a  disease  of  the  beard  and  whiskers,  very  rarely  of  any  other 
part,  though  Mr.  Nayler  refers  to  cases  in  which  the  eyebrows  or  the  hair 
of  the  back  of  the  neck  have  been  att'ected,  and  I  believe  cases  have  been 
recorded  in  the  female.  It  is  due  to  the  lodgment  of  a  parasite — the  mi- 
crosporon  mentagrophytes — in  the  hair-follicle,  the  presence  of  which 
excites  an  inflammatory  swelling  of  the  follicle,  like  that  of  the  sebaceous 
follicle  in  acne,  followed  bv  suppuration.  A  hair  is  seen  to  traverse  each 
pustule,  which  would  sufliciently  distinguish  it  from  acne,  to  which  other- 
wise it  bears  a  considerable  resemblance,  as  it  does  to  impetigo ;  but  in 
sycosis  there  is  much  more  thickening  around  the  pustules  than  in 
impetigo. 

Sycosis  is  often  very  difficult  to  cure.  The  patients  are  frequently  out 
of  health,  either  from  intemperance  or  starvation,  so  that  tlie  first  thing 
is  to  correct  either  of  these  excesses,  to  bring  the  patient's  digestion  into 
good  order,  and  supplj'  him  with  a  generous  unstimulating  diet.  The 
scabs  must  be  removed  by  poulticing,  the  hairs  removed  if  possible,  and 
some  of  tlie  parasiticide  ointments  above  prescribed  applied.  Iodide  of 
sulpliur  ointment  and  white  precipitate  ointment  are  the  favorite  applica- 
tions, but  if  the  eruption  does  not  yield  to  one,  another  must  be  tried. 

Chloasma. — Another  uiidoubtedly  parasitic  disease  is  the  one  so  often 
seen  on  the  chest  and  loins,'  especially  in  young  people  of  delicate  skin, 
and  in  others  who  neglect  cleanliness,  and  especially  who  constantly  wear 
the  same  unwashed  flannel.  The  eruption,  however,  though  favored  by 
such  dirty  habits,  does  not  arise  exclusively  from  them,  for  in  some  cases, 
persons  of  scrupulous  cleanliness  are  found  to  be  affected.  It  never 
occurs  in  childhood.  It  is  characterized  by  the  presence  of  numerous  cir- 
cular brownisii  patches  ("chloasma"),  which,  however,  vary  in  shade  from 
yellow  to  dark-brown,  or  even  a  reddish  tinge,  in  different  persons,  and 
in  the  same  person  at  different  times,  whence  its  synonym,  "pityriasis 
A'ersicolor."  The  patches  consist  of  epithelium  which  is  branlike  and 
desfpiamating,  and  if  these  scales  be  removed  and  examined  in  an  alka- 
line fluid,  or,  as  Mr.  Nayler  recommends,  in  acetic  acid,  abundant  spores 
and  mycelium  of  the  fungus — microsporon  furfurans — will  be  detected, 

The  complaint  is  a  very  common  one — and  is  consistent  with  the  most 
perfect  health — the  only  inconvenience  the  patient  experiences  being  that 
his  skin  is  irritable  when  he  gets  hot. 

It  is  to  be  diagnosed  from  "liver-spot"  (lentigo  hepatica),  a  very  rare 
disease,  which  has  no  scaling  of  the  epidermis  and  no  parasitic  origin, 
and  wiiich  occurs  in  childhood  as  well  as  in  afterlife, — and  also  from  the 
other  kinds  of  pityriasis  presently  to  be  described. 

Its  cure  must  be  sought,  as  before,  in  the  destruction  of  the  parasite, 
for  which  purpose  all  dirty  habits  must  be  reformed,  the  skin  well  rubbed, 

'  Otlier  parts  of  the  body  iiro  occasionally  though  rarely  atToctcd — the  face  very 
seldom. 


BULL^.  877 

after  thorough  washing,  with  a  flesh-brush  daily,  and  then  sulphur  oint- 
ment or  a  lotion  or  ointment  of  bichloride  of  mercury  will  cure  tlie  dis- 
ease, though  it  is  very  liable  to  recur.  Like  other  parasitic  diseases  it  is 
contagious. 

Scabies. — The  only  parasitic  animal  which  causes  an  eruption  is  the 
acarus  ncahiei  ov  sarcopUs  hominis,  which  burrows  and  hides  itself  in  the 
deeper  layers  of  the  epidermis,  and  thus  gives  rise  to  an  irritation  which 
develops  a  definite  erui)tiou — "the  itch" — of  either  a  vesicular  or  pus- 
tular nature.  Tlie  intolerable  itching  excites  the  i)atient  to  scratch  iiim- 
self,  and  thus  much  aggravates  tlie  eruption. 

Scabies  is  seen  first  in  the  adult  usually  in  the  hands  and  wrists,  espe- 
cially in  the  clefts  between  the  fingers ;  in  children  in  arms  on  the  but- 
tocks. It  is  known  by  the  itcliing  and  scratching  and  by  the  vesicles  or 
phl^'zacious  pustules  mixed  with  small  cracks  or  burrows  leading  from  the 
bases  of  some  of  the  vesicles,  and  marking  the  spot  where  the  animal  may 
be  found  if  the  burrow  l)e  carefully  opened  with  a  needle  and  searched 
■with  a  magnifying-glass. 

The  remedy  for  scabies  is  sulphur,  which  never  fails  to  kill  the  animal, 
if  only  the  disease  is  not  excited  by  fresh  parasites  from  the  clothes.  If 
these  are  fumigated  with  sulphur  or  baked  for  a  sufficient  time,  and  all 
parts  affected  with  the  eruption  smeared  well  over  with  the  ung.  sulphuris 
twice  a  day,  the  patient  will  be  well  in  a  few  days.  Sir  W.  Jenner  says 
that  at  the  St.  Louis  Hospital  at  Paris  a  cure  is  obtained  in  two  hours  by 
the  patient  being  well  rubbed  over  with  soft  soap  for  half  an  hour,  then 
smeared  with  an  ointment  composed  of  eight  parts  of  lard,  two  of  sulphur, 
and  one  of  carbonate  of  potash  for  half  an  hour,  and  then  placed  in  an 
alkaline  bath. 

If  there  is  anj^  objection  to  the  color  or  odor  of  the  sulphur,  the  former 
may  be  concealed  by  the  admixture  of  the  bisulphuret  of  mercur}',  and 
the  latter  by  a  few  drops  of  essence  of  bergamot. 

BuUse. — A  bulla  or  bleb  diff'ers  from  a  vesicle  only  in  size.  It  is  a 
cavity  between  the  skin  and  epidermis  filled  with  serous  fluid. 

The  bullous  eruptions  are  two — pemphigus  and  rupia. 

Penfphigus^  otherwise  called  pompholyx,  is  an  eruption  of  large  bulLie, 
often  in  small  numbers,  sometimes  even  solitary,  with  little  or  no  inflam- 
mation around  them,  attaining  in  some  cases  an  enormous  size,  and  con- 
taining pure  serum,  alkaline  at  first,  which  may  turn  acid  and  become 
puriform.  The  bullae  Iturst  and  the  epidermis  dries  down  into  a  scab, 
while  fresh  bulhie  probably  form. 

Si/philific  pemphigus  is  sometimes  due  in  infancy  no  doubt  to  con- 
genital syphilis,  and  this  is  distinguished  from  the  ordinary  eruption  by 
appearing  on  the  feet  and  hands,  and  in  some  other  cases  it  may  be  a 
tertiary  symptom  in  later  life.  It  occurs  also  as  an  acute  disease  attended 
with  a  febrile  disturbance — febris  bullosa.  It  also  occurs  in  an  acute 
form  in  old  and  cachectic  persons ;  but  more  commonly  it  is  a  chronic 
eruption,  and  depending  on  visceral  disease. 

The  treatment  must  be  directed  mainly  to  the  constitutional  condition. 
In  the  syphilitic  variety  iodide  of  potassium  is  indicated,  with  generous 
diet  and  opium.  In  cachectic  persons  the  treatment  must  var}'  with  the 
nature  of  the  cachexia. 

The  blebs  should  be  pricked  ;  the  part  pencilled  with  a  strong  solution 
of  nitrate  of  silver  (5J  :  sj),  and  after  the  cuticle  has  been  tluis  hardened 
into  a  scab,  this  should  be  detached  b}'  a  poultice.  If  the  cutis  be  ulcer- 
ated below,  the  ulcer  should  be  stimulated  with  nitrate  of  silver. 


878  SKIN    DISEASES. 

JRiipia  originates  as  a  hullons  eruption,  tlie  bulUe  being  comparatively 
small  and  seated  on  an  inflamed  base;  bnt  the  contents  of  the  bnllnesoon 
become  purulent,  and  tlie  jnis  dries  up  into  a  rougli,  coarse,  prominent 
scab  \vliich  remains  attaclied  for  some  time,  and  when  it  falls  off  leaves  a 
circular  ulcer — the  rupial  ulcer.  Sometimes  the  ulcer  spreads  without 
an}'  falling  otl'  of  tlie  scab,  and  then  a  larger  scab  forms  under  the  original 
one  and  raises  it  up,  and  so  on  until  a  projecting  mass  of  scab  is  formed 
like  a  limi)et-shell.  This  variety  is  called  R.  prominens.  Other  varieties 
are  R.  escharotica,  marked  b}'  a  spreading  or  phagedenic  condition  of 
the  rupial  ulcer,  and  R.  gangrsenosa,  when  the  surface  of  the  ulcer 
sloughs. 

Si/philitic  rupia,  particularly  the  R.  prominens,  is  a  frequent  symptom 
of  tertiary  syphilis,  especially  in  cachectic  or  dissipated  persons,  but  it 
occurs  also  in  other  conditions  of  general  cachexia. 

In  its  second  stage,  when  the  contents  of  the  bullae  have  become  purulent, 
it  is  hardly  to  be  diagnosed  from  ecthyma,  except  by  the  more  decided 
inflammation  round  the  pustules  in  tlie  latter  disease.  Later  on,  the 
prominence  of  the  scab  in  rupia  is  plainly  distinguished  from  the  sunken 
adherent  scab  of  ecthyma. 

The  treatment  of  all  forms  of  rupia  must  be  by  supports  and  stimulants; 
for  the  patients  are  always  broken  down  in  health.  In  the  syphilitic 
variet}',  rest,  shelter,  equable  temperature,  good  diet,  opium  and  sarsa- 
parilla,  should  precede  an}'  specific  treatment.  Then  iodide  of  potassium 
ma}'  be  administered  for  a  long  time,  followed  b}'  mild  mercurial  fumiga- 
tion. In  other  cases  various  tonics  and  stimulants  will  be  found  service- 
able. In  the  early  stage  of  the  eruption  the  bulljB  should  be  punctured 
at  once.  When  scabs  are  formed  they  should  be  removed,  and  the  ex- 
posed surface  dressed  with  some  stimulant. 

Pui<lidse. — A  pustule  is  a  small  collection  of  pus  beneath  the  epidermis, 
and  generally  seated  in  the  substance  of  the  true  skin.  "  Tlie  inflamma- 
tion, on  Avhich  the  formation  of  pus  depends,  extends  some  depth  iiito 
the  cutis,  so  that  the  collection  of  pus  which  constitutes  the  pustule  is 
situated  in  the  cutis,  and  not  merely  on  it  immediately  beneath  the 
cuticle."  Pustules  are  divided  into  three  sorts,  viz.,  psydraciae^  in  which 
the  pustule  forms  in  a  hair-follicle,  and  the  hair  is  seen  passing  through 
the  pustule,  the  skin  around  being  inflamed:  phlyzacise^  which  are  rather 
large  collections  of  pus  seated  on  inflamed  bases,  which  burst  and  form 
small  bi'own  scales  ;  and  ach.orea,  which  are  small  pustules,  usually  in 
considei'able  numliers,  with  much  redness  of  the  intervening  skin.  Their 
secretion  dries  up  into  thick  yellow  crusts  like  dried  honey.  The}-  are 
formed  l)y  the  inflammation  of  the  hair  and  sebaceous  follicles. 

Impetigo  and  ecthyma  are  the  only  diseases  which  are  to  be  described 
here.  Equinia  and  variola  are  added  in  the  formal  classifications,  but 
the  former  is  a  si)ecial  lesion  treated  of  elsewhere  (page  100),  and  the 
latter  is  not  iiroperly  a  skin  disease. 

Imjwliijo  is  almost  as  common  a  disease  as  eczema.  It  is  characterized 
by  a  copious  eruption  of  pustules,  both  psydracioe  and  achores,  and  by 
the  thick  honey-like  crusts  which  they  leave,  as  well  as  by  the  glandular 
enlai'gement  whicli  always  (according  to  Sir  W.  Jenner)  accompanies  the 
eruption.  The  seat  of  the  suppuration  is  in  the  hair-follicles,  at  any  rate 
in  the  great  majority  of  cases ;  though  in  some  instances  impetigo  may 
be  found  in   [)laces  where  there  is  no  hair,  as  beneath  the  nails.'     The 


^  See  Nayler,  op.  cit.,  p.  170. 


IMPETIGO.  879 

connection  between  eczema  and  impetigo  is  a  very  close  one.  True  im- 
petigo often  follows  eczema,  and  oi'teii  also  a  mixture  of  the  two  erup- 
tions is  met  with;  the  vesicles  of  eczema  either  supi)urating  rapidly,  or 
being  mixed  in  places  with  the  pustules  of  impetigo.  To  this  t'onn  of 
eruption,  the  name  eczema  impctiginodes  is  in'oi)crly  ai^plied. 

Impetigo  is  divided  into  a  great  number  of  species  derived  eitlier  from 
its  seat  (I.  capitis,  faciei,  etc.)  ;  from  the  arrangement  of  the  pustules,  I. 
sparsa,  I.  figurata,  where  the  pustules  are  approximated  on  a  defined 
patch  of  inflamed  skin;  from  the  nature  of  the  crusts  left,  I.  larvalis, 
when  the  face  is  covered  by  a  thick  crust,  like  a  mask ;  I.  scabida,  an 
obstinate  affection  seen  in  the  lovver  limbs  of  adults,  and  often  combined 
witli  anasarca ;  I.  granulata,  when  the  crust,  after  separating  from  the 
skin,  remains  attached  as  a  small  lump  to  the  hair;  or  from  the  course  of 
the  disease,  I.  acuta,  I.  chronica.  These  are  only  some  of  the  many  sub- 
divisions which  have  been  made  of  this  eruption.  Impetigo  is  in  some 
measure  contagious,  i.  f.,  tiie  disease  ma}'  be  implanted  by  means  of  the 
pus  from  the  pustules  or  crusts.  Thus  it  may  be  transferred  from  one 
child  to  another  b,y  wearing  the  same  cap.  Its  contagion,  however,  is 
conveyed  by  actual  contact,  not  through  the  air,  as  a  fungus  may  be 
carried. 

Forn'go. — Impetigo  capitis,  one  of  the  most  common  varieties  of  the 
disease,  is  still  sometimes  called  Porrigo,  a  term  used  by  Willan  and 
Bateman  in  a  somewhat  indefinite  manner.  It  is  well  therefore  to  ex- 
plain that  as  Sir  W.  Jenner  says,  "  Willan  figures  six  varieties  of  his 
genus  2)orrigo ;  of  these  P.  larvalis  and  P.  favosa  are  merely  varieties  of 
impetigo.  P.  furfurans  is  a  species  of  eczema.  P.  scutulata  is  tinea 
tonsurans.  P.  lupinosa  is  tinea  favosa,  and  P.  decalvans  is  tinea  de- 
calvans."  But  that  Willan's  description  is  not  absolutely  clear  may  be 
inferred  from  the  fact  tliat  other  recent  writers  interpret  these  terms 
somewhat  differently. 

Syphilitic  impetigo  occurs  as  a  syphilitic  eruption,  but  is  not  a  com- 
mon one,  and  usually  in  persons  whose  general  health  is  bad.  It  is  re- 
markable for  the  large  extent  of  its  patches,  and  is  usually  mixed  with 
syphilitic  tubercle. 

Other  causes  of  impetigo  are  the  irritation  of  the  liands  b}'  sugar — 
"grocer's  itch" — the  irritation  of  dirt  or  stone-grit;  and  of  lice  in  the 
head.     Equinia  is  only  a  variety  of  tliis  local  impetigo. 

Impetigo  is  to  be  distinguished  from  sycosis  (see  page  870),  from 
ecthyma,  by  the  smaller  size  of  tlie  pustules  in  impetigo,  and  by  tlieir 
having  no  base  ;  from  favus,  by  tlie  absence  of  an}'  parasite  ;  from  eczema, 
by  the  implication  of  the  hair-follicles. 

Its  treatment  should  be  to  cut  the  hair  off  as  completely  as  possilde, 
and  remove  the  crusts  by  poulticing,  and  then  apply  some  slightly 
stimulating  ointment^" ung.  zinci,  ung.  hydr.  nitratis,  ung.  hydr.  nitr. 
oxidi,  ung.  sulph.  iod.,  and  ung.  sulph.  hypochlor.,  are  all  occasionallv 
useful,  and  one  will  sometimes  answer  wlien  the  others  have  failed,  and 
without  the  reason  being  apparent." 

But  combined  with  this  local  treatment  must  be  general  regimen  and 
medicine  appropriate  to  the  individual  case.  Alteratives  and  tonics  are 
almost  always  required,  quinine  being  tlie  most  useful.  Change  of  air, 
sulphurous  waters,  and  sulphur  baths — especially  when  the  disease  is 
S3'philitic — are  often  of  great  service. 

Ecthyma  is  a  disease  difficult  to  distinguish  from  the  early  stage  of 
rupia,  if  indeed  there  be  any  distinction.  Many  authors  {c.  (7.,  Mr.  Nayler) 
include  the  two  eruptions  in  a  common  description.     Ecthyma  consists 


880  SKIN    DISEASES. 

in  an  eruption  of  large  phl\-zacious  pustules  on  a  red,  elevated,  and  in- 
durated base,  which  hurst  and  leave  a  brown  scab.  When  this  separates 
a  red  inHanied  portion  of  cutis,  or  a  small  nicer,  is  left.  The  pustules 
and  crusts  are  never  so  large  as  those  of  rupia  are,  nor  do  the  latter 
assume  the  prominent  adherent  shape  of  rupia.  It  is  a  cachectic  affec- 
tion, frequently  d(>pending  on  syphilis  ;  often  preceded  by  burning  pain 
in  the  part  from  which  the  pustules  afterwards  spring.  The  usual  dura- 
tion of  the  disease  when  due  simpl}^  to  depression  of  the  general  health 
is  onl}^  about  a  fortniglit ;  but  it  is  apt  to  recur  or  to  propagate  itself  in 
the  form  of  a  constant  succession  of  crops  of  pustules,  and  so  becomes 
chronic.  In  the  variety  which  is  complicated  with  purpura  (E.  luridum), 
the  pustules  are  surrounded  with  an  areola  of  a  purple  color,  in  conse- 
quence of  luBmorrhage.  The  eruptions  which  follow  on  the  irritation  of 
tartar  emetic  or  sugar,  applied  to  the  skin,  are  variously  classed  as  im- 
petigo or  ecthyma,  according  as  the  affection  of  the  hair-follicle  is  or  is 
not  regarded  i)y  the  classifier  as  an  essential  character  of  impetigo. 

Little  local  treatment  is  required  in  ecthyma.  The  crusts  should  not 
be  detached,  as  they  protect  the  skin  below.  The  part  should  be  de- 
fended from  friction  or  irritation  by  some  simple  ointment,  and  the  same 
general  treatment  pursued  as  in  rupia. 

Fapulse. — A  papule,  or  pimple,  is  an  elevation  of  the  cutis  covered  by 
its  cuticle ;  the  elevation  being  due  to  ef!"usion  of  inflammatory  lymph 
into  the  substance  of  the  true  skin. 

The  diseases  classed  as  papular  are  strophulus,  lichen,  and  prurigo. 

Stropliulus^  the  common  "red-gum,"  is  a  disease  of  inftmcy  character- 
ized by  the  eruption  of  small  pimples,  usually  red  and  close  together,  S. 
confertus — sometimes  white  and  rather  large,  S.  candidus' — sometimes 
-with  red  spots  intermixed,  S.  intertinctus.  The  eruption  is  generally  due 
to  disorder  of  the  bowels,  or  irritation  about  the  gums,  and  is  accompa- 
nied by  slight  itching  in  most  cases;  sometimes,  in  S.  confertus,  by  a 
good  deal  of  distress  from  irritation  and  cracking  of  the  skin.  It  will 
in  most  cases  subside  in  a  few  days  with  some  aperient,  and  attention  to 
the  state  of  the  gums  and  of  the  digestion.  Care  should  be  taken  not  to 
confound  this  fugacious  affection  with  the  permanent  lichen  of  congeni- 
tal syphilis  (see  p.  407),  and  not  to  mistake  fleabites  or  irritation  of  the 
skin  from  dirt,  for  strophulus. 

Lichen  is  characterized  by  the  eruption  of  a  large  number  of  red,  prom- 
inent, hard  papules,  which  retain  their  shape,  and  to  a  great  extent  their 
color,  under  pressure.  There  is  often  some  itching  and  tingling  about 
the  part,  and  occasionally'  so  much  febrile  disturbance  that  it  is  taken 
for  an  attack  of  measles.  It  is  sometimes  mixed  with  urticaria  ( L.  urti- 
catus), the  papules  becoming  apparent  as  the  wheals  subside.  It  is  a 
frequent  syi)hilitic  eruption,  generally  in  the  earlier  stages  of  the  consti- 
tutional ati'ection,  often  becoming  tubercular  in  its  progress.  Syi)liilitic 
lichen  is  known  by  its  coppery  color,  its  appearance  in  curved  figures 
(L.  gyratus),  its  occasional  presence  on  the  soles  of  the  feet,  especially 
in  infants,  its  tendency  to  crack  at  the  base,  and  the  history  or  concomi- 
tant symptoms  of  syphilis. 

Other  forms  of  lichen  are  the  L.  tropicus  or  "  prickly-  heat,"  a  familiar 
disease  in  hot  countries,  and  often  seen  here  in  hot  summers,  though  in 

1  There  is  an  eruption  of  larger  white  papules  called  S.  alliidus,  whicli,  liowever, 
has  been  shown  to  be  a  form  of  acne,  the  elevation  being  really  distended  sebaceous 
follicles. 


PRURIGO.  881 

a  milder  form  ;  L.  circiimscriptus,  where  the  pimples  appear  in  defined 
patches  ;  L.  pilaris,  where  each  papule  is  found  on  a  hair-follicle,  and 
has  a  hair  runnint;  IhroutJjh  it;  L.  agrius,  characterized  l\v  the  numerous 
hard  rough  pimples,  generally  on  the  face,  where  the  skin  feels  like  a 
nutmeg-grater,  and  by  the  excessive  itching;  L.  lividns,  a  step  between 
lichen  and  pnrpura,  where  the  pimples  are  dusky-red  or  livid,  and  pur- 
puric spots  may  be  interspersed,  showing  much  cachexia  and  generally 
in  old  broken-down  patients,  and  finally  the  L.  ruber  of  Hebra,  in  which 
large  portions  of  the  skin  become  inflamed  and  thickened  with  copious 
eruption  of  dark-red  papules  on  it,  the  thickening  of  the  skin  impeding 
motion,  and  the  disease  generally  running  onto  a  fatal  termination. 

Sim])le  cases  of  lichen  will  l»e  cured  by  purgatives,  the  avoidance  of 
all  sources  of  heat,  simple  unstimulating  diet,  and  tepid  or  cold  bathing, 
mucilaginous  baths  Iteing  most  to  be  recommended.  In  the  chronic 
forms  arsenic  (as  in  other  dry  erui)tions)  is  of  the  geatest  service.  The 
syphilitic  variety  is  under  the  control  of  mercury,  and  Mr.  Nayler  regards 
mercury  in  small  doses  as  being  of  service  in  all  forms  of  lichen.  The 
itching  is  allayed  by  sponging  the  parts  with  vinegar  or  lemon-juice,  and 
anointing  them  with  dilute  citrine  ointment,  or  by  a  prussic  acid  lotion — 
3iss.  or  5ij  of  the  dilute  acid  to  six  ounces  of  almond  emulsion,  or  of 
rose-water,  to  which  a  drachm  of  liq.  potassa?  may  be  added. 

Prurigo  is  an  eruption  char.'icterized  by  its  itching  and  by  the  presence 
of  flattened  papules,  so  much  the  color  of  the  skin  as  to  be  with  difficulty 
perceived  in  some  cases.  The  itching  is  increased  by  any  stimulant  or 
by  heat,  so  that  it  often  becomes  intolerable  in  bed.  It  is  often  mixed 
with  urticaria.  Sometimes  there  is  a  sensation  as  of  insects  crawling 
over  the  skin.  P.  formicans.  Old  persons  suffer  from  prurigo,  which  is 
then  called  P.  senilis,  and  is  often  very  obstinate.  In  younger  subjects 
it  usually  disappears  in  a  short  time.  There  is  no  doubt  that  in  many 
cases  the  complaint  is  caused  by  the  presence  of  lice,  and  such  cases 
may  be  cured  at  once  by  destroying  or  baking  the  clothes,  and  by  free 
bathing  and  the  application  of  the  white  precipitate  ointment.  There 
are  other  cases  in  which  the  prurigo  is  local,  usualh'  about  the  genitals 
or  anus — P.  podicis,  pulvae,  scroti,  etc.  In  these  cases  the  designation 
is  usually  a  misnomer.  The  disease  should  be  called  pruritus,  for  there 
is  intolerable  itching,  so  that  the  patient  is  sometimes  withdrawn  from 
society  by  the  impossibility  of  abstaining  from  scratching  the  part,  but 
no  pimples  can  l)e  seen.  Prurigo  or  pruritus  is  also  sometimes  a  sequela 
of  another  eruption,  i.e.,  intolerable  itching  is  left  in  the  part  from 
which  the  previous  eruption  has  disappeared.  This  is  most  common 
after  eczema  and  scabies. 

The  first  principles  of  treatment  in  prurigo  are  precisely  similar  to  those 
in  lichen.  The  patient's  bowels  must  be  cleared,  his  digestion  regulated, 
and  all  causes  of  heat  and  irritation  avoided.  In  pruritus  ani,  vulvae, 
etc.,  any  unnatural  condition  which  can  be  detected  must  be  remedied. 
The  former  sometimes  depends  on  ascarides,  or  on  fissure,  the  latter  on 
the  presence  of  a  vascular  tumor  of  the  meatus,  or  on  the  habit  of  self- 
abuse.  The  most  various  local  applications  are  in  use  and  appear  of  ad- 
vantage ;  of  these  the  mercurial  lotions  and  ointments,  or  lotions  of  sul- 
phuret  of  potassium,  sulphur  baths  and  ointments,  and  prussic  acid 
lotions  have  the  greatest  reputation.  Whatever  is  found  best  to  allay 
the  itching  should  be  kept  at  hand  for  immediate  application  when  the 
patient  becomes  warm  in  bed,  and  he  should  abstain  as  much  as  possible 
from  scratching. 

56 


882  SKIN    DISEASES. 

Sqttama'  or  scales  are  collections  of  dry  epithelium,  loosely  connected 
to  the  subjacoiit  skin,  so  that  they  may  be  easily  rubbed  off. 

Pifi/i'ia!<i!<. — The  squamous  diseases  are  pityriasis  and  psoriasis.  One 
form  of  pityriasis  due  to  tlie  presence  of  a  parasite  has  already  been 
spoken  of  as  chJoa.^ma.  The  characteristic  of  pityriasis  is  the  smallness 
of  the  scales,  like  those  of  bran,  and  the  ease  with  which  in  most  cases 
they  fall  off.  The  common  pityriasis,  or  dandriff,  of  the  scalp  is  the  most 
familiar  example  of  the  disease.  Pityriasis  is  also  often  produced  by  the 
imperfect  dr3'ing  of  the  skin,  and  tlien  exposing  it  to  the  sun  or  wind. 
In  these  cases  the  skin  is  often  a  good  deal  reddened,  and  the  disease  is 
then  called  P.  rubra. 

In  the  treatment  of  pityriasis  the  object  is  to  slightly  astringe  the  ves- 
sels of  the  skin  and  soften  the  epidermis,  protecting  the  part  from  any 
irritation  by  some  mild  ointment.  Borax  is  the  lotion  generally  used,  and 
diluted  white  precipitate  ointment.  The  hair  ought  to  be  cut  short  and 
very  gently  brushed,  and  if  it  fills  out  (as  is  very  common),  a  liniment  of 
equal  parts  of  acetum  cantharidis  and  spirit  of  rosemary  raa}^  be  applied. 
Any  derangement  of  health  or  digestion  must  he  at  the  same  time  at- 
tended to.     The  hair  may  alwa3^s  be  expected  to  grow  again. 

Ph-oyHaais  is  an  exceedingly  common  disease,  both  without  and  with 
syphilis.  It  is  characterized  by  shining  white  scales  situated  on  slightly 
inflamed  portions  of  skin.  In  the  ordinary  non-syphilitic  psoriasis  these 
patches  have  no  definite  figure;  the}^  are  situated  mainly  on  the  coarser 
parts  of  the  skin,  chiefly  on  the  outer  sides  of  the  limbs,  the  elbovvs,  and 
the  knees.  Another  form  is  called  P. guttata,  in  which  the  patches  are  very 
small,  and  seem  as  it  were  to  liave  been  dropped  or  dredged  on  the  skin. 
When  the  affected  portions  of  skin  assume  a  circular  form  the  disease 
used  to  be  called  lepra  ;  b}'  others  this  appellation  is  reserved  for  syphil- 
itic psoriasis,  wliich,  like  other  syphilitic  eruptions,  is  prone  to  assume  a 
circular  or  curved  shape,  and  which  does  not  shovv  any  such  preference 
for  one  over  the  other  aspect  of  the  limbs  as  P.  vulgaris  does. 

The  other  varieties  of  psoriasis  are  of  less  importance.  When  very 
extensive  it  is  called  "  diffusa,"  when  peculiarly  obstinate,  "  inveterata," 
etc.  Psoriasis  is  often  an  accompaniment  of  struma,  and  is  habitual 
with  some  persons,  who  suffer  from  it  regularly  at  intervals. 

The  syphilitic  variety  requires  mercury  in  some  form.  It  is  a  secondary 
eruption  in  most  cases,  and  is  usually  rapidly  cured  by  fumigation.  In 
non-syphilitic  cases  tlie  great  remedy  is  arsenic,  which  should  be  pushed 
till  the  characteristic  effi'cts  of  tlie  poison  begin  to  be  manifested,  or 
arsenic  may  l)e  exhil)ited  in  combination  with  mercuiy,  as  in  Donovan's 
solution.  In  cases  wliich  are  not  cured  by  arsenic,  cantharides  or  pil. 
picis  may  be  tried,  and  copaiba  is  said  sometimes  to  succeed.  Tar  in 
some  form  is  the  best  local  application,  as  the  nnguentum  picis,  or  the 
Barbadoes  tar.     Sulphur  baths  and  vapor  baths  are  also  often  useful. 

Tuheix-ulala. — Tubercles  are  pimples  on  a  larger  scale,  i.  e.^  solid  hard 
elevations  of  the  cutis. 

The  tuberculous  diseases  are  of  the  most  varied  clinical  characters. 
They  are  acne,  lupus,  molluscum,  ele[)liantiasis,  framboisia,  and  keloid. 
Cancer  is  sometimes  added,  which  indeed  forms  tubercles  in  the  skin  in 
some  rare  cases,  but  cannot  properly  be  classed  as  a  skin  disease. 

Acne. — In  acne  the  tul)erclcs  are  caused  by  obstruction  of  the  sebaceous 
follicles  and  elfusion  into  the  skin  around  them.  Suppuration  often  occurs 
at  the  apex  of  the  tubercle,  constituting  acne  simplex  vel  punctata,  so 
frequently  seen  on  the  neck,  face  and  shoulders,  intermixed  with   black 


LUPUS.  883 

points,  which  are  the  orifices  of  the  sebaceous  follicles,  from  whicli  a 
worinlike  mass  of  secretion  may  be  pressed,  which  is  popularly  i'e<>arded 
as  a  parasitic  animal,  and  which  does  often  contain  a  microscopic  parasite, 
the  acarus  folliculorum. 

In  acne  iiidurata  tlie  hardening  and  thickeninsf  around  the  tubercles  is 
greater,  the  tubercles  coalesce,  causing  great  deformity,  and  there  is  little 
tendency  to  suppuration. 

Acne  rosacea  is  chiefly  seen  on  the  nose  and  parts  adjacent,  and  has 
been  spoken  of  on  p.  594. 

Acne  sebacea  is  a  rare  form  of  acne,  characterized  by  a  superabundance 
of  the  sebaceous  secretion,  which  sometimes  covers  the  skin,  dries  upon 
it,  and  turns  hard  and  black,  constituting  what  is  called  (not  very  ac- 
curately) spurious  or  sebaceous  ichthyosis. 

The  treatment  of  acne  is  in  great  measure  local,  consisting  in  opening 
the  sebaceous  follicles  l)y  bathing  and  friction,  pressing  out  the  secretion 
from  them,  and  puncturing  the  tubercles  which  have  suppurated.  The 
tubercles  may  be  lightly  touched  with  acid  nitrate  of  mercury,  or  strong 
nitric  acid.  Lotions  of  bismuth  and  mercury,  or  mercurial  and  sulphur 
ointments,  may  then  be  useful  as  permanent  applications. 

At  the  same  time  much  care  must  be  used  in  regulating  the  diet,  cor- 
recting any  excesses  in  it,  and  forbidding  the  use  altogether  of  anything 
which  can  promote  acidity. 

Syphilitic  Acne. — The  term  syphilitic  acne  used  to  be  applied  to  the 
tubercular  eruption  so  often  seen  on  the  face  in  the  later  stages  of  sec- 
ondary syphilis,  but  incorrectl}' if  the  word  acne  is  restricted  to  an  affec- 
tion of  the  sebaceous  follicles.  The  color  of  the  eruption,  its  dense  ar- 
rangement over  the  face,  and  the  presence  of  other  syphilitic  symptoms 
sufficiently  mark  its  nature.  There  is  not  the  tendency  to  suppuration 
which  is  seen  in  true  acne,  and  a  mercurial  course  is  generally  followed 
by  its  rapid  subsidence. 

Molluscum  is  a  singular  disease,  seen  usually  in  children,  in  which 
there  is  a  crop  of  large  tubercles,  frequently  of  a  dead  white  or  of  the 
natural  color  of  the  skin,  many  of  them  presenting  a  dark  point  with  a 
depression,  and  regarded  as  being  obstructed  sebaceous  follicles,  others 
having  no  such  depression.  Molluscum  is  regarded  by  many  authors  as 
contagious,  and  Hardy  teaches  that  a  cryptogamic  plant  is  to  be  found 
in  it,  but  others  doubt  that  the  eruption  possesses  any  such  property. 
The  only  treatment  required  is  to  lay  the  tubercles  open  and  rub  their 
interior  with  caustic,  or  to  snip  them  off".  There  is  no  constitutional 
affection. 

Mr.  Pollock  has  lately  communicated  to  the  profession  two  cases  of  a 
very  peculiar  aff'ection  in  women,  bearing  some  resemblance  to  molluscum, 
in  which  large  pendulous  fibro-fatty  masses  occupied  a  great  part  of  the 
neck,  chest,  and  other  portions  of  the  body.  In  one  of  these  cases  much 
benefit  followed  on  the  removal  of  some  of  the  largest  of  these  pendulous 
masses,  in  the  other  case  the  patient  died  from  the  effects  of  the  opera- 
tion.^ 

Lupus  is  a  disease  characterized  by  a  tubercular  eruption  which  in  most 
forms  of  the  disease  perishes  in  a  destructive  ulceration,  leading  to  the 
"lupous  ulcer,"  spoken  of  on  p.  415.  Various  forms  of  lupus  are  de- 
scribed, all  of  which  are  most  frequent  on  the  face,  and  chiefly  on  or  near 
the  alfie  nasi,  though  all  may  occur  on  other  parts  of  the  body.  Lupus  is 
never   contagious ;  it  shows   little  tendency  to  recovery  except  under 

1  See  Med.-Chir.  Trans.,  vol.  Ivi,  and  Path.  Trans.,  vol.  xxvi. 


884  SKIN    DISEASES. 

careful  and  often  protracted  treatment.     The  varieties  described  b.y  Mr. 
Najler  are  as  follows  : 

1.  Tubercular  (or  lupus  non-exedens),  in  wliich  there  is  an  eruption  of 
pale  tubercles,  which  become  red  under  excitement,  and  which  remain  in 
much  the  same  condition  for  _years,  crusts  like  those  of  eczema  forming 
on  them,  occasionally  but  very  rarely  ulcerating.  "  It  is  not  infrequent 
to  find  the  disease,  after  the  lapse  of  twenty  years  and  more,  not  exceed- 
ing in  diameter  that  of  a  crown  piece."  This  is  essentially,  as  it  seems, 
a  strumous  affection,  and  leads  naturally  to  the  mention  of — 

2.  Strumous  lupus,  in  which  the  tubercles  rapidly  give  rise  to  a  super- 
ficial painless  ulceration,  which  slowly  advances  for  an  indefinite  time, 
cicatrizing  in  parts,  and  often  causing  ectropium  or  other  deformities. 

.3.  Luinis  exedens  is  a  form  in  which  the  destruction  of  parts  is  much 
more  active  than  in  strumous  lupus.  It  commences  with  a  small  hard 
tubercle  ;  and  as  other  tubercles  form,  the  original  ones  break  down  into 
a  rapidly  spreading  ulcer,  with  a  light-yellowish  surface,  which  perforates 
all  the  tissues  and  sometimes  destroys  the  nose  altogether,  at  other  times 
heals,  or  is  brought  to  heal,  and  leaves  a  peculiarly  sharp  or  pointed  edge 
with  a  purplish  color. 

4.  Syphilitic  lupus  is,  in  fact,  syphilitic  tubercle,  complicated  with 
ulceration,  or  syphilis  attacking  a  person  affected  with  one  of  the  previous 
forms  of  ulcerating  lupus,  which  generally  adds  to  the  severity'  of  the 
disease  and  the  destructive  nature  of  the  ulceration. 

5.  Impetiginous  or  papulo-pustular  lupus  is  a  name  given  b}'  Mr.  Startin 
to  a  form  of  the  strumous  variety  in  which  numerous  pustules  resembling 
those  of  impetigo  are  found  on  the  part  affected. 

The  treatment  of  all  these  forms  of  lupus  is  by  some  powerful  escha- 
rotic.  For  the  tubercular  and  exedent  forms  nitric  acid,  the  acid  nitrate 
of  mercury,  or  potassa  fusa,  are  appropriate,  any  scabs  being  removed, 
the  surface  carefully  dried,  and  the  caustic  thoroughly  applied  to  a  small 
portion  of  the  tuberculated  surface  in  the  non-exedent  form,  and  to  the 
whole  ulcer  under  chloroform  in  lupus  exedens.  For  strumous  and  im- 
petiginous lupus  Mr.  Nayler  recommends  an  arsenical  and  calomel  caustic, 
acid,  arseniosi  gr.  iij,  hydr.  bisulphuret.  gr.  ij,  hydr.  chlor.  5j,  the  powder 
to  be  made  into  a  paste  with  water,  and  applied  with  a  camel's-hair  brush 
after  the  scab  is  removed.  In  most  cases  the  anti-struraous  regimen,  or 
cod-liver  oil  with  small  doses  of  arsenic,  proves  serviceable;  but  active 
local  treatment  is  in  all  cases  urgently  requisite. 

6.  To  these  forms  Mr.  Nayler  adds  another,  for  a  complete  account  of 
which  I  must  refer  to  his  work  on  Diseases  of  the  SHn^  or  to  the  article 
in  the  System  of  Sui-gery  ;  the  erythematous,  commencing  as  a  patch  of 
erythema  on  the  face,  and  this  becoming  covered  with  scales  or  crusts 
adhering  to  the  surface,  seldom  ulcerating,  but  terminating  either  in 
complete  recovery  or  in  a  white  cicatrix  on  a  level  with  the  surrounding 
skin.  The  disease  is  usually  seen  after  middle  life,  generally  in  women, 
and  prevails  more  in  tlie  upper  classes  tlian  in  those  who  have  been  ex- 
posed to  liardships.  The  remedies  recommended  are  stiniulating  appli- 
cations to  tiie  patch,  as  nitric  acid  lotion,  if  there  is  much  redness, 
alternated  with  l)orax  and  hydrocyanic  acid,  if  there  is  smarting  pain  at 
night,  or  blistering  in  the  early  stage  of  the  eruption.  The  internal 
remedies  are  maiidy  steel  and  arsenic. 

Elephantiasis  is  a  name  applied  in  common  to  two  very  different  dis- 
eases, distinguislied  from  each  other  as  E.  Graecorum,  the  tubercular 
leprosy,  and  E.  Aral>um,  or  Barbadoes  leg. 

Leprosy. — The    former   is    an  endemic   disease,  which    is    at  present 


ELEPHANTIASIS.  885 

unknown,  or  nearly  so,  in  these  islands,  lhon<>h  it  seems  that  it  used  to 
prevail  here,  and  it  is  still  prevalent  in  the  Baltic;  but  its  more  favorite 
seat  is  in  hot  countries.  It  is  more  common  in  males  than  females,  and 
is  rarely  seen  till  after  puberty.  It  occurs  in  two  forms,  the  amesthetic 
and  the  tubercular.  In  the  former  the  skin  loses  its  sensibility  in  })atches, 
the  affected  parts  soon  ulcerate,  the  fingers  and  toes  shrivel  and  droj)  off, 
and  the  patient  usually  dies  from  some  exhausting  disease,  as  diarrlujea 
or  dysenter3%  In  the  other  form,  after  more  or  less  pain  in  the  part  and 
disturbance  of  health,  irregular  discolored  patches  of  skin  are  seen,  which 
become  covered  with  small  tubercles,  the  face,  palate,  eyes,  and  larynx 
are  af!ected,  and  ulcerate;  and  the  patient  usually  sinks  gradually,  or 
dies  suddenly  from  laryngeal  symptoms.  The  cause  of  the  malady  is 
unknown  ;  nor  does  any  treatment  appear  of  use.  The  disease  is  plainly 
proved  not  to  be  contagious.  Dr.  Vandyke  Carter  has  published  (in  the 
Trciusarfions  of  the  Med.  and  Phtjs.  Soc.  of  Boinba!/^  and  in  vols,  xiii, 
xiv  of  those  of  the  Path.  Soc.)  some  very  interesting  researches  showing 
the  atrophied  condition  of  the  sensory  nerves  in  leprosy.  As  the  disease 
is  not  seen  in  this  country,  and  is  more  a  medical  than  a  surgical  affec- 
tion, it  is  unnecessary  to  dwell  on  it  here. 

ElephaiitiamH  A?'abum. — The  elephantiasis,  which  we  are  called  upon 
to  treat  surgically  in  this  country,  is  that  which  is  called  P].  Arabum,  or 
Barbadoes  leg.  It  occurs  in  the  lower  extremity  or  in  the  genitals,  and 
no  doubt  originates  spontaneously  in  this  country,  though  it  is  not  prev- 
alent to  any  extent,  in  fact  is  rare,  apart  from  some  cause  of  obstructed 
circulation.  In  the  leg  the  limb  swells  enormously,  mainly  from  hyper- 
trophy of  the  cellular  tissue ;  the  skin  becomes  hard,  thick,  and  warty, 
and  in  some  cases  distinct  tubercles  are  developed  upon  it.  It  cracks 
and  ulcerate,  and  sometimes  the  toes  drop  oK  In  many  cases  (at  least 
in  the  tropical  disease)  there  are  intermittent  attacks  of  fever,  and  in  the 
opinion  of  some  experienced  practitioners  the  disease  owns  a  malarious 
origin.  In  other  cases  it  seems  to  be  venereal.  In  some  cases  it  appears 
to  be  connected  with  lymphatic  fistula.  I  have  at  present  a  patient  under 
my  care,  laboring  under  elephantiasis  of  the  labia  and  thigh,  in  whom 
during  the  febrile  paroxysms  clear  fluid,  displaying  lymph-corpuscles 
under  the  microscope,  exudes  from  minute  openings  in  the  groin  and 
vulva.  The  treatment  of  elephantiasis,  as  far  as  I  have  seen,  has  not 
been  very  successful.  The  size  of  the  limb  may  be  much  reduced,  espe- 
cially in  recent  cases,  by  careful  pressure  and  the  application  of  mercurial 
lotions  and  ointments,  or  by  iodine,  with  the  administration  of  biniodide 
of  mercury  in  small  doses,  but  I  believe  that  the  disease  generall}',  if 
not  always,  reappears.  The  ligature  of  the  main  artery  of  the  liml)  was 
practiced  b}^  Dr.  Carnochan,  of  New  York,  and  spoken  of  at  first  as 
universally  successful;  but  since  its  more  extended  trial  in  this  country 
it  has  been  so  clearly  shown  that  the  benefit  which  follows  the  operation 
is  in  most  cases  but  temporary  as  to  render  it  probable  that  it  always  is 
so,  and  that  the  operation  ought  only  to  be  considered  in  the  light  of  an 
experiment,  which  failing,  amputation  of  the  limb  is  indicated.  Con- 
sidered in  that  light,  it  ma}'  be  justifiable  to  tie  the  femoral  arter}^ 
Failing  this,  when  the  enlargement  makes  the  patient's  life  intolerable, 
it  must  be  removed,  whether  the  leg.  the  scrotum,  or  the  vulva  and  labia 
are  the  seat  of  the  disease  (see  p.  841). 

Keloid  tumoi'H,  as  usuall}'  seen,  are  developed  in  scars ;  and  I  have 
spoken  of  them  on  a  former  page  (see  p.  419).  Dr.  Addison  has  applied 
the  same  name  to  a  condition  which  he  calls  "  true  keloid,"  but  which  is 
perfectly  different  from  the  flattened  tumors   (like  gigantic  tubercles) 


886  SKIN    DISEASES. 

which  arise  from  tlie  cicatrices  of  burns,  floggings,  and  other  extensive 
and  slowly  healing  injuries.  Addison's  keloid  is  not  a  tumor  at  all,  hut 
a  patcli  of  hidebound  skin,  in  which  the  skin,  fascia,  and  muscles  are  ad- 
herent together,  and  the  surface  is  yellowish  and  covered  with  scales.  I 
am  not  aware  that  treatment  has  any  efl'ect  on  this  condition. 

Fra.mbccsia. — Of  framboesia,  or  yaws,  I  will  merely  say  that  it  is  a 
highly  contagious  erui)tion  of  red  tubercles,  soon  ulcerating,  which  affects 
chiefly  the  negroes  in  the  West  Indies,  but  has  been  seen  in  remote 
parts  of  Scotland  and  Ireland. 

Macxdde. — I  need  only  enumerate  the  maculiTe,  or  permanent  stainings 
of  the  skin.  None  of  these  affections  come  under  the  treatment  of  the 
surgeon  ;  and,  in  fact,  the}'  are  hardly  under  the  dominion  of  an}-  treat- 
ment. They  are  the  ^'■bronzing  ^'  of  the  skin  connected  witli  the  de- 
generation of  the  suprarenal  capsules  found  in  Addison's  disease;  the 
"mo/e.s,"  or  congenital  deposits  of  pigment,  which  are  so  often  found 
covered  with  hair,  and  which  are  liable  occasionally  to  degenerate  into 
epithelioma;  the  silver-stain,  or  lividity  of  the  surface  which  is  found  in 
persons  who  have  taken  nitrate  of  silver  internally  for  a  long  time  ;  and 
the  want  of  pigment  which  when  universal  is  called  "aZ6inzsw,"  and 
when  localized  in  patches  "  uitiligo.'" 

Xeroderma  Ichlhyoais. — The  only  other  disease  of  the  skin  which  I 
think  it  worth  while  to  mention  is  the  malformation  which  consists  in  the 
imperfect  development  or  entire  absence  of  the  sweat-glands  and  ducts, 
which  produces  the  condition  named  ichthyosis,  a  condition  characterized 
by  the  collection  of  dry  scales  over  a  part  or  the  whole  body;  congenital 
in  the  worst  cases,  in  others  occurring  in  later  life,  as  after  the  cessation 
of  the  catamenia.  I  merely  mention  the  subject  here  in  order  to  caution 
the  reader  not  to  confound  pityriasis  or  psoriasis  with  this  affection, 
which  is,  as  Mr.  Nayler  says,  rather  a  malformation  than  a  disease  of  the 
skin  ;  and  which  is  sufficiently  distinguished  from  those  diseases  by  its 
history  as  well  as  by  the  appearance,  for  in  ichthyosis  it  is  not  merely 
the  scaly  eruption,  but  also  the  thickening  and  dryness  of  the  skin  which 
constitute  the  morbid  state. 

Plica  Polonica. — I  must  now  turn  to  the  affections  of  the  appendages 
of  the  skin.  The  only  distinct  disease  which  affects  the  hair  is  Plica  po- 
lonica— a  matted  state  of  the  hair  of  the  scalp,  and  in  rarer  cases  of  other 
parts  of  the  body,  met  with  in  Poland  and  tlie  neigliboring  countries.  The 
matted  hairs  are  stuck  together  by  a  glutinous  material  in  which  foreign 
substances  are  found,  and  in  old-standing  cases  a  fungus.  The  exact 
nature  of  the  afliection  is  not  known.  Most  authors  now  adopt  Hebra's 
ex[)lanation  that  it  is  due  to  eczema  or  some  other  skin  affection  long 
neglected. 

Corns  are  elevations  of  tiic  epidermis  formed  by  intermittent  pressure, 
which  acts  as  an  irritant  and  produces  inflammatory  effusion.  Con- 
tinuous pressure,  on  tlie  contrar} ,  causes  absorption.  Corns  are,  for  ob- 
vious reasons,  usually  found  on  the  feet,  though  they  may  grow  on  any 
part  wiiich  is  irritated  in  a  similar  way,  as  on  the  fingers  of  tailors,  musi- 
cians, or  rowers  ;  but  it  will  be  sullicient  to  speak  of  the  ordinary  corns 
of  the  feet.  They  are  cither  hard  or  soft,  the  first  being  seated  on  the 
dorsum  or  more  rarely  the  plantar  aspect  of  the  toes  and  feet,  and  con- 


WAKTS.  887 

sisting  of  thickened  and  heaped-up  epidermis;  the  corn  sometimes  when 
it  has  lasted  long  producing  absorption  of  the  true  skin,  and  then  often 
having  a  bursa  below  it.  The}-  are  peculiarly  liable  to  form  on  toes  de- 
formed by  the  i)ressure  of  ill-fitting  boots.  They  cause  a  good  deal  of 
pain  in  walking,  and  sometimes  lead  to  more  serious  mischief,  as  to 
lateral  curvature  from  the  une(]ual  use  of  the  limbs.  Or  suppuration  may 
occur  in  the  bursa,  or  in  the  cellular  tissue  beneath  the  corn,  and  this  may 
spread  so  deeply  as  to  oi)en  the  articulation  or  expose  the  bone  below, 
and  then  may  spread  to  the  other  surface  of  the  foot,  constituting  the 
"  mal  perfoi'ant  du  pied  "  of  French  authors.  Soft  corns  form  between 
the  toes,  and  bear  a  greater  resemblance  to  warts,  consisting  often  of 
enlarged  papilliie  ensheathed  by  epidermis.  They  often  grow  to  some 
size  and  then  give  rise  to  great  annoyance,  and  they  may  inflame  and 
suppurate  as  hard  corns  do.  Another  variety  which  also  bears  a  certain 
resemblance  to  warts  is  the  fibrous  corn,  sometimes  seen  on  the  sole  oi 
the  foot,  and  formed  of  the  papillte  of  the  skin  covered  with  epidermis. 
These  are  often  acutely  painful,  and  from  their  position  altogether  hinder 
the  patient  from  active  exercise. 

Tlie  treatment  of  corns  in  all  their  stages  or  forms  must  commence 
with  correcting  an3^  defect  in  the  boots  and  withdrawing  the  parts  from 
pressure,  which  can  be  managed  if  necessary  with  a  "corn-plaster" — a 
piece  of  thick  plaster  with  a  hole  in  it  to  receive  the  corn.  The  hard- 
ened epidermis  may  be  gradually  rubbed  down  with  glacial  acetic  acid 
or  with  nitrate  of  silver  applied  after  the  outer  hard  part  of  the  corn  has 
been  pared,  or  with  a  corn-file  ;  or  the  cuticle  ma}^  be  softened  by  the  ap- 
plication of  strong  alkalies.  The  chiropodists  cure  corns  by  cautiously 
digging  round  the  thickened  epidermis  till  it  can  be  turned  out  of  the  hole 
which  it  has  formed  in  the  cutis,  which  they  called  extracting  the  root 
of  the  corn.  When  suppuration  forms  beneath  a  corn  the  littte  abscess 
should  be  opened  at  once,  and  then  the  corn  will  often  fall  off  altogether. 
When  the  corn  forms  on  the  back  of  a  bent  toe  it  cannot  probably  be 
cured  till  the  toe  is  straightened.  Soft  corns  mav  generall}'  be  cured  by 
keeping  the  toes  apart  with  a  plug  of  cotton-wool,  and  steeping  the  corns 
in  acetic  acid,  or  dusting  them  with  oxide  of  zinc,  pure  or  mixed  with 
pnlv.  a3ruginis. 

In  the  perforating  disease  I  have  seen  such  extensive  denudntion  of  a 
metatarsal  bone  in  both  feet  that  I  was  compelled  to  excise  the  bones  be- 
fore the  patient  could  be  restored  to  activit}-. 

Bunion  has  been  spoken  of  on  page  501. 

Wa,7-ts  are  collections  of  hyi)ertrophied  papillae  covered  with  epithe- 
lium, and  someiimes  hardened  on  the  surface  by  friction  and  exposure. 
They  are  situated  very  commonly  on  children's  hands,  and  occasionally 
on  other  parts  of  the  body.  'Vhe  verruca  digitata  or  bi-anching  wart, 
which  forms  sometimes  on  the  scalp  in  women  ;  the  sub-ungual  warts, 
which  foim  below  and  at  the  side  of  the  nails,  and  are  ver}'  painful;  and 
the  verruca  contluens,  in  which  a  crop  of  small  warts  collects  into  a  mass 
on  the  back  of  the  hand  or  arm,  or  on  the  neck  and  thorax,  so  that  the 
skin  resembles  coarse  i)lush,  are  varieties  which  deserve  special  mention 
on  account  of  the  desirability  of  eradicating  them  at  once. 

Venereal  Warts  and  Condylomata. — The  warts  which  occur  from  ven- 
ereal causes,  and  which  are  very  common  on  the  female  genitals,  and  to  a 
less  extent  on  the  male,  are  due  to  the  irritation  of  discharge  retained  in 
contact  with  the  skin  or  mucous  membrane.  The}'  often  spread  over  a 
large  surface  and  attain   a  considerable  size.     Those  which  are  truly 


AFFECTIONS    OF    THE    CUTANEOUS    SYSTEM. 

called  wfirts  consist  of  epitheliuiu  and  papilhy  only.  The  condylomata 
are  masses  often  of  very  large  size,  consisting  of  all  the  structures  of  the 
skin  hypertrophied,  sometimes  to  an  enormous  extent,  ami  covered  with 
a  copious  warty  growth. 

Verruca  Necrogenica. — Other  warts,  which  are  due  to  the  irritation  of 
morbid  fluids,  are  the  dissection-warts  or  "verructe  necrogenicae,"  which 
are  found  occasionally  on  the  hands  of  dissectors  and  morbid  anatomists. 
Sometimes  this  irritation  produces  not  exactly  a  wart,  but  a  condition  of 
skin  marked  l)y  a  thickening  of  all  its  tissues,  and  especiall}'  perceptible 
around  the  hair-follicles. 

Chimney-sweep's  cancer  is  sometimes  spoken  of  as  a  kind  of  wart  pro- 
duced by  the  irritation  of  soot,  and  certainly  it  commences  with  a  warty 
or  papillomatous  growth  on  the  surface  of  the  skin  ;  but  at  the  time  we 
generally  see  it  the  deposit  of  epithelioma  extends  far  beyond  the  papil- 
lar}'  structure. 

JNo  cause  is  known  for  the  common  warts.  'They  appearand  disappear 
in  the  most  capricious  manner.  The  venereal  warts  are  no  doubt  conta- 
gious, and  this  is  popularly  believed  of  the  common  warts,  and  especially 
of  the  blood  from  them,  but  without  any  proved  foundation.  In  some 
rare  cases  warts  may  become  the  seat  of  epithelial  cancer,  and  they  may 
in  others  prove  the  starting-point  of  horns,  but  usually  they  are  merely  a 
disfigurement.  They  may  be  removed  by  thoroughl}'  soaking  them  in 
nitric  acid,  or  the  acid  nitrate  of  mercurj^,  or  glacial  acetic  acid,  or  perchlo- 
ride  of  iron,  or  b}-  repeated  applications  of  stick-caustic.  I  have  personal 
experience  of  the  efficacy  of  the  acid  nitrate  of  mercury'  in  the  verruca 
necrogenica.  The  venereal  warts  must  be  treated  by  scrupulous  cleanli- 
ness, by  the  application  of  the  strong  liquor  plurabi,  and  by  a  mercurial 
course  if  other  secondary  symptoms  are  present,  or  they  ma}-  be  removed. 
When  large  condylomatous  masses  exist  it  is  necessary  to  remove  them; 
and,  as  much  haemorrhage  may  take  place  in  such  operations,  it  seems 
better  to  avoid  the  knife,  if  possible,  and  effect  their  removal  with  the 
ecraseur  or  the  elastic  ligature. 

Horns  are  occasionally'  seen  growing  from  the  surface  of  the  body  in 
various  parts.  They  originate  either  in  accumulated  sebaceous  secretion, 
or  from  overgrowth  of  the  epithelium,  or  from  overgrowth  of  the  nails,  or 
from  the  hardened  and  continued  growth  of  a  wart." 

The  vvhole  horn  must  be  removed,  and  if  there  is  a  sebaceous  cyst  at 
the  bottom  this  is  also  to  be  cut  out. 

Boils.— ^A  common  boil  or  furuncle  is  an  inflammation  of  the  skin  and 
cellular  tissue,  limited  to  a  very  small  extent,  and  containing  in  its  inte- 
rior a  small  slough  of  cellular  tissue  called  the  '-ore  of  the  boil.  Another 
kind  of  boil,  however,  called  a  "blind  boil,"  is  less  defined  or  limited,  and 
contains  little  if  any  core.  The  common  boil  increases  in  size  and  pain- 
fulness  for  a  da}-  or  two,  forming  a  red  angry  lump  in  the  skin,  and  then 
bursts,  and  the  core  or  slough  presents  at  the  opening.  This  is  drawn 
out,  or  gradually  makes  its  own  wa}',  and  then  the  infiamniation  and  swell- 
ing rajjidly  sul)side  and  healing  soon  follows.  In  some  cases  the  furun- 
cular  inflammation  gradually'  subsides,  and  the  patient  recovers  without 
any  suppuration.  IMiis,  however,  is  not  often  seen  in  acutely  painful 
boils. 

In  blind  boils,  after  some  da3s  of  pain  and  inflammation,  a  vesicle  or  a 

'  See  T.  Smith,  inSyst.  of  Surg.,  2d  ed.,  vol.  v,  p.  442. 


CARBUNCLE.  889 

superficial  pustule  forms,  and  then  the  hardening  gradually  recedes  and 
finally  disappears. 

The  causes  of  boils  are  very  numerous.  Locally  they  may  be  caused  by 
dissecting-room  poisons,  and  perhaps  by  otlier  morbid  matters  applied  to 
the  skin  ;  but  in  the  great  majority  of  cases  tlie  cause  is  constitutional, 
and  consists  in  some  error  of  diet,  some  lovveriug  influence,  as  parturi- 
tion, or  some  disturbance  of  health  from  climatic  causes.  The  surgical 
importance  of  the  boil  is  usually  trifling,  but  the  remote  cause  should  be 
carefully  investigated,  for  the  constant  recurrence  of  a  crop  of  boils — -no 
infrequent  event — is  a  very  serious  annoyance  and  sometimes  even  a 
source  of  danger.  The  presence  of  sugar  in  the  urine  is  sometimes  asso- 
ciated with  tiie  appearance  of  boils  and  carbuncles,  often,  as  it  seems,  as 
a  cause,  and  sometimes,  as  is  said,  as  an  effect  of  the  boil,  though  this 
seems  doubtful. 

The  general  treatment  is  therefore  of  more  importance  than  the  local, 
and  this  should  as  a  general  rule  be  tonic,  due  attention  being  paid  to 
clearing  out  the  bowels.  Baric  and  quinine,  with  acid,  are  the  tonics 
usually  selected,  with  wine  and  good  food.  Surgically  little  should  be 
done.  In  the  early  stage  it  is  said  tliat  caustics,  as  strong  liquor  ainmo- 
niae,  the  acid  nitrate  of  mercury,  or  pure  liquor  potassfB  may  prevent  sup- 
puration ;  but  this  (as  Mr.  T.  Smith  saj's)  appears  to  be  successful 
usually  only  in  blind  boils,  which  probably  would  never  have  suppurated 
in  any  case.  In  general  the  less  the  patient  is  teased  with  local  applica- 
tions the  better.  A  small  poultice  with  a  little  laudanum  in  it  is  the  best 
application,  and  when  su|)puration  has  formed,  a  tolerably  free  incision. 
A  thousand  domestic  remedies  are  in  use,  which  probabl}'  are  all  inert 
except  so  far  as  they  relax  tension  by  heat  and  moisture. 

Carbuncle  is  a  name  given  to  a  spreading  inflammation  of  the  cellular 
tissue,  involving  also  the  skin  which  covers  it,  having  a  considerable  re- 
senililance  to  boil,  as  it  tends  to  rapid  sloughing  of  the  cellular  membrane; 
but,  unlike  boil,  not  limited  by  any  definite  boundary,  and  often  spread- 
ing to  an  enormous  size.  The  disease  commences  with  hardness  anrl  pain 
in  the  part,  dusky  redness  of  the  skin  covering  the  indurated  tissue,  and 
often  some  constitutional  affection,  low  fever,  and  much  depression.  Soon 
the  affected  skin  gives  way  in  numerous  places,  and  the  slough  is  exposed. 
If  the  case  runs  a  favorable  course  the  inflammation  stops,  the  skin 
between  some  of  the  openings  sloughs  to  a  greater  or  less  extent,  so  as  to 
permit  the  escape  of  the  slough  of  the  cellular  tissue,  and  very  commonly 
the  skin  perishes  in  the  whole  area  of  the  disease.  Thus  a  healthy  ulcer 
is  left,  which  granulates  in  the  ordinary  way.  When  the  disease,  on  the 
other  hand,  tends  to  death,  the  carbuncle  goes  on  spreading,  the  fever 
increases,  the  patient  becomes  delirious  and  comatose,  and  dies  probably 
with  symptoms  of  blood-poisoning  and  secondary  abscesses.  The  chief 
cause  of  death  in  carbuncle  are  pysemia  and  asthenia.  A  very  common 
situation  for  carbuncle  is  on  the  nape  of  the  neck  or  between  the 
shoulders.     The  disease  is  far  more  common  in  men  than  in  women. 

The  objects  of  treatment  are  to  stop  the  spread  of  the  inflammation,  to 
allay  fever,  and  to  support  the  patient's  strength.  Carbuncle  is  a  disease 
which  (;ccurs  chiefly  in  persons  broken  down  either  by  high  living,  or  by 
some  constitutional  affection,  as  gout,  diabetes,  or  kidney  disease.  Hence 
few  of  the  sufferers  from  it  can  bear  anything  like  lowering  treatment, 
nor  do  they  bear  well  any  shock  or  haiinorrhage.  There  are  three  main 
plans  of  local  treatment:  1.  To  make  a  crucial  incision,  taking  care  to 
carry  the  knife  into  healthy  tissues  both  at  the  borders  and  at  the  base 


890  AFFECTIONS    OF    THE    CUTANEOUS    SYSTEM. 

of  the  carbuncle.  Tliis  is  an  eftectual,  but  a  veiy  severe,  measure  when 
the  carbuncle  is  of  <ireat  extent,  as  it  cannot  be  carried  out  without  a 
good  deal  of  !)leeding  at  the  time,  and  secondary  ha?morriiage  is  very 
common.  2.  The  tiiorough  application  of  caustic  potash  is  usually  equally 
eHicacious  in  relieving  the  pain  and  checking  the  spread  of  the  sloughing, 
without  any  drawback  from  either  shock  or  hstmorrhage.  When  the  skiu 
has  not  given  way  the  caustic  is  freely  rubbed  on  it  till  a  slough  has 
formed,  or  (better)  the  skin  is  divided  with  a  scali)el  to  insert  the  caustic. 
A  small  piece  of  the  caustic  should  be  put  in  and  allowed  to  remain,  and 
if  the  carbuncle  is  very  large,  this  must  be  done  at  several  points.  3.  In 
many  of  the  less  severe  cases  neither  of  these  measures  are  necessary. 
The  carbuncle  may  be  covered  with  a  warm  poultice  and  left  to  slough 
out. 

In  choosing  one  of  these  three  plans  of  treatment,  perhaps  the  best 
rule  is  to  take  into  account  the  amount  of  pain,  the  extent  of  the  disease, 
and  the  condition  of  the  patient.  In  a  healthy  man  suffering  grievous 
pain  from  a  rapidly  extending  carbuncle  of  no  great  size,  the  treatment 
by  incision  may  be  preferable-/  but  in  large  carbuncles  on  unhealtliy  sub- 
jects, and,  in  fact,  in  all  ordinary  cases,  I  have  no  doubt  that  the  treat- 
ment by  caustic  potash  is  the  best.  The  expectant  treatment  I  should 
myself  reserve  for  cases  in  which  I  saw  reason  to  tiiink  that  the  progress 
of  the  disease  had  ceased  before  the  patient  presented  himself.  At  the 
same  time  the  expectant  treatment  is  that  which  is  recommended  bj-  the 
high  authority  of  Sir  J.  Paget  and  Mr.  Le  Gros  Clark.  Sir  J.  Paget 
entirely  rejects  the  treatment  1)3^  incision,  and  he  dissuades  all  adminis- 
tration of  stimulants  or  of  any  medicine  except  opium  when  the  disease 
is  attended  with  much  pain,  and  especially  dissuades  confinement  in  bed, 
or  to  the  house,  believing  that  fresh  air  is  very  conducive  to  the  patient's 
recovery,  and  that  nothing  is  really  needed  beyond  keeping  the  part 
clean  and  avoiding  the  contact  of  the  discharge  with  the  neighboring 
integument,  which  should  be  protected  Ity  a  circular  piece  of  some  un- 
irritating  plaster.  The  idea  that  carbuncle  is  in  itself  a  dangerous  affec- 
tion he  utterly  repudiates,  believing  that  tlie  few  persons  who  die  with 
carbuncle  under  the  expectant  treatment  die,  not  of  the  carbuncle,  but 
of  some  of  the  visceral  diseases  which  often  precede  it,  and  that  any 
danger  which  might  have  attended  the  maladj'  when  the  treatment  b}'  in- 
cision was  in  vogue  was  really  caused  b}^  that  treatment.'^ 

It  is  customary  in  surgical  text-books  to  notice  the  plans  of  treating 
carbuncle  by  subcutaneous  incision,  as  recommended  by  Mr.  French,  or 
by  pressure,  as  Dr.  O'Ferrall'  prescribed.  I  think,  however,  I  am  correct 
in  saying  that  they  have  been  found  less  efficient  than  the  plans  above 
mentioned,  and  have,  therefore,  fallen  into  disuse. 

Facial  (Jarlnmcle. — There  is,  however,  one  species  of  carbuncle  which 
is  undoul)tedly  very  fatal.  I  mean  those  which  form  on  the  lips  and  face, 
usually  in  young  men,  and  which  have  been  regarded,  though  apparently 
erroneously,  as  malignant  pustule.  These  rapidly  fatal  cases  are  seen 
almost  exclusively  in  3oung  persons  from  fifteen  to  twenty-one,  and  Sir 
J.  Paget  says  that  out  of  fifteen  cases  he  has  seen,  onl}'  one  recovered. 
The  disease  "commences  at  one  spot,  infiamniation  of  the  whole  lip 
follows  and  spreads  to  the  face,  and  then  disease  of  the  lymphatics 

'  iSpoiiking  for  myself,  I  niu.-it  allow  tliiit  it  is  many  years  since  I  have  tiius  incised 
a  carbuncle. 

'^  See  Paget,  "On  the  treatment  of  Carbuncle,"  Clin.  Lect.,  p.  252. 
3  Dublin  Hosp.  Gazette,  1868. 


CHILBLAIN.  891 

ensues,  with  pyfpmia  as  its  consequence." — Paget.  At  the  commence- 
ment of  the  disease  it  is  impossible  to  distinguish  it  from  the  ordinary 
carbuncle,  which  does  sometimes  attack  the  face,  though  the  occurrence 
in  a  3'oung  healthy  adult  siiould  always  excite  api)rehension.  Sir  J.  Paget, 
who  was  at  one  time  inclined  to  deny  tlie  identity  of  this  disease  with 
common  carlnmcle,  has  now  changed  his  opinion,  and  is  convinced  that 
the  disease  "is  true  carbuncle,  which,  because  of  some  [jcculiarit}-  in  the 
textures  of  the  lip,  especially  in  3'oung  persons,  is  ixn-uliarly  apt  to  infect 
the  blood  and  generate  acute  })yo£'mia."  No  local  n)easures  are  of  any 
avail.  The  patient's  only  i)ros[)ect  of  benefit  from  treatment  seems  to 
be  in  the  copious  administration  of  quinine,  so  as  to  produce  the  symp- 
toms denominated  cinchonism  ;  but  the  statement  above  quoted  from  Sir 
J.  Paget's  experience  shows  how  feeble  the  chance  is. 

Ilolignojit  piiiftidc^  or  "charbon,"  is  a  disease  communicated  to  the 
human  subject  from  herbivorous  animals,  usually  cattle ;  though  other 
animals  may  be  the  source  of  the  infection  when  sutfering  from  a  disease 
known  to  farriers  as  "the  blood,"  "joint-murrain,"  or  "quarter-evil." 
The  name  in  common  use  is  a  very  bad  oue,  since  one  of  the  character- 
istic features  of  the  disease  is  that  pus  never  forms  at  the  part  inoculated. 
The  usual  course  of  a  malignant  pustule  is  "at  first  a  red  spot,  then  a 
vesicle,  then  a  solid  and  circumscribed  swelling  beneath,  surrounded  by 
a  diffused  and  softish  oedema,  a  dry  leathery  central  eschar,  and  a 
secondary  formation  of  vesicles  or  bullae." — T.  Smith.  Very  striking 
features  in  the  disease  are  the  remarkable  freedom  from  severe  pain,  the 
little  increase  in  the  temperature  of  the  part,  the  dryness  of  the  slough, 
the  absence  of  pus,  and  the  fact  that  the  destruction  of  parts  proceeds 
from  the  surface  to  the  deeper  parts,  and  not  in  the  reverse  direction,  as 
in  carbuncle  or  abscess.  The  complaint  is  prone  to  destroy'  life  by  a 
rapidly  fatal  form  of  septicjemia,  in  which  the  post-mortem  appearances 
are  chiefly  seen  in  the  alimentary  canal,  as  in  the  third  form  of  that  affec- 
tion spoken  of  on  p.  (18.  The  indications  of  the  treatment  are  to  destroy 
the  diseased  tissue  by  some  active  caustic  as  early  as  possible  in  the  com- 
plaint before  the  constitutional  symptoms  have  set  in.  Put  the  disease 
is  one  which,  if  it  occurs  often  in  this  country,  is  certainly  not  often 
recognized  here,  and  the  difficult}'  would  be  to  make  sure  of  the  diagnosis 
in  time. 

Chilblain  is  an  affection  especially  of  childhood,  though  it  is  not  con- 
fined to  children.  Men  suffer  from  it  far  less  than  women.  The  affec- 
tion consists  in  inflammation  of  the  skin,  often  proceeding  to  ulceration 
(broken  chilblains),  and  even  in  some  cases  to  gangrene;  but  character- 
ized by  the  peculiarity  that  the  chilblains  are  liable  to  periodic  attacks  of 
congestion,  generally  in  the  afternoon,  or  after  dinner,  sometimes  also 
after  going  to  bed.  Chilblains  appears  to  be  directly  caused  more  by 
thawing  after  cold  than  by  the  immediate  action  of  the  cold  itself.  They 
attack  the  most  exposed  parts  of  the  body — the  hands,  the  lobes  of  the 
ears,  the  end  of  the  nose,  and  particularly'  the  feet,  where  the  circulation 
is  most  languid.  The  persons  chiefly  affected  are  those  whose  hands  and 
feet  are  liable  to  become  cold  and  livid  from  slight  causes. 

Much  may  be  done  to  obviate  the  tendency  to  chilblains  by  attention 
to  the  general  health,  by  insisting  on  vigorous  exercise,  by  warm  clothing, 
and  by  good  diet. 

"As  long  as  chilblains  remain  unbroken,  and  if  the  external  surface  is 


892  AFFECTIONS    OF    THE    CUTANEOUS    SYSTEM. 

not  too  sensitive  to  pressure,  various  stimulating  embrocations  may  be 
benelirially  employed:  such  as  Wardrop's  liniment,  a  mixture  of  two 
parts  of  tincture  of  cantliarides  with  six  of  soap  liniment;  camphorated 
spirit;  equal  parts  of  turpentine  and  copaiba;  or  tincture  of  iodine  and 
soap  liniment.  When  the  external  surface  is  very  tender,  a  good  local 
application  is  formed  by  a  mixture  of  two  ounces  of  collodion,  six  drachms 
of  Venice  turpeiitine,  and  three  drachms  of  castor  oil ;  or  tender  chilblains 
that  do  not  itch  may  be  covered  over  by  adhesive  plaster  spread  upon 
kid  or  chamois  leather."^  Itching  may  be  relieved  by  mustard  baths,  or 
by  rubbing  witii  snow.  Vesicated  chilblains  may  l)e  coated  with  collodion 
and  castor  oil.  For  the  ulcers  a  dressing  of  poultice  and  Friar's  balsam, 
or  of  balsam  of  Peru,  may  be  recommended. 

The  nails  are  liable  to  man3'  disorders,  of  which  it  will  be  enough  to 
enumerate  the  following: 

Onijchia,,  or  onychia  maligna,  is  a  peculiar  form  of  foul  ulceration 
around  tlie  nails,  in  childhood,  originating  in  a  crush  of  the  end  of  tiie 
finger,  which  seems  to  loosen  the  connection  between  the  nail  and  its 
matrix.  The  end  of  the  fingc^r  becomes  unusually  enlargefl,  red,  and  con- 
gested, and  the  nail  is  thinned,  blackened,  and  separated  from  the  soft 
parts  by  a  very  foul  ulcer  running  like  a  crescent  across  the  finger.  This 
ulceration  may  go  on  till  the  phalanx  is  exposed  and  mortifies,  or  till  the 
joint  becomes  involved.  The  remedy  consists  in  removing  the  nail,  if 
loose,  with  a  pair  of  forceps,  dressing  the  ulcer  with  an  arsenical  lotion 
(liq.  potass,  arsenit.  5iji  aqutB  3j),  or  with  black  wash,  and  attending  to 
tiie  state  of  the  general  health. 

Si/pJiilitic  -Difieane  of  the  Nails. — The  toenails,  and  sometimes  those  of 
the  fingers,  are  affected  in  constitutional  s^'philis.  There  is  ulceration 
beneath  the  nail  as  in  onychia  maligna;  but  unaccompanied  by  the  pe- 
culiar fetor  of  that  disease,  and  not  attended  with  so  much  swelling  of 
the  soft  parts.  Thei'e  are  the  cracks  between  tlie  toes  (rhagades)  which 
are  so  often  formed  in  syphilis,  and  most  probably  other  marks  or  re- 
mains of  constitutional  syphilis.  It  is  a  late  symptom,  generally  in  the 
tertiary  stage,  and  yields  rapidly  to  local  mercurial  treatment  (fumigation 
or  black  or  yellow  wash)  and  large  doses  of  iodide  of  potassium. 

Psoriasia  of  the  nails  occurs  either  as  a  syphilitic  or  spontaneous 
affection  ;  in  the  latter  case  it  seems  that  a  parasite  like  that  of  ringworm 
is  sometimes  present.-  The  nail  becomes  partly  separated  from  the  soft 
parts,  and  its  layers  heaped  up  on  each  other,  like  the  scales  of  an  oyster- 
shell,  much  in  the  same  way  as  tlie  scales  of  epidermis  are  heaped  up  in 
psoriasis  of  tiie  skin.  It  is  a  troublesome  atfection,  which  must  be 
treated,  if  syphilitic,  by  a  prolonged  but  mild  mercurial  course  ;  if  non- 
syphilitic  Ity  arsenic.  Locally  Mr.  T.  Smith  recommends  I'ubbing  off  the 
superfluous  scales  gently  with  glass  or  fine  sandpaper,  or  tlie  api)lication 
of  dilute  acetic  acid,  and  dressing  the  margin  of  the  nail  at  night-time 
with  a  mixture  of  white  precipitate  and  tar  ointment. 

Ingrowing  toenail  is  a  very  trcMiblesome  afiection,  and  causes  incon- 
venience, by  preventing  active  exertion,  far  out  of  proportion  to  its  ap- 
parent gravity.  It  occurs  from  pressure  of  the  toes  together,  whereby 
the  outer  edge  of  the  nail  of  the  gi'cat  toe  becomes  imbedded  in  the  skin, 
and  this  pressure  gradually  produces  ulceration,  leading  to  the  formation 

1  T.  Smith,  Syst.  of  Surg  ,  vol.  v,  p   475. 

2  Hilton  Fagge,  in  Palli.  Trans.,  vob  xxi,  p.  407. 


MINOR    SURGERY.  893 

of  a  crop  of  irritable  and  painful  granulations  at  the  margin  of  the  ulcer- 
ated part.  The  imbedded  portion  of  the  nail  is  often  cut  awa}'  by  the 
patient  or  b}'  some  one  whom  he  consults  ;  but  this  is  only  a  palliative, 
and  often  not  even  that,  for  the  pressure  still  continues  to  act,  and  the 
newly  cut  edge  of  the  nail  is  sometimes  even  more  irritating  than  before. 

The  principles  of  treatment  are  twofold.  The  most  important  is  to  re- 
lieve the  toes  from  all  pressure  by  the  use  of  proper  boots,  or  even  of  an 
apparatus  to  disengage  the  toes  and  prevent  them  from  compressing  each 
other. 

Then  the  ingrown  nail  must  be  disengaged  from  the  flesh.  This  is 
effected  bj^  raising  the  Iniried  edge,  A  little  lint  is  to  be  tucked  in  be- 
tween the  nail  and  the  Hesh,  the  centre  of  the  nail  being  if  necessary 
scraped  or  notched  in  order  to  allow  its  side  to  be  raised  more  easily. 
The  irritable  granulations  are  to  be  repressed  by  dusting  them  with  the 
oxide  of  zinc,  or  by  the  use  of  the  nitrate  of  silver  in  stick. 

Avuhion  of  the  Nail. — Finally,  there  are  many  cases  where  the  re- 
moval of  the  nail,  though,  I  believe,  it  is  never  actually  necessary,  is  very 
expedient.  For  though,  no  doubt,  by  dexterity  and  ))otience  the  com- 
plaint can  always  be  cured,  yet  the  patient -will  be  deprived  of  the  power 
of  active  exercise  for  a  long  time,  so  that  in  severe  or  long-standing 
cases  it  appears  on  the  whole  better  to  remove  the  nail  under  anfesthesia. 
The  sharp  point  of  a  strong  pair  of  scissors  being  driven  beneath  the 
middle  of  the  nail  down  to  its  root,  each  half  is  torn  out  with  a  stout  pair 
of  forceps.  In  a  day  or  two  the  patient  can  walk  about,  the  sore  being 
protected  with  a  little  cotton-wool  to  prevent  the  friction  of  the  shoe,  and 
the  granulations  will  have  disappeared  before  the  nail  grows  again. 


CHAPTER  XLIV. 

MINOR  AND  OPERATIVE  SURGERY. 

MINOR  SURGERY. 

The  subject  of  minor  surgery  will  comprise  bandaging,  the  making  of 
splints,  sutures  and  their  application,  counter-irritation  and  cauteries, 
bloodletting  and  vaccination. 

Bandaging. — The  essence  of  success  in  bandaging  is  to  appl}'  the 
bandage  so  as  to  cover  the  whole  surface  with  it,  and  to  make  equable 
pressure  over  the  whole  suffi(nent  for  the  purpose  in  hand,  but  never  so 
severe  as  to  produce  oedema  of  the  part  below^,  still  less  to  cause  slough- 
ing of  the  skin.  A  bandage  is  made  usually  of  linen  or  calico,  for  some 
purposes  flannel  is  more  convenient,  and  occasionally  elastic  webbing 
may  be  used,  but  this  requires  more  care  in  its  application,  since,  if  it  is 
stretched  too  much  whilst  it  is  applied,  its  recoil  may  easil}^  produce 


894 


MINOR    SURGERY 


more  pressure  than  is  safe.     The  bandage  is  generally  rolled  up  into  a 
single  roller  (Fig.  381)  sometimes  into  a  double-headed  roller  (Fig.  385),  the 

bandage beingrolled  up 
Fig.  381.  from  both  ends  to  the 

middle. 

Bandages  are  spoken 
of  as  simple,  or  continu- 
ous, and  compound. 
The  continuous  band- 
ages are  best  exemi)li- 
fied  by  those  of  the  leg 
and  arm  (Figs.  381, 
382).  These  bandages, 
which  are  carried  con- 
tinuously up  the  limb, 
are  thence  called  "spi- 
ral." In  consequence 
of  the  increase  in  thick- 
ness of  the  limb  upwards 
the  bandage  if  simply 
rolled  round  would  be  quite  loose  and  soon  fall  off.  It  is  necessary,  as 
shown  in  the  figures,  to  rever><e  the  bandage,  by  laying  a  finger  on  its 
centre  while  the  bandage  is  turned  round  on  itself,  till  a  part  of  the  limb 
is  reached  which  is  cylindrical,  when  the  reverses  are  no  longer  needed. 
Each  turn  of  the  bandage  should  lie  half  over  the  one  below  it,  and  when 
the  whole  is  completed  the  liandage  should  lie  quite  evenl}'^  without  any 
pucker,  with  the  reverses  forming  a  continuous  line  up  the  limb.  In 
bandaging  the  leg  (Fig.  381)  a  turn  of  the  bandage  is  first  taken  from 
the  ankle  to  the  foot  and  back  again,  like  a  figure  of  8,  to  afford  a  hold 
for  the  bandage,  and  then  the  bandage  is  carried  as  far  over  the  foot  as 
necessary.  If  it  is  required  to  include  the  heel  this  may  be  done  bj'^  a 
turn  carried  from  the  ball  of  the  great  toe  over  the  heel,  and  secured  by 
circular  turns  round  the  foot.     In  bandaging  the  arm  (Fig.  382)  an  ex- 


Tlu'  coniinon  leg  bandage. 


Fig.  382. 


Bandage  for  tlie  baud  and  foroarni. 


Spica  liandage. 


cellent  liold  is  alforded  by  the  tliunib.  '{'he  l)andage  commences  over  the 
wrist,  turns  i-f)un(l  the  ijaim  of  the  hand,  tlirough  tiie  cleft  l)etween  the 
thumb  and  index  finger,  makes  as  many  turns  round  the  hand  as  is  nee- 


BANDAGES. 


895 


essai'v  to  secure  aii}^  dressing  vvhieli  may  be  applied  tliere,  and  then  passes 
spirally  up  the  limb,  being  reversed  as  may  be  necessary. 

In  bandaging  the  chest,  it  is  often  necessary,  as  mentioned  at  page 
219,  to  reverse  the  bandage,  and  a  brace  or  sui)i)ort  should  always  be 
applied. 

When  the  flexures  of  the  joints,  knee,  groin,  elbow,  or  shoulder  are 
reached,  it  is  no  longer  j^ossible  to  apply  the  bandage  continuously,  so  as 
to  make  even  pressure,  even  by  means  of  reverses.  Either  the  figure  of 
8  bandage  must  be  employed,  or  a  special  bandage  contrived. 

The  figure  of  8  bandage  is  best  exemplified  b}^  the  spica  bandage, 
which  is  used  to  secure  the  dressings  after  an  operation  for  hernia,  or  a 
poultice  to  a  bubo.  One  or  two  turns  are  first  taken  round  the  thigh  to 
afford  a  hold.  Thence  the  bandage  is  carried  to  the  iliac  crest  on  the 
same  side,  and  across  the  back  to  the  opposite  ilium,  returns  across  the 
groin,  and  is  carried  round  in  this  figure  of  8  fashion  as  often  as  neces- 
sary, being  finished  off  and  fixed  by  a  circular  turn  or  two  round  the 
abdomen.  It  is  a  useful  precaution  to  tack  the  bandage  together  at  the 
crossings.  The  knee  or  shoulder  may  also  be  included  in  numerous 
turns  of  a  figure  of  8  bandage  graduall}'  converging  as  they  cross,  or  a 
very  convenient  bandage  may  be  made  as  in  the  figure  (Fig.  384),  by- 
tearing  an  oblong  piece  of  calico  or  linen  down  the  middle  at  either  end 

Fig.  384. 


Four-tailed  bandage  for  the  knee. 

till  a  square  undivided  piece  is  left  in  the  middle.  To  avoid  further 
tearing  a  stitch  is  put  at  tiie  end  of  each  tear  and  knotted.  Then  the 
square  part  is  applied  over  the  projecting  part  of  the  joint,  and  the  tails 
are  crossed  over  each  other  and  tied,  the  lower  ends  at  the  upper,  the 
upper  ends  at  the  lower  side  of  the  joint. 

The  figure  of  8  bandage  is  also  very  commonly  used  in  fracture  of  the 
clavicle,  the  crossing  being  made  between  the  scapulae. 

The  double-headed  roller  bandage  is  used  when  it  is  necessary  to  secure 
the  turns  of  one  of  the  heads  of  the  roller  by  crossing  the  otiier  over  it, 
as  in  the  "capelline"  or  scalp  bandage  represented  in  Fig.  385.  The 
centre  of  the  bandage  between  the  two  rollers  is  laid  on  the  occiput,  and 
when  the  rollers  meet  on  the  forehead,  they  are  crossed  one  under  the 
other,  and  the  first  is  turned  vertically  over  the  scalp,  while  the  second 
pursues  its  horizontal  direction.  Starting  again  over  the  occiput  the  two 
bandages  are  changed  into  opposite  hands  and  the  first  is  brought  back 
again  across  the  vertex  to  the  forehead,  half  covering  its  former  turn  and 
so  on.  When  it  has  become  nearly  horizontal  the  second  roller  is  taken 
vertically  across,  and  is  managed  in  the  same  wa}',  and  thus  the  whole 
head  is  covered  with  an  evenly  pressing  cap  of  bandage.  This  is  a  very 
eflflcient  bandage  when  pressure  is  required  over  a  number  of  difi'erent 
parts  of  the  scalp.     When  onlj'  a  single  point  requires  compression,  as  in 


896 


MINOR    SURGERY, 


Scalp  or  capelline  bandage. 


Fig.  886. 


bleeding  from  one  artery,  the  central  part  of  the  bandage  is  laid  on  the 

compress  which  seenres  that  ves- 
^i*^-  '^^^-  sel ;    tlien  the    ends   are   i)assed 

horizontally  around  the  head,  or 
vertically  round  the  head  and 
chin,  as  may  be  most  convenient ; 
then  crossed  over  each  other  and 
turned  at  right  angles  to  their 
former  direction,  and  so  on  till 
sufficient  pressure  is  made,  when 
they  ma3'  be  firmly  tied  together 
over  the  compress  and  secured 
to  it  by  stitches.  Stitches  may 
also  be  placed  at  the  crossings  of 
the  bandages  to  make  all  secure. 
The  T-bandage  is  used  for  the 
perineum,  in  order  to  secure  ca- 
theters, to  support  a  pad  put  on 
the  anus  in  prolapse  of  the  bowel, 
poultices  in  the  perineum,  and 
other  dressings  in  this  region. 
Fig.  386  represents  one  made  expressly.  A  belt  passes  around  the 
abdomen,  above  the  iliac  spine.  To  this  is  attached  in  the  middle  line 
behind  a  vertical  piece  which  is  divided  into  two  at  the  sacrum,  and  the 
two  ends  are  brought  up  on  either  side  in  front  and  secured  through  a  loop 

on  the  horizontal  belt.  In  practice  this  appa- 
ratus is  usually  made  impromptu,  out  of  two 
pieces  of  bandage  or  thick  tape.  Care  must 
be  taken  to  place  a  stitch  where  tiie  vertical 
tape  is  split  behind  to  prevent  its  tearing,  since 
that  would  loosen  the  whole  bandage.  In  ty- 
ing in  a  catheter,  it  is  usual  to  secure  the  end 
of  the  instrument  by  trying  a  double  ligature 
on  it  with  a  clove-hitch,  so  that  there  arc  two 
ends  in  front  and  two  behind.  The  anterior 
ends  are  tied  to  the  horizontal  piece  or  to  the 
ascending  pieces  not  far  from  it,  and  the  pos- 
terior ends  to  the  ascending  pieces  near  the 
ischial  tuberosities,  both  being  left  just  slack 
enough  to  allow  the  catheter  a  little  motion  as 
the  patient  changes  his  position,  but  not  so 
much  as  to  allow  the  end  to  pass  out  of  the  bladder.  In  applying  tlie  T- 
bandage  to  a  female  the  vertical  piece  may  be  made  single  if  it  is  re- 
quired to  make  pressure  on  the  vulva,  being  unpinned  when  the  patient 
wants  to  make  water. 

The  suapenaory  bamJar/e  supports  the  testicles.  It  is  best  procured 
ready  made  from  the  instrument-maker.  When  one  is  not  at  hand  a  band- 
age is  passed  horizontally  round  the  abdomen,  the  testicles  are  included 
in  the  centre  of  a  handkercliief,  the  anterior  ends  of  which  are  passed  be- 
neath the  bandage,  brought  down  and  tied  to  each  other  in  front,  while 
the  posterior  ends  are  also  crossed  under  the  bandage  and  tied  below  the 
penis.  In  tliis  way  the  scrotum  can  be  raised  to  the  level  of  the  front  of 
the  thiglis. 

ITi.e  many-tailed  ha/iiflnge^  or  24-tailed  bandage  as  it  used  to  be  called, 
is  now  rarely  employed.     It  is  made  on  a  foundation  of  a  single  strip  of 


T-bandage. 


SPLINTS.  897 

bandage  or  cloth,  which  is  laid  along  the  linil)  to  which  it  is  to  be  applied 
on  its  posterior  aspect.  To  this  foiiiidation  a  ninnber  of  stri()s  of  bandage 
have  been  sewn  at  right  angles  from  altove  downwards,  each  overlap- 
ping the  former  by  about  half  its  width,  the  strips  being  about  half  as 
long  as  the  circumference  of  the  limb.  'IMie  lowest  (most  superficial)  is 
first  drawn  tight,  then  covered  by  the  next  one,  and  so  on.  The  limb  is 
thus  bandaged  evenly,  as  if  by  the  spiral  roller.  The  whole  ai)paratus 
can  be  withdrawn  by  loosening  the  transverse  strips  from  above  down- 
wards, and  drawing  the  whole  away  behind  the  limb.  A  fresh  one  can 
then  be  slip[)ed  under  the  limb,  and  the  bandage  renevved,  without  dis- 
turbing the  patient  at  all.  The  foundation  piece  is  sometimes  omitted, 
but  then  the  bandage  is  not  so  secure,  nor  can  such  firm  pressure  be 
made  with  it. 

Splinfx. — Closely  connected  with  the  subject  of  bandages  is  that  of 
splints,  or  immovable  apparatus.  The  permanent  wooden  splints  used 
in  fractures  are  generally  l)ought  ready-made  from  the  instrument-makers, 
thougli  the  surgeon  sliould  always  be  prepared  to  fashion  them  for  him- 
self on  an  emergency.  A  useful  form  for  country  practice  is  what  iscalled 
"■  Gooch's  splint,"  composed  of  thin  strips  of  light  wood,  bound  together 
with  a  webhing.  This  is  solid  enough  to  give  support  in  most  fractures, 
easily  moulds  itself  to  tlie  convexities  of  the  limb,  and  can  be  readily  cut 
by  the  surgeon  with  a  stout  sharp  knife  to  such  lengths  and  shapes  as  the 
case  before  him  requires. 

The  ordinary  forms  of  immovable  apparatus  are  made  of  bandages  or 
cloths  applied  to  tiie  limb  and  either  stiffened  with  some  composition,  or 
lined  with  leather,  pasteboard,  guttapercha,  or  some  such  malleable  mate- 
rial. The  simplest  of  all  these  is  tiie  starch  bandage,  which  is  usually 
applied  over  tlie  pasteboard  splint,  or  may  be  used  by  itself,  a  layer  of 
wadding  or  soft  cloth  being  between  it  and  the  limb.  It  consists  merely 
of  a  common  roller  which  is  soaked  in  thick  starch  after  it  has  been  ap- 
plied, the  limb  being  kept  perfectly  at  rest  till  the  starch  is  dry.  Grum- 
and-chalk  is  stouter  than  this,  but  cracks  more  readily.  It  is  made  of 
mucilage,  thickened  by  chalk,  rubbed  up  with  it  to  the  consistence  of 
thick  cream.  In  applying  these  substances  they  sliould  be  freely  smeared 
into  the  bandage  by  the  hand  or  a  coarse  brush  in  the  direction  of  the  turns 
of  the  roller,  and  they  may  be  made  thicker  l>y  applying  another  band- 
age over  the  first.  Many  other  substances  have  been  introduced  for 
making  splints,  such  as  parattin,  silicate  of  [jotash,  and  glue.  The  par- 
affin seems  to  be  in  every  way  inferior  to  starch  or  gum  ;  the  silicate  of 
potash  I  have  not  tried.  Glue  makes  a  very  good  splint  if  the  l)est 
French  glue  can  be  got;  but  lately  this  has  seemed  difficult.  About  one- 
fourth  of  its  bulk  of  methylated  spirit  is  added  to  the  melted  glue,  and 
when  the  splint  is  hardened  it  is  cut  down  the  middle,  and  a  series  of 
eyelets  let  into  holes  which  are  punched  in  it,  and  it  is  then  laced. 
The  splint  is  not  so  solid  as  that  of  plaster  of  Paris  or  pasteboard,  but 
it  possesses  the  recommendation  that  it  can  be  taken  off  and  i)ut  on  as 
easily  as  a  laced  boot. 

The  padelvjard  splint  is  an  excellent  one,  in  fact,  after  trying  all  the 
modern  substitutes  for  it,  I  see  little  advantage  in  any  of  them,  for  ordi- 
nary cases  of  fracture,  over  this  old  one.  Pieces  of  pasteboard  are  cut 
to  a  pattern  which  shall  embrace  the  limb,  the  pattern  being  generall}^ 
cutout  of  an  old  newspaper.  They  are  then  soaked  in  warm  water  tor  a 
sufficient   time.     When  quite  flexible  they  are  rapidly  moulded  to  the 

57 


898  MIXOR    SURGERY. 

limb,  their  edges  trimmed  off"  with  the  fingers,  and  the_y  fire  bandaged  on. 
After  the  pasteboard  is  quite  dry  tlie  outer  bandage  is  starched. 

Leather  and  OHtta-percha  Splints. — A  leather  splint  is  still  more  secure 
than  one  of  pasteboard,  since  it  cannot  crack;  but.it  is  more  costly,  and 
a  little  more  troublesome  to  make.  A  pattern  is  taken  as  before,  the 
leather  soaked  in  warm  water  till  quite  soft,  moulded,  trimmed  with  stout 
scissors,  and  finished  as  the  pasteboard  splint.  Gutta-percha  is  more 
easily  moulded,  is  much  cheaper,  and  requires  only  dipping  in  nearly 
boiling  water  for  a  very  short  time  to  soften,  but  it  has  the  great  disad- 
vantage of  being  impermeable  to  the  perspiration. 

Plaster  of  Paris  Splint. — The  great  advantage  over  all  these  of  the 
plaster  of  Paris  splint  for  certain  emergencies  is  the  rapidity  with  which 
it  hardens  ;  against  which  must  be  set  the  disadvantage  that  it  is  more 
ditlicult  of  removal,  and  cannot  be  reapplied  or  modified  as  the  others 
can,  if  swelling  occurs,  or  if  for  any  cause  it  becomes  desirable  to  examine 
the  limb.  The  ordinary  splint,  therefore,  appears  better  for  most  cases. 
On  the  other  hand,  it  is  easy  to  cut  a  hole  in  the  plaster  splint  to  expose 
the  wound  of  a  compound  fracture  or  operation,  and  for  such  cases  it  is 
now  in  extensive  use.  It  is  thus  made:  One  or  two  rollers  of  open  ma- 
terial are  charged  with  dr}'  plaster  of  Paris  by  rubbing  in  as  much  as 
the  bandage  will  hold.^  The  surgeon  has  a  bag  of  plaster  and  a  basin  of 
water  read3^  The  usual  layer  of  wadding  or  cotton-wool  being  applied, 
the  bandage  is  placed  in  the  water  for  a  very  short  time,  and  is  then  ap- 
plied, water  being  washed  over  each  turn  as  it  goes  on,  and  fresh  plaster 
being  rul)bed  over  it,  as  much  as  required.  Two  la^'ers  of  bandage  well 
plastered  will  make  a  good  splint,  the  exterior  of  which  can  be  smoothed 
and  varnished  with  paraffin.  In  order  to  expose  a  wound  its  position 
should  be  marked  with  a  thick  wad  of  cotton-wool,  and  then  the  plaster 
can  be  dissolved  with  acid  in  that  part  and  picked  away  till  the  wad  is 
entirely'  exposed.  If  the  plaster  is  good  the  bandage  will  have  set  in  a 
quarter  of  an  hour,  and  the  patient  can  then  be  removed— a  great  desid- 
eratum in  military  practice.  Mr.  Bryant  speaks  highly  of  the  Bavarian 
splint,  which  is  certainly  easily  applied,  but  is  rough  and  fits  far  less  well 
than  the  plaster  splint  made  with  the  bandage  as  aforesaid.  Two  pieces 
of  oblong  flannel  are  sewn  together  down  the  middle.  The  upper  (or 
inner)  one  is  swathed  round  the  limb,  well  charged  with  plaster  of  Paris 
paste,  and  crossed  by  the  outer  one,  which  is  pressed  into  the  jilaster, 
and  secured  with  one  or  two  straps  or  bandages.  The  splint  is  easily  re- 
moved by  tearing  the  edges  of  the  flannel  asunder,  the  stitching  of  the 
two  pieces  behind  acting  as  a  hinge. 

The  most  convenient  of  all  these  apparatus  is  that  made  of  Ilides's 
patent  felt.  The  splint  is  made  of  felt  lined  with  soft  leather,  and  is 
hardened  by  a  preparation  sold  with  the  felt  and  put  on  with  a  brush,  but 
it  is  too  costly  for  general  use. 

All  these  immovaltle  aj)paratus  should  have  a  layer  of  cotton-wool  be- 
tween the  splint  and  the  limb.  They  are  removed  with  '•  Seutin's  scis- 
sors," or  with  a  thick,  strong  pair  of  common  scissors.  Some  place  a 
piece  of  tai)e  under  the  splint  before  it  is  made,  which  serves  to  pull  it 
up  and  afford  a  space  for  the  scissors.  Those  which  are  at  all  elastic  may 
be  allcrcMl  in  size  by  being  cut  up  the  middle  and  laced  on  again,  or  their 
halves  jcMued  together  with  a  fresh  piece  of  gummed  l)andage. 

Sutures  are  made  of  silk,  silver,  catgut,  hair,  and  occasionally  of  other 

'  In  some  parts  of  the  body  it  may  he.  bett«r  to  miike  the  splint  of  pieces  of  muslin 
or  any  open  tissue  similarly  charged  with  plaster  and  cut  to  the  sliai)e  of  the  part. 


SUTURES. 


899 


substances.  Silver  or  wire  sutures  have  the  great  advantaoe  of  causing 
the  least  possible  irritation,  since  they  do  not  imbibe  moisture  oi- putrefy; 
but  they  are  not  supple  enough  for  the  more  comi)licate(l  forms  of  suture. 
It  is  sometimes  said  tliat  silver  sutures  do  not  cut.  But  that  is  true  only 
when  they  have  no  tension  upon  them.  If  tied  too  tight  at  first,  or  if  the 
parts  swell  afterwards,  all  sutures  will  and  must  cut  the  tissues,  and  silver, 
I  think,  cut  faster  than  others  as  being  more  rigid.  Catgut  sutures  are 
very  little  irritating,  and  they  require  no  removal,  since  they  melt  away 
with  the  heat  of  the  parts,  leaving  the  knot  to  drop  off  in  the  course  of 
about  a  week.  For  the  same  reason  they  are  inappropriate  for  sutures 
which  must  be  long  retained.  Horsehair  is  very  pliant,  makes  very  little 
mark,  does  not  absorb  moisture,  and  may  be  retained  any  length  of  time, 
but  is  difficult  to  tie,  brittle,  and  too  delicate  to  l)ear  any  strain.  On  the 
whole  silk  remains  the  most  universally  useful  suture. 
The  forms  of  suture  are  as  follows  : 

1.  Tlie  interruptt'd^  in  which  each  stitch  is  knotted  as  it  is  made.  If 
silver  is  used  the  stitches  are  fixed  b}'  crossing  each  end  perpendicularly 
across  the  other,  and  twisting  them  two  or  three  times.  The  knot  should 
lie  on  one  side  of  the  line  of  wound. 

2.  The  continuous  or  glover's  suture  (Fig.  387)  as  used  in  the  post- 
mortem room.  In  applying  this  to  the  intestine  (which  is  the  part  gen- 
erally sewn  up  with  this  suture  in  the  living  body)  the  first  knot  is  passed 
inside  the  bowel,  and  the  suture  is  finished  off  with  a  knot  as  small  and 
lying  as  close  to  the  coat  of  the  bowel  as  possible. 

3.  The  twisted  suture  (Fig.  388;  is  made  with  a  pin,  around  which  the 


Fig.  388. 


The  continuous  suture. 


The  twisted  suture. 


suture  is  wound  in  the  form  of  a  figure  of  8.  It  is  chiefly  used  in  harelip 
and  in  wounds  made  in  removing  cancer  of  the  lip.  When  several  pins 
are  used  the  suture  can  be  finished  ofi'  separately  on  each  pin  (as  shown 
in  the  figure),  or,  as  is  more  common,  one  long  piece  of  silk  is  used,  which 
is  carried  on  from  one  pin  to  the  next.  The  former  plan  has  the  recom- 
mendation that  each  pin  can  be  separately  withdrawn,  but  it  takes  longer 
to  make  the  suture. 


900 


MINOR    SURGERY. 


Clove-hitch. 


4.  The  qailled  suture  is  used  almost  exclusively  iu  the  operatiou  for 
rupture  of  the  periueuui,  aiul  will  be  fouud  desc'ril)ed  ou  page  S48  with 

that  operation.  It  maj'  also  be  re- 
quired in  some  ver}' deep  wounds, 
in  order  to  prevent  the  bajigingof 
matter  into  their  cavity,  and  keep- 
ing the  dee})  parts  together. 

Glooe-hitch. — For  tying  a  string 
or  towel  securely  on  to  anything 
wliich    it   is    intended    to    fix   so 
firmly  that  it  shall  resist  traction 
(as  the  jaclc-towel  or  strap   with 
wliich  extension  is  made  in  dislo- 
cation, or  the  string  by  wliicli   a 
catheter  is  tied  in  the  bladder)  tiie 
clove-liitch   is    useful.     Here    tiie 
string  is  made  into  two  loops,  and 
the  ends  of  the  second  loop  are  passed  through  tlie  first  in  the  manner 
represented  in  the  figure.     If  the  hitch  is  properly  made,  traction  on  the 
ends  only  fixes  tlie  loops  more  firmly. 

Counter-irt'itauts  and  Cauteries. — Blisters  are  the  commonest  form  of 
counter-irritation,  and  are  most  commonly  made  of  the  Spanish  fly,  either 
in  the  form  of  the  common  blister,  the  lilistering  fluid,  or  the  blistering- 
paper.  For  mere  stimulation  (rubefacients)  mustard  is  almost  univer- 
sally employed.  Tlie  method  of  employing  these  substances  belongs 
more  to  treatises  on  Medicine.  When  instantaneous  A'esication  is  re- 
quired it  can  be  obtained  by  applying  lint  steeped  in  chloroform  to  the 
skin,  covered  with  a  watch-glass,  or  by  liquor  ammonire,  or  by  the  tran- 
sient application  of  a  hot  iron,  but  the  latter  is  not  a  very  safe  form  of 
vesicant,  for  if  left  on  too  long  it  might  produce  sloughing.^  There  are 
few  cases  in  which  there  is  any  real  necessity  for  more  rapid  blistering 
than  cantharides  will  produce,  and  in  these  chloroform  can  be  employed. 
"When  the  blister  has  fully  risen,  the  serum  is  to  be  let  out  by  pricking  it, 
and  a  little  cooling  ointment  applied,  unless  it  is  desired  to  keep  up  the 
discharge,  when  the  cuticle  must  be  cut  all  round,  left  to  cover  the  raw 
surface,  and  covered  with  ung.  sabiime,  or  ceratum  cantharidis,  or  blue 
ointment. 

More  ))otent  counter-irritation  is  procured  by  the  croton  oil  liniment  or 
the  tartar  emetic  ointment,  which  bring  out  a  crop  of  pustules  over  the 
whole  part  to  which  they  ajiplied. 

Lssuen  are  now  much  moi'e  rarely  employed  than  was  the  case  formerly, 
but  their  beneficial  influence  in  some  of  the  severer  cases  of  joint  disease 
seems  to  be  indubitaiile.  Tliey  are  now,  I  believe,  always  made  with 
caustic  potash,  either  pure  or  in  the  form  of  the  Vienna  paste,  a  mixture 
of  5  parts  ol' caustic  potash  with  (i  pai'ts  of  quicklime.  A  piece  of  [»las- 
ter,  with  a  hole  corresponding  to  the  size  of  the  proposed  issue  is  ap|»lied,''^ 
the  hole  filled  with  the  caustic,  and  covered  with  cotton-wool  or  lint  and 
strajiping.  When  the  skin  is  thoroughly  destroyed  a  poultice  hastens  its 
separation,  and  the  ulcer  is  kept  from  liealing  by  occasionally  touching 

'  A  "  tlicriiiiil  hammer"  was  in  use  sume  time  (ii^d  bearing  the  name  of  Dr.  Coi'ri- 
gan.  It  was  prc.«oiiI)ecl  to  be  immersed  in  water  at  \2u"  F.  and  held  in  contact  with 
the  .=l<in  li>r  i  wo  or  three  seconds  as  a  rnbeCaeient  and  for  5  to  10  seconds  as  a  vesicant. 

2  Mr.  T.  Smith  says  the  slough  will  always  be  about  twice  the  size  of  the  hole  in 
the  plaster. 


CAUTERIES.  901 

its  ed2;es   with  caustic  potash.     'I'his  is  less    painful  and  inconvenient 
than  the  old  plan  of  bandaging  peas  on  the  sore. 

Ifo.ra. — Mr.  T.  Smith  speaks  of  establishing  issues  by  means  of  tlie 
moxa,  but  I  have  never  seen  this  done,  nor,  indeed,  liave  I  seen  the 
moxa  used  for  many  years.  It  is  a  very  painful  application,  which  used 
to  be  employed  either  as  a  counter-irritant  or  a  cautery.  A  piece  of 
lighted  German  tinder  was  placed  on  a  frame,  and  the  flame  directed  on 
to  the  skin  by  means  of  a  blowi)ipe.  The  use  of  the  method  is  hardly  so 
indubitable  as  to  justify  such  a  barbai'ous  proceeding.  I  remember,  how- 
ever, once  seeing  it  work  as  instantaneous  a  cure  in  a  case  of  hysterical 
paraplegia  as  "Duke  Humphry's  miracle"  in  Shakspeare's  play. 

Seion.^  also,  as  counter-irritants,  are  becoming  rapidly  things  of  the 
past.  They  are  made  by  pinching  up  a  large  fold  of  skin  and  passing  a 
skein  of  silk  threads  underneath  it  through  the  cellular  tissue  above  the 
deep  fascia.  For  this  i)urpose  a  needle  of  peculiar  construction,  with  a 
very  large  eye,  is  convenient.  If  this  is  not  at  hand  a  straight  knife 
must  be  passed  in  the  track  of  the  seton,  and  the  silk  conveyed  along  it 
by  means  of  an  eyed  probe  before  the  knife  is  withdrawn.  The  skein  of 
silk  is  loosely  knotted,  and  should  be  moved  a  little  each  day  l)ackvvards 
and  forwards  as  soon  as  suppuration  has  commenced.  When  used  to 
empty  abscesses  or  cysts  one  or  two  threads  run  through  with  a  common 
needle  will  suffice. 

Actual  Cauteries. — Cauteries  are  divided  into  actual  and  potential. 
The  actual  cautery  is  sometimes  used  as  a  counter-irritant,  in  which  re- 
spect it  is  of  the  most  signal  service  in  painful  affections  of  the  joints,  a 
white-hot  iron,  shaped  like  a  hatchet,  being  drawn  rapidly  in  cross  lines 
over  the  skin  of  the  part,  so  as  just  to  scorch  the  epidermis  and  possibly 
produce  very  superficial  sloughs.  When  used  as  a  haemostatic  the  cau- 
tery should  be  broader  and  should  be  kept  longer  in  contact  with  the 
tissues,  but  not  so  long  as  to  stick  to  them  and  pull  them  off.  Some 
surgeons  prefer  to  use  the  iron  at  a  dull-red  heat  for  this  pui'pose.  In 
destroying  morbid  growths,  for  which  purpose,  however,  it  is  generally 
inferior  to  the  potential  cauteries,  it  should  be  applied  very  lightly  at 
first,  and  then  others  should  be  applied  more  deeply  till  the  parts  are  as 
thoroughly  charred  as  possible. 

Galvanic  Cautery. — The  galvanic  cautery  has  the  great  advantage 
that  its  heat  is  renewed  as  fast  as  it  is  lost,  but,  of  course,  it  can  only  be 
applied  over  a  very  small  surface.  Its  chief  use  is  in  cutting  through 
vascular  parts,  such  as  the  tongue  or  the  base  of  a  pile,  and  it  is  used 
also  for  destroying  the  vvalls  of  sinuses  and  producing  a  healing  surface. 
Many  ingenious  apparatus  have  been  constructed  for  applying  this  form 
of  cautery  in  various  operations,  based  on  the  cautery  of  Middeldorpff, 
but  it  would  be  out  of  place  to  describe  them  here. 

Potential  Cauterie><. — The  potential  cauteries  are  substances  which 
enter  into  rapid  chemical  combination  with  the  tissues  of  the  skin  or 
other  parts,  chiefly  by  withdrawing  its  fluid  element  from  it,  and  so  dis- 
integrating the  part  to  which  they  are  applied.  The  chief  substances  in 
use  are  as  follows:  Sulphate  of  copper,  which  is  used  chiefly  in  the  form 
of  blue  lint — i.e.,  lint  steeped  in  a  saturated  solution  of  the  salt.  This 
is  a  useful  haemostatic,  and  produces  a  superficial  slough  of  the  exposed 
parts  to  which  it  is  applied.  Sulphate  of  zinc  in  the  form  of  powder,  or 
made  into  a  paste  with  glycerin,  is  a  useful  caustic  in  warts,  condylom- 
ata, and  growths  about  the  female  urethra,  according  to  Sir  J.  Simpson. 
I  have  seen  these  growths  treated  more  frequently  with  the  fluid  caustics, 
of  which  acid  nitrate  of  mercury  and  nitric  acid  are  the  most  manageable 


902  MINOR    SURGERY. 

and  the  handiest.  Sulphuric  acid  also  made  into  a  sort  of  paste  with 
sawdust  or  asbestos  is  a  very  eHieacious  and  a  very  painless  caustic. 
Arsenical  paste,  the  formula  for  which  is  given  on  p.  884,  is  recommended 
by  many  writers  on  skin  diseases  as  more  eflicacious  for  stopping  the 
spread  of  destructive  ulceration  than  any  other,  but  there  is  no  question 
that  its  use  is  by  no  means  free  from  danger,  and  that  fatal  results  have 
occasionally  followed.' 

The  most  universally  serviceable  of  the  potential  cauteries  are  the 
chloride  of  zinc  and  the  potassa  fusa.  The  former  is  disguised  in  va- 
rious ways  by  quacks  and  sold  as  a  nostrum.  It  may  be  used  pure — 
rubbed  on  to  the  parts  in  stick,  and  mixed  with  flour  or  plaster  of  Paris 
into  a  paste,  or  made  into  sticks  or  pencils  with  flour,  which  are  stuck 
like  arrowheads  into  the  substance  of  the  growth  to  be  destroyed.  This 
is  the  i)lan  of"  Cauterisation  en  fleches"  of  M.  Maisonneuve,  and  it  is  an 
admiiable  method  of  removing  morbid  masses  below  the  skin — e.g.,  en- 
larged glands.  The  patient  being  narcotized  if  it  is  thought  necessary,  a 
knife  is  passed  deeply  into  the  growth,  and  the  arrow  of  caustic  inserted. 
This  is  done  in  several  places,  the  caustic  arrows  cut  close  to  the  skin 
and  left  in.  A  dose  or  a  subcutaneous  injection  of  morphia  will  dull  to  a 
certain  extent  the  severe  pain  which  follows  for  some  hours.  Then  the 
skin  turns  a  dead  white.  A  poultice  is  applied,  and  in  a  few  days  a  mass 
shells  out  something  like  a  billiard  ball,  exposing  a  surface  which  if 
healthy  will  cicatrize,  and  if  not  may  be  treated  with  renewed  applica- 
tions of  the  caustic.  Another  way  of  applying  the  chloride  is  by  pro- 
ducing a  superficial  slough,  and  then  scoring  it,  and  stuffing  the  incision 
with  the  caustic.  Potassa  fusa  is  applied  pure,  or  as  Vienna  paste,  and 
is  also  a  most  excellent  caustic. 

The  pain  of  the  cautery  is  somewhat  dulled  by  the  application  imme- 
diately afterwards  of  some  substance  which  will  decompose  it,  as  chalk 
for  the  mineral  acids,  and  vinegar  for  caustic  potash  ;  and  their  action  is 
limited  to  the  part  which  is  to  be  destroyed  b}^  smearing  those  in  the 
neighborhood  with  oil  or  covering  them  with  a  ring  plaster. 

Bloodlettivg  is  either  general — venesection  and  arteriotomy — or  local — 
leeching  and  cupping. 

Arteriotomij  is  now,  I  think,  given  up;  at  least,  I  never  saw  it  prac- 
ticed but  once.  If  any  one  should  choose  to  open  the  anterior  branch  of 
the  temporal  artery  no  special  directions  would  be  necessary.  The  ves- 
sel lies  close  under  the  skin,  and  all  that  is  required  is  to  touch  it  with 
the  point  of  a  lancet.  When  the  required  quantity  of  blood  is  obtained, 
the  puncture  may  be  closed  with  compress  and  bandage  or  the  artery  cut 
across. 

Veneiicction. — But  the  only  method  of  general  bloodletting  now  in  use 
is  venesection  at  the  bend  of  the  elbow.  A  bandage  is  tied  round  the 
arm  tight  enough  to  make  the  veins  of  the  forearm  start  out.  Then  the 
more  prominent  of  the  two  veins  at  the  bend  of  the  elbow  is  selected. 
This  is  usually  the  median  basilic,  which  has  the  further  great  recom- 
mendation that  it  is  firmly  supported  by  the  bicipital  fascia,  and  will  not 
retract  from  the  lancet.  The  surgeon  should  assure  himself  previously 
that  there  is  no  abnormal  artery  coursing  l)elow  the  skin,  and  that  he  is 
away  fi-om  the  position  of  the  In-achial.     He  then  steadies  the  vein  with 

'  J'  In  the  practice  of  M.  Roux  the  application  diirinn;  a  singlo  nijfht  of  a  paste  con- 
taining 4  por  cent,  of  arsenic  to  a  surface  of  little  more  than  an  incli  in  diameter 
proved  fatal."— Syst.  of  Surg.,  2d  ed.,  vol.  v,  p.  547. 


VACCINATIOX. 


903 


his  left  tliiunli  wliile  he  dips  the  lancet  into  it,  and  lets  the  lancet  cut  it- 
self out  l»y  descrihino-  a  circle  with  it,  thus  niakin<i;  a  free  incision  which 
lies  rather  obliquely-  to  the  axis  of  the  vein.  The  patient  can  increase 
the  flow  of  blood  b}-  grasping  a  stick  or  a  piece  of  bandage  and  working 


Fig.  390. 


Venesection. — After  C.  Heath. 

his  fingers  upon  it.  When  as  much  lilood  as  is  desired  has  been  ob- 
tained, the  wound  in  the  vein  is  closed  with  the  thumb,  the  arm-bandage 
unloosed,  a  compress  of  lint  applied,  and  bound  on  the  wound  by  the 
arm-bandage  arranged  in  a  figure  of  8.  A  wound  of  the  bvacthial  artery 
has  often  been  caused  by  want  of  skill  in  this  little  operation,  and  very 
often  has  been  successfully  treated  by  firm  compression.  If  it  does  not 
heal  and  a  varicose  aneurism  forms,  it  must  be  treated  on  the  principles 
explained  on  page  528. 

Cupping. — Leeching  need  not  be  here  spoken  of,  and  cupping  also  is 
now  seldom  prescribed  ;  still  it  is  a  very  useful  measure  in  many  cases, 
and  I  cannot  think  that  its  present  neglect  will  be  permanent.  At  any 
I'ate,  a  surgeon  ought  to  know  how  to  cup  if  required.  The  operation  is 
done  with  a  scarificator,  which  is  a  box  containing  a  spring  to  which  are 
attached  a  number  of  lancet  blades  in  two  parallel  rows,  so  set  that  when 
the  spring  is  drawn  up  and  the  bottom  of  the  box  laid  on  the  skin,  by 
touching  the  spring  the  blades  are  released,  and  as  they  pass  through  the 
slits  made  for  them  in  the  bottom  of  the  box  they  project  out  of  the  slits, 
and  so  cut  the  skin,  making  a  number  of  scarifications  or  small  incisions 
through  it,  just  into  the  cellular  tissue.'  Then  the  surgeon  takes  one  of 
the  cups  and  puts  "the  torch" — a  wick  steeped  in  spirit — into  the  cup 
so  as  to  exhaust  it  and  claps  it  rapidly  over  the  scarifications.  The  cups 
are  graduated  in  order  to  mark  tlie  quantity  of  blood  drawn,  and  the 
given  quantity  is  obtained  by  renewing  the  cups,  which,  however,  should 
never  be  put  on  in  exactly  the  same  line.  The  depth  of  the  incisions  can 
be  regulated  in  setting  the  spring  according  to  the  thickness  of  the  skin 
about  to  be  operated  on.  Dexterity  in  cupping  can  only  be  acquired  by 
constant  practice  and  attention  to  a  number  of  small  details,  which  it 
seems  hardl}^  worthwhile  to  describe  here,  but  which  are  soon  learned  by 
experience. 

Vaccinatwn  consists  in  the  insertion  below  the  cuticle  of  the  matter 
from  the  cowpox,  so  as  to  produce  that  disease  in  the  person  vaccinated, 
the  vaccine  lymph  being  absorbed  by  the  vessels  of  the  cutis  vera.  The 
first  object  of  the  vaccinator  is  to  bring  the  lymph  into  proper  contact 
with  the  vessels  of  the  skin  without  drawing  any  lilood,  or  as  little  as 


1  The  incisions  ought  not  to  be  too  deep,  otherwise  the  subcutaneous  fiit  may  bo 
squeezed  out  and  so  plug  the  cuts  as  to  prevent  bleeding. 


904  MINOR    SUKGERY. 

possiI>le.  To  this  end  the  skin  is  stretched  tight,  the  cnticle  is  gently 
raised  by  inserting  the  lancet  point  oI)liqnely  through  it,  and  the  lymph 
is  then  introduced.  Numerous  contrivances  have  been  devised  for  vac- 
cination. The  lancet  may  have  a  groove  in  it  which  is  filled  with  lymph 
before  its  introduction,  or  after  the  puncture  is  made  may  be  charged  hy 
dipping  it  into  the  lymph,  then  again  inserted  into  the  puncture,  and  the 
lymph  squeezed  off  by  pressing  the  edges  of  the  puncture  together,  or 
an  ivory  or  quill  jioint  may  be  used  instead  of  the  lancet  for  this  latter 
purpose.  Instead  of  the  lancet  [)uncture,  scratches  maybe  made  through 
the  cuticle,  into  which  the  lymph  is  rulibed,  or  the  cuticle  may  be  raised 
by  a  minute  blister,  and  when  this  is  pi-icked  it  may  be  filled  vvitli  lymph, 
as  Mr.  Ellis  recommends;  or  the  cuticle  maybe  entirely  scratched  off 
.the  part  to  which  the  vaccine  is  to  be  applied.  The  lymph  also  is  pro- 
cured from  the  vaccinifer  in  many  different  ways.  The  one  now  most  in 
use  is  to  charge  capillary  glass  tubes  with  it,  seal  them  up,  and  preserve 
them  for  use,  when  the  ends  are  broken  off  and  the  lymph  blown  out  of 
them  on  to  the  lancet.  It  is  more  satisfactory,  however,  to  take  the  lymph 
fresh  from  the  arm  of  an  infant  who  has  been  successfull}^  vaccinated 
and  use  it  the  moment  it  is  drawn,  and  perhaps  more  satisfactory  still  to 
obtain  it  fresh  from  the  cow.  Another  method,  but  a  less  secure  one,  is 
to  charge  ivory  points  with  it  and  allow  them  to  dry,  moistening  them 
in  steam  before  using  them,  or  to  preserve  it  dry  between  two  plates 
of  glass. 

The  result  of  primary''  successful  vaccination  is  stated  in  the  instruc- 
tions to  public  vaccinators  to  be  as  follows  : 

"Tiie  puncture  may  be  felt  slightly  elevated  on  the  second  day;  on 
the  third  it  is  surrounded  by  a  sliglit  halo  of  redness;  by  the  fifth  a  dis- 
tinct vesicle  will  be  formed,  having  a  slightly  elevated  margin  and  a 
depressed  centre ;  on  the  eighth  day  the  vesicle  should  have  reached  its 
perfect  condition,  when  it  is  pearl-colored  and  distended  with  clear 
lymph,  its  margin  being  tinged,  firm,  and  shining.^  From  this  period 
tiie  redness  around  increases  in  extent  and  intensity  until  the  tenth  day, 
whe!i  there  is  often  well-marked  swelling  and  induration  of  the  subjacent 
cellular  tissue.  On  the  eleventh  day  the  areola  begins  to  subside,  leav- 
ing as  it  fades  two  or  three  concentric  rings  of  redness,  the  vesicle  begins 
to  dry  up,  assuming  a  brownish  color,  the  remaining  lymph  becomes 
opaque,  and  generally  concretes,  forming  by  tiie  fourteenth  or  fifteenth 
day  a  dry  reddish-l)rown  scab  ;  this  contracts,  dries,  blackens,  and  finally 
falls  off  about  the  twenty-first  day.  Tiie  resulting  cicatrix  is  permanent, 
slightly  de[)ressed,  dotted,  or  minutely  pitted." 

Hecondary  vaccination,  or  the  vaccination  of  persons  who  have  been 
vaccinated  before,  sometimes  gives  results  identical  with  these,  or  differ- 
ing only  very  slightly  from  them,  showing  that  the  subjects  were  in  no 
respect  protected  by  the  previous  vaccination,  although  probably  if  they 
had  contracted  small-pox  the  disease  would  have  been  milder.  But  it  is 
more  common  for  the  results  to  be  variously  modified,  and  sometimes 
severe  inflammation  of  tlie  glands  and  absorbents  is  produced. 

It  is  always  usual  to  vaccinate  in  three  different  si)ots,  about  an  inch 
distant  from  eacli  other,  and  some  believe  that  the  protection  is  more 
complete  when  this  is  done  in  botli  arms — i.  e.,  when  the  patient  is 
vaccinated  in  six  places  at  once. 

*  It  is  at  this  period  that  the  lymph  should  be  taken  from  the  vesicle  for  use  in 
vaccination. 


ANiESTHETICH.  905 


OPERATIVE    SURGERY — AN/ESTHETICS. 

The  subject  of  Operative  Surgery,  considered  in  itself  apart  from  tlie 
questions  of  the  diagnosis  of  the  disease  or  lesion,  the  indications  for  the 
operation,  and  the  [)revious  and  subsequent  management  of  the  patient, 
comprises  the  three  following  topics  :  (\)  the  administration  of  antes- 
thetics,  (2)  the  arrangements  for  the  prevention  of  h;emorriiage,  and  (3) 
the  operative  manipulations. 

The  administration  of  anjiesthetics  has  now  been  developed  almost  into 
a  special  branch  of  practice  in  large  cities;  and  the  custom  is  a  conve- 
nient one,  as  it  permits  the  surgeon  to  attend  to  the  details  of  the  opera- 
tion exclusively,  though  it  cannot  be  said  to  be  necessary,  since  every 
surgeon  who  can  trust  himself  to  operate  must  be  competent  to  super- 
intend, and  if  necessary  to  administer  the  ana?sthetic. 

Anaesthetics  are  divided  into  local,  or  those  which  merely  benujnb  the 
part  to  which  they  arc  applied,  and  general,  or  tliose  which  abolish  the 
sensation  of  the  whole  system.  The  latter  are  of  universal,  the  former 
only  of  very  limited  utility.     We  will  speak  first  of  local  amestliesia. 

Local  AnseiitheticH. — The  local  anjesthetics  at  present  in  use  are  a  freez- 
ing mixture  of  ice  and  salt  and  the  pulverized  vapor  of  ether,  and  in  both 
of  them  the  rapid  action  of  extreme  cold  is  the  agency  employed  for  abol- 
ishing the  cutaneous  sensation.  This  it  does  so  rapidly  that  there  is  no 
necessity  for  continuing  the  action  of  the  cold  for  any  length  of  time. 
The  skin  turns  of  a  dead-white  color  and  becomes  somewhat  puffy,  and 
may  then  be  cut,  cauterized,  or  otherwise  treated  without  any  sensation 
on  the  part  of  the  patient.  This  insensibility  lasts  for  a  few  minutes, 
after  which  the  circulation  and  sensation  return.  No  pain  accompanies 
either  the  freezing  or  the  thawing. 

The  mixture  of  ice  and  salt  is  more  convenient  when  the  antiesthesia 
has  to  be  distributed  over  a  considerable  surface,  the  ether-spray  when  it 
is  to  be  limited  to  a  small  portion  of  skin  or  to  the  line  of  a  single  incision. 
In  the  former — introduced  into  practice  by  Dr.  J.  Arnott' — a  quantity  of 
rough  ice  is  pounded  into  pieces,  none  of  which  should  be  larger  than  a 
nut,  and  rapidly  mixed  with  as  much  salt.  The  pounded  mixture  is  then 
put  into  a  bag  of  rough  muslin  (so  that  the  brine  may  run  off  as  it  is 
formed),  and  is  laid  closely  round  the  skin  which  is  to  be  frozen.  After 
about  four  minutes  the  characteristic  appearance  of  the  skin  will  show 
that  the  desired  effect  has  been  produced.  The  application  of  the  vapor 
of  ether  as  an  anaesthetic  was  first  suggested  by  a  Dr.  Guerard,'^  and  has 
been  applied  by  Dr.  Richardson  by  means  of  the  spray-producer,  which 
is  modelled  on  the  instrument  recently  invented  for  pulverizing  the  vapor 
of  essences.  The  ether  should  be  pure,  or  washed,  and  the  direction  of 
its  vapor  to  the  spot  or  the  line  cliosen  for  the  incision  during  a  ver}'- 
brief  period  will  produce  such  intense  cold  as  to  render  the  skin  quite 
insensible. 

The  great  objection  to  local  anaesthesia  is  the  very  limited  extent  to 
which  it  reaches.  It  can  only  be  applied  to  the  very  surface  of  the  body, 
and  only  extends  to  the  part  which  is  actually  frozen,  the  parts  around 
being  rather  more  sensitive  than  natural.  It  has  been  apprehended  that 
the  frozen  parts  would  be  liable  to  slough,  but  I  never  saw  any  founda- 
tion for  this  apprehension. 

1  Lancet,  Oct.  30,  1858. 

'■^  Trousseau  et  Pidoux,  Th^rapeutique,  vol.  ii,  p.  349,  8th  ed. 


90&  AN.g^STHETICS. 

Ether  and  Chloroform. — The  "feneral  aniiesthetics  wliich  are  in  the 
most  common  use  are  ether  and  chloroform.  After  the  first  discovery  of 
anaesthesia  by  the  inhalation  of  ether,  by  the  American  dentists  Morton 
or  Wells,  the  details  of  tiie  novel  method  were,  of  course,  somewhat  un- 
certain, and  the  administration  was  attended  with  some  difficulty,  which 
resulted  chiefly  from  the  surgeon  not  trustino-  to  the  ether  sufficiently 
and  administering  it  too  gradually.  I  do  not  know  that  I  can  do  better 
than  quote  a  recent  letter  from  Mr.  Warrington  Haward  {Brit.  Med. 
Journ.,  Aug.  14,  1875),  which  gives  in  a  short  space  all  the  precautions 
necessary  for  the  administration  of  this  aniijsthetic,  to  which  1  need  only 
add  that  in  this  as  in  all  other  anjiesthetics  it  is  very  desirable  to  have  the 
stomach  empty — ^.  c,  to  enforce  abstinence  for  food  for  about  four  hours 
whenever  it  is  possible.  On  an  emergency,  however,  this  is  of  no  great 
importance,  but  the  patient  will  probably  be  troubled  with  vomiting  after 
the  operation. 

Administration  of  Ether. — "  For  the  safe  and  efficient  administration 
of  ether  vapor  for  producing  anaesthesia,  several  things  are  needful  to  be 
known  and  remembered,  which  are  chiefly  these: 

''  1.  That  kind  of  ether  should  be  used  which  is  fittest  for  the  purpose 
of  inhalation,  and  this  is  the  pure  anhydrous  washed  ether,  of  specific 
gravity  .720,  free  from  alcohol  and  water.  Robbins's  'ether  for  local 
anaesthesia'  is  a  dangerous  compound  for  inhalation. 

"  2.  The  ether  siiould  be  given  in  such  a  way  that  the  inhalation  may 
be  commenced  vvitli  a  very  weak  vapor,  which,  after  a  few  inspirations, 
can  be  rapidly  increased  in  strength.  If  we  begin  with  too  powerful  a 
vapor  the  air-passages  are  intolerant  of  it,  and  the  patient  resists  the  in- 
halation ;  but  after  a  few  moments'  inhalation  of  a  weak  vapor,  its  sti-ength 
can  be  increased  without  inconvenience  and  the  patient  rai)idly  brought 
under  its  influence.  I  think  a  cone  of  felt,  covered  witli  thin  mackintosh, 
is  the  simplest  and  best  apparatus  for  this  purpose. 

"3.  Stimulants  should  not  be  administered  before  the  inhalation. 
Ether  is  itself  a  stimulant,  and  can  be  safely  given  iu  cases  where  there 
is  great  depression  ;  liut^  as  Mr.  Clover  has  pointed  out,  it  is  very  un- 
des^irable  to  have  alcohol  in  the  stomach  when  ether  is  being  inhaled. 

"  4.  Whatever  danger  may  belong  to  ether  has  relation  to  the  respi- 
ratory function  ;  the  breathing  should,  therefore,  be  watched.  And  I  ma}-- 
add,  it  is  desirable  so  to  place  the  head  of  the  patient  that  the  saliva  (the 
secretion  of  which  is  increased  by  the  ether)  may  run  out  at  the  corner 
of  the  mouth  i-ather  than  into  the  trachea." 

Administration  of  Chloroform. — Chloroform  is  a  more  potent  agent 
than  ether,  and  takes  less  time  to  produce  complete  anaesthesia.  The 
production  of  this  state  is  marked  by  an  absence  of  all  voluntary  motion 
and  sensation  and  of  reflex  motion.  As  a  test  of  this  the  e3^elid  is  usually 
taken,  and  when  the  eyel)all  can  be  touched  without  any  winking  being 
induced,  the  patient  is  reported  as  being  fit  for  operation.  The  danger  of 
ansesthesia  consists  iu  the  risk  that  the  poisonous  effects  thus  manifested 
in  tlie  cerebro-spinal  axis  should  extend  to  the  central  ganglia  which  pre- 
side over  the  functions  of  respiration  and  circulation,  and  so  either  the 
breathing  cease  or  the  heart  become  paralyzed. 

The  methods  of  administering  chloroform  vary.  Dr.  Snow  was  led  by 
tiie  experiments  he  made  to  believe  tliat  5  per  cent,  of  chloroform  in  the 
inspired  air  is  a  proportion  wliich  could  never  produce  danger,  and  he 
contrived  an  inhaler  by  means  of  which  a  certain  surface  of  blotting- 
paper  charged  with  chloroform  is  exposed  to  tiie  contact  of  air  at  a 
definite  temperature,  so  that  the  proportion  of  chloroform  vapor  could 


CHLOROFORM.  907 

not,  as  he  believed,  rise  above  the  limit  of  safet}'.  Mr.  Clover  attains 
the  same  end  more  surely  by  mixing  definite  quantities  of  the  vapor  of 
chloroform  and  air  in  a  lai'ge  bag,  carried  over  tlie  shoulders  and  attached 
to  the  mask  which  covers  the  i)atient's  mouth.  But  Mr.  Lister  has,  I 
think,  siiovvn  satisfactorily  that  the  evaporation  from  the  usual  quantity 
of  chloroform  poured  on  to  a  cloth  never,  even  at  high  temperatures, 
rises  above  4.5  per  cent,  (of  which,  of  course,  a  great  part  is  dissipated 
into  tlie  air),'  and  therefore  that  the  method  of  administration  witli  the 
cloth  or  handkerchief  is  quite  as  safe  as  that  by  Dr.  Snow's  inlialer  and 
a  fortiori  by  other  inhalers,  which,  in  fact,  are  rather  contrivances  for 
economizing  cliloroform  tiian  for  regulating  its  dilution.  Another  ad- 
vantage in  tliis  simple  method  is  tliat  tiie  quantity  of  chloroform  poured 
on  to  the  handkerchief  is  a  matter  of  secondary  importance,  wliile  in  Dr. 
Snow's  inhaler  it  is  essential  to  the  meclianism  that  not  more  than  Jij 
should  ever  be  in  the  instrument  at  tlie  same  time.  About  5i''f^--5'j  then 
of  the  cliloroform  are  to  be  poured  on  the  handkerchief,  and  the  patient 
is  to  be  gradually  accustomed  to  the  taste  and  pungenc}'  of  the  vapor  by 
holding  it  rather  far  from  his  face,  and  giving  him  occasional  l)reatlis  of 
pure  air,  and  when  he  is  getting  somewhat  intoxicated  pressing  it  rather 
more.  A  period  of  excitement,  noise,  and  struggling  usually,  but  not 
always,  comes  on,  and  then  the  patient  hinks  into  a  slumber,  the  limlis  no 
longer  I'esist  when  moved,  he  does  not  resent  a  pinch  or  prick  with  the 
knife,  and  the  eye  is  insensible.  Then  the  operation  may  be  begun. 
Mr.  Lister  is  a  strong  advocate  of  the  theory  that  all  that  is  necessary 
for  safety  in  chloroform  inhalation  is  to  watch  the  breathing,  and  when 
any  lividity  of  the  face  occurs,  or  any  laryngeal  stertor,  to  pull  the 
tongue  out  of  the  mouth  with  a  pair  of  forceps  sufficiently  far  to  open 
the  larynx  freely'  and  allow  the  patient  to  breathe  naturally,  withdrawing 
the  cloth  till  the  indications  of  returning  sensibility  necessitate  the  re- 
administration  of  the  vapor.  And  doubtless  these  precautions  would 
reduce  the  mortality  after  chloroform  materially.  Still  there  has  been 
many  deaths  resulting,  as  far  as  we  can  judge,  from  sudden  failure  of 
the  heart's  action,  under  the  hands  of  persons  quite  aware  of  the  im- 
portance of  watching  the  respiration,  and  whom  we  have  no  ground  for 
charging  with  negligence ;  and,  in  fact,  Mr.  Lister  allovvs  that  there  ma}'' 
be  varying  idiosyncrasies  in  respect  of  chloroform.  The  onl}'  death  from 
chloroform  that  I  ever  happened  to  witness  was  in  a  young  man  of 
perfectly  healthy  appearance,  and  in  whom  an  experienced  chloroformist 
certainly  noticed  no  obstruction  to  the  respiration  before  the  failure  of 
pulse  which  proved  at  once  fatal.  It  seems,  therefore,  safest  to  watch 
both  the  pulse  and  the  respiration,  the  latter  most  narrowly,  as  it  is  the 
side  from  which  danger  most  commonly  occurs.  On  the  first  symptom 
of  the  failure  of  the  pulse  the  chloroform  must  be  suspended,  if  the 
galvanic  battery  is  at  hand  it  should  be  applied,  and  the  breast  should 
be  well  slapped  with  cold  towels,  while  hot  affusion  is  practiced  to  the 
head.  When  the  respiration  is  suspended,  if  forcible  traction  on  the 
tongue  fails  to  restore  it,  artificial  respiration  should  be  practiced,  the 
tongue  being  still  held  forward. 

Relative  Safety  of  Ether  and  Chloroform. — The  question  of  the  relative 


1  See  Syst.  of  Surg.,  2d  ed.,  vol.  v,  p.  48G,  note. 

2  I  must  refer  the  reader  to  Mr.  Lister's  article  (p.  491)  for  his  theory  of  the  effect 
on  the  larynx  of  drawing  forward  the  tongue  and  for  his  views  of  the  nature  and 
symptoms  of  laryngeal  obstruction.  The  main  point  in  practice  is  to  recollect  that 
defective  breathing  comes  on  very  insidiously  and  suddenly,  and  may  be  relieved  by 
forcible  traction  on  the  tongue. 


908  ANAESTHETICS. 

safety  of  ether  and  (.■hloroform  is  being  just  now  anxiously  debated.  I 
have  no  wish  to  dogmatize  on  the  subject,  but  I  have  used  ether  with 
great  comfort  for  many  years,  and  have  never  seen  any  but  the  most 
trivial  inconveniences  from  it,  such  as  blistering  of  the  lips  from  evapora- 
tion, and  cough  or  irritation  of  the  bronchial  tul)es  from  its  pungency. 
During  the  same  time  I  have  also  employed  chloroform  perhaj^s  as  com- 
monly, and  have  been  so  fortunate  as  to  escape  any  fatal  accident  from 
this  in  my  own  practice,  and,  as  I  have  said  above,  never  to  see  more 
than  one  death  from  it.  But  I  tliiuk  we  can  hardly  resist  the  unanimous 
opinion  of  the  American  surgeons,  founded  ou  nearly  30  years  of  exten- 
sive experience  as  to  the  relative  safet}-  of  ether,  and  if  so  we  should  only 
employ  chloroform  in  exceptional  cases.  There  are  some  persons  (chiefly 
old  to[)ers)  in  whom  ether  pi'oduces  such  excitement,  or  whose  bronchial 
membrane  is  so  sensitive,  tliat  it  has  to  be  given  up,  and  with  them  if 
any  aujesthetic  is  used  it  should  be  chloroform.  Chloroform  seems  also 
perfectly  safe  in  childhood,  but  so  is  ether  also. 

Anieslhetics  in  Heart  Disease. — An  idea  seems  still  to  prevail  that 
anaesthesia  is  especially  dangerous  in  disease  of  the  heart,  but  I  think 
this  is  an  error.  It  is  true  that  in  extensive  disease  of  the  heart  any  ex- 
citement may  prove  fatal,  and  so  may  of  course  that  of  taking  ether  or 
chloroform.  But  then  the  shock  of  the  operation  without  an  anaesthetic 
is  far  more  likely  to  cause  death  in  that  condition,  so  that  if  any  opera- 
tion is  required  it  seems  safer  to  perform  it  under  anaesthesia  than  with- 
out.^ In  themselves  both  ether  and  chloroform  are  stimulants,  especially 
the  former.'^ 

Bichloride  of  methylene  is  an  anaesthetic  which  possesses  the  advan- 
tages of  producing  insensibility  very  quickly,  and  of  not  causing  any  sub- 
sequent sickness  or  discomfort.  The  patient  also  recovers  very  rapidly 
from  its  eflfects.  On  account  of  the  immunity  from  sickness  it  is  much 
used  for  ovariotomy ;  and  on  account  of  the  rapidity  with  which  persons 
can  be  brought  under  its  influence,  it  is  reported  to  be  much  used  in 
some  e3'e  institutions  where  many  operations  are  performed.  But  ether 
seems,  with  proper  precautions,  almost  as  free  from  after-vomiting,  and 
the  saving  of  time  in  producing  anaesthesia  is  a  poor  reason  for  employ- 
ing an  agent  which  seems  to  be  more  dangerous  than  the  other  anaes- 
thetics. 

Nitrous  ocnide,  or  laughing  gas,  has  now  been  made  available  for  prac- 
tical purposes  bj^  giving  it  freely  and  pure,  i.  p.,  unmixed  with  air.  In 
this  way  it  does  not  excite,  but  produces  at  once  a  condition  of  complete 
insensibilit3'.  The  patient  becomes  entirely  comatose,  the  whole  blood 
is  unoxygenated,  so  that  the  surface  is  of^  a  dark  livid  color,  and  the 
blood  which  exudes  from  an  incision  quite  black.  The  condition  of  the 
patient  appears  most  alarming,  but  in  two  or  three  minutes  the  color  re- 
turns and  he  recovers,  with  no  symptoms  whatever,  and  no  traces  of  the 
alarming  state  in  which  he  has  been.  During  those  two  or  three  minutes 
any  operation  can  be  performed  with  as  complete  absence  of  sensation  as 

'  I  have  already  alluded  to  a  death  which  I  saw  from  chloroform  in  a  perfectly 
healthy  person,  in  whom  post-mortem  examination  detected  no  visceral  disease  of 
any  kind.  The  next  patient  brought  into  the  o|)erating  theatre  was  one  of  my  own 
— an  old  man,  witii  extensive  disease  of  the  heart.  He  was  phiced  under  chloroform, 
and  the  operation  com])leted  without  any  bad  sj'mptoms.  A  few  days  afterwards  he 
fell  down  dead  while  walking  across  the  wa7'd.     Path.  Trans.,  vol.  xv,  p.  69. 

2  "  An  amputation  jicrformcd  under  chloroform,"  says  Mr.  Lister,  ''  has  often  the 
effect  of  improving  instead  of  lowering  the  pulse,"  and  he  gives  a  striking  example 
of  this. 


HEMORRHAGE.  909 

under  any  other  anfcsthotic.  And  as  the  administration  can  be  repeated, 
long  operations  may  be  performed  without  any  remembrance  on  the  part 
of  the  patient.  But  it  is  doubtful  whether  tliis  would  not  be  as  danger- 
ous as  any  other  an.nesthetic,  and  it  is  certainly  much  less  convenient,  so 
that  nitrous  oxide  is  now  reserved  for  very  short  operations,  like  tooth- 
drawing,  or  sometimes  as  a  prelimimary  to  the  administration  of  ether, 
though  tills  seems  unnecessary.  Tiie  gas  is  stored  under  pressure  in  a 
liquid  state,  and  on  tlie  removal  of  the  stopper  from  the  bottle  a  certain 
quantity  resumes  its  gaseous  condition  and  fills  a  bag  which  is  screwed  on 
to  the  bottle,  and  contains  enough  for  one  administration.  The  bag  is 
then  attached  to  the  mouthpiece. 

MEANS  OF    RESTRAINING  HEMORRHAGE. 

The  Towniquet. — Hemorrhage  is  restrained  in  amputations,  and  other 
operations  on  the  limbs,  by  the  tourniquci,  a  contrivance  wliereby  pres- 
sure is  made  directly  on  the  main  artery,  and  also  by  means  of  a  circular 
strap  on  the  whole  limb.  The  common  tourniquet  consists  of  a  pad 
which  is  pressed  down  by  a  screw,  and  the  screw  is  attached  to  a  large 
stra[)  whicli  encircles  the  limb,  and  thus  as  tlie  screw  is  pressed  down,  it 
tightens  the  strap  and  makes  pressure  equally  on  the  limb  all  round.  The 
pad  is  eitlier  attached  to  the  screw  or  is  placed  below  it,  secured  also  by  a 
circular  webbing  strap,  or  is  replaced  by  a  piece  of  roller  laid  on  the  artery. 
Care  should  be  taken  so  to  direct  the  pressure  as  to  compress  tlie  arterj' 
against  the  subjacent  bone.  This  is  a  most  efficient  method  of  control- 
ling htx?morrhage,  but  it  produces,  of  course,  considerable  venous  engorge- 
ment, and  cannot  be  tolerated  for  any  lengtli  of  time.  The  Italian,  Sig- 
norini's,  or  the  horseshoe  tourniquet,  is  an  arch  of  metal  larger  than  the 
limb,  having  an  expanded  piece  to  rest  against  tlie  side  opposite  to  the 
arttry,  while  a  screw  carrying  a  pad  is  directed  against  the  artery  from 
the  opposite  end  of  the  arch.  This  makes  no  circular  compression  of 
tlie  liinh,  and  does  not  produce  venous  congestion  except  by  ths  un- 
avoidable pressure  on  the  main  vein  accompanying  the  artery.  All  the 
aneurism  compressors  are  made  on  this  principle,  as  well  as  the  aortic 
toui'uiquet  for  amputation  at  the  hip. 

Digital  Presaiire. — Some  surgeons  are  fond  of  using  finger  pressure  on 
the  artery  instead  of  a  tourniquet,  and  this  is  necessaiy  in  many  situa- 
tions, as  in  amputations  performed  so  high  that  there  is  no  room  for  the 
tourniquet.  Whenever  the  tourniquet  can  be  applied  I  believe  it  is 
much  better,  as  saving  the  loss  of  l)lood.  In  making  digital  com})ression, 
the  assistant  who  takes  charge  of  the  artery  should  take  a  sufficient  grasp 
of  the  limb  to  steady  his  tliumb,  wiiich  is  to  be  firmly  pressed  on  the 
artery  in  the  proper  direction,  and  supported  by  pressure  with  the  thumb 
or  fingers  of  tlie  opposite  hand.  Wlieu  tiiat  tliumb  gets  quite  tired  the 
other  is  to  be  rapidly  suiistituted  for  it  and  supported  in  the  same  way. 

Esmarch''i<  Bandage. — The  tourniquet  does  not  render  the  parts  blood- 
less ;  in  fact,  it  causes  A'enous  congestion  ;  but  conqjlete  absence  of  blood 
in  the  parts  divided  maj^  be  secured  by  the  application  of  an  elastic  ban- 
dage as  recommended  by  Prof.  Esmarch.^  A  bandage  consisting  of 
stout  india-rubber  tissue  is  rolled  round  the  limb  exactly  as  a  spiral  roller 

1  Esmarch's  method  of  rendering  a  limb  bloodless  by  the  constant  pressure  of  an 
elastic  bandage  is  altogether  different  from  the  long-known  method  of  applying  a 
common  bandage  before  putting  on  a  tourniquet,  which  was  so  far  from  rendering 
the  parts  bloodless  that  it  was  found  hardly  worth  the  trouble  of  ajjplication,  and  fell 
out  of  use. 


910  OPERATIVE    SURGERY. 

is.  No  great  force  need  be  employed,  but  the  constant  resilience  of  the 
elastic  tissue  will  squeeze  the  blood  out.  In  order  to  hinder  its  return  a 
stout  piece  of  elastic  tubing  is  i)assed  twice  round  the  limb  just  below  the 
upi^er  edge  of  the  bandage  and  secured  by  hooks.  Then  the  bandage  is 
unwound  from  the  limb,  which  is  seen  to  be  perfectly  pale  and  bloodless, 
and,  when  out  into,  its  tissues  are  as  free  from  blood  as  in  the  dead  sub- 
ject. Even  the  bones  are  sometimes  entirely  empty  of  blood.  The  bene- 
fits of  this  metliod  are  great  during  any  operation  in  which  the  oozing 
from  the  parts  is  annoying,  i.e.,  all  dissecting  oi)erations;  and  the}^  are 
also  striking  in  excisions,  since  the  precise  limits  of  the  disease  can  be 
seen  as  well  as  in  tlie  post-mortem  room.  In  cases  also  of  traumatic 
aneurism,  of  wound  of  tlie  artery,  and  of  the  old  operation  for  aneurism, 
the  method  seems  applicable.  I  am  not  sure  that  blood  is  really  saved 
by  it,  for  in  many  cases  the  very  free  oozing  whicli  takes  place  as  soon 
as  the  circular  tube  is  removed  pretty  nearly  balances  what  would  have 
escaped  if  the  operation  liad  been  performed  in  the  usual  wa3^  I  have 
not  seen  an3-  prevalence  of  sloughing  after  operations  so  performed,  nor 
have  I  realized  the  dangers  of  pressing  the  products  of  suppuration  up 
the  veins,  or  producing  internal  congestion  by  squeezing  the  blood  back; 
in  fact,  I  l)elieve  them  to  be  imaginary,  but  further  experience  is  necessary 
to  show  us  what  is  the  real  value  of  the  metliod.  The  attempts  to  show  that 
the  mortality  after  operations  so  performed  is  lessened  by  the  method 
are  quite  premature.  After  tlie  constricting  band  is  removed  a  few  min- 
utes should  be  allowed  for  the  bleeding  to  subside  under  the  use  of  cold 
water  after  all  the  main  vessels  liave  been  tied,  and  with  this  precaution 
I  have  not  met  with  any  secondary  or  recurrent  haemorrhage. 

We  have  now  to  treat  of  the  strictly  manipulative  part  of  operative 
surgery.  All  the  surgical  operations,  however,  whicli  are  employed  only 
in  special  parts  of  the  body  have  been  spoken  of  above  in  their  appro- 
priate places,  as  lithotomy  with  diseases  of  the  urinary  organs,  trache- 
otomy with  those  of  the  larynx,  etc.  It  remains  to  speak  of  plastic  sur- 
gery, amputations,  and  excisions. 

PLASTIC   SURGERY. 

The  operations  of.  plastic  surgery  are  directed  to  filling  up  the  gaps 
left  by  destruction  of  the  nose,  by  the  incisions  made  in  dividing  or  ex- 
cising cicatrices,  and  in  refreshing  the  edges  of  unnatui'al  clefts.  Some 
of  tiiese  operations,  especially  tiiose  of  the  latter  class,  have  been  spoken 
of  in  previous  pages.  Such  are  the  operations  of  harelip,  fissured  palate, 
and  ruptured  perineum.  Tiie  prin(!iple  of  this  class  of  plastic  operations 
is  to  lu'ing  the  edges  of  the  cleft  into  ai)position  by  means  of  some  form 
of  suture  and  obviate  tension,  if  necessary,  by  incisions.  Incisions, 
however,  are  not  always  necessary.  Thus,  in  harelip,  no  incisions  are, 
as  a  general  rule,  required.  If  any  are  so  they  are  made  along  the  border 
of  the  nose.  In  fissure  of  the  soft,  palate  the  oliject  of  the  incisions  is 
chiefly  to  divide  the  muscles,  while  in  that  of  the  hard  palate  free  lateral 
incisions  are  made  through  the  muco-pcriosteal  structures.  In  ruptured 
perineum  and  in  recto-vnginal  fistula  incisions  are  usually  superfluous, 
but  sometimes  the  sphincter  may  require  division.  In  vesico-vaginal  fis- 
tula it  is  generally  impossible  to  place  incisions  so  as  to  give  any  assist- 
ance to  the  sutures,  l)ut  occasionally  such  incisions  may  be  made  through 
cicatrices  in  the  wall  of  the  vagina. 

TranaijlankUion  of  Hkiv. — The  operations  for  restoring  the  nose  and 


RHINOPLASTY.  911 

for  contracted  cicatrix  involve  tlie  process  of  transplantation  of  skin,' 
which  is  rarely  required  in  the  oi)erations  for  the  closure  of  listulii'.  Up 
to  the  present  time  I  think  it  may  he  said  with  truth  that  nothing  except 
the  skin  has  been  successfully  transplanted  ;  but  attempts  are  being 
made  to  transplant  periosteum  which  may  form  the  nidus  of  bone  (osteo- 
plasty), and  if  such  attempts  succeed  they  might  much  extend  the  prac- 
tice of  plastic  surgery,  and  especially  in  the  operation  of  nose-making. 

Two  ways  of  transplanting  skin  are  recognized,  viz.,  b_y  displacement 
or  gliding,  and  by  torsion.  In  tlie  former  tiie  piece  of  skin  is  dissected 
up,  left  attaciied  to  the  surrounding  parts  by  a  broad  isthmus,  and  then 
its  direction  is  so  shifted  that  it  can  be  fitted  into  the  part  where  it  is 
intended  to  lie.  The  neck,  or  isthmus,  remains  permanently,  and  tlie 
puckering  or  twisting  caused  by  tlie  displacement  gradually  disai>pears. 
In  the  method  by  torsion,  the  position  of  the  flap  of  skin  is  entirely 
changed  (for  instance,  it  is  brought  down  from  the  forehead  to  the  nose) 
and  for  this  purjjose  it  is  left  attaciied  by  a  neck  as  slender  as  is  consist- 
ent with  the  maintenance  of  vitality,  which  neck  is  twisted  so  as  to  per- 
mit of  an  entire  change  of  position.  Then  the  edges  of  the  skin  are 
stitched  to  those  of  the  cleft,  and  after  a  sufficient  time,  when  the  trans- 
planted skin  has  fully  received  tlie  elements  of  vitality  from  the  neigh- 
boring parts  into  which  it  was  transplanted,  the  neck  is  divideii  and  tliat 
part  also  of  the  transplanted  flap  inserted  into  the  edge  of  the  cleft,  so 
that  now  the  flap  is  permanently  fixed  in  its  novel  position.  Such  trans- 
plantation can  be  effected  from  one  part  of  the  body  to  another,  as  from 
the  arm  to  the  nose,  or  from  tlie  thigh  to  the  hand,  the  parts  being  kept 
in  a[)position  by  some  mechanism  until  the  transplanted  flap  has  grown 
into  the  cleft.  It  can  even  be  effected  from  the  body  of  one  person  into 
that  of  another,  an  o})eration  of  which  we  have  heard  a  good  deal  in 
prose  and  verse,  but  which  is  not  a  part  of  practical  surgery  in  the  pres- 
ent day. 

lihhiopla^ty. — The  operation  of  restoring  a  nose  which  1ms  been  cut 
off,  or  lost  by  lupus  or  syphilis,  is  one  which  is  little  in  favor  with  most 
surgeons  of  the  present  day,  since  it  is  found  that  the  new  nose,  being 
formed  only  of  skin,  generally  either  withers  away  or  remains  flat  on  the 
face,  and  in  either  case  the  patient's  appearance  is  not  improved.  Be- 
sides, in  the  usual  method  of  operating,  the  flap  being  taken  from  the 
forehead,  another  scar  is  added  to  the  previous  deformity. 

Tlie  common  plan,  or  the  Indian  operation,  is  to  take  a  piece  of  paper, 
gutta-i)ercha,  or  leather,  and  adapt  it  to  the  stump  of  the  nose  so  as  to 
form  as  shapely  a  feature  as  may  be  ;  then  lay  this  pattern  on  the  fore- 
head, and  cut  a  flap  of  skin  accordingly,  leaving  it  attached  b}^  as  broad 
a  neck  as  possible  to  the  bridge  of  the  nose.  In  cutting  this  or  any  other 
flap,  allowance  must  be  made  for  the  shrinking  of  the  skin^  so  tliat  the 
flai)  must  always  exceed  the  pattern  a  little  in  all  directions.  A  little 
tongue  is  left  on  the  middle  of  what  was  the  upper  border  of  the  flap,  and 
which  when  it  is  twisted  becomes  the  lower,  in  order  to  form  the  colu- 
mella. The  edges  of  the  cleft  should  be  refreshed  before  cutting  the  flap, 
and  the  latter  brought  down  and  attached  as  rapidly  as  possilile  in  its 
new  position  by  several  points  of  silver  suture.     The  new  nose  must  be 

^  Tlicse  flaps  are  always  spoken  of  as  being  formed  of  skin,  but  in  trutii  as  much 
as  pos.-ible  of  the  subcutaneous  tissue  also  should  always  bo  taken  up  along  with  the 
skin.  The  more  fat  and  vessels  can  be  raised  with  the  skin,  the  less  risk  is  there  that 
the  skin  will  slough. 


912  OPERATIVE    SURGERY. 

supported  in  position  by  a  i^lug,  or  two  plugs,  of  suitable  size  and  shape, 
and  of  some  non-absorbing  material,  and  sui)ported  on  the  plug  by  a  pad 
and  bandage  loosely  applied.  When  the  union  of  the  edges  is  complete 
and  the  transplanted  flap  perfectly  warm  and  full,  the  neck  may  be  di- 
vided, the  rest  of  the  cleft  over  the  bridge  of  the  nose  pared,  and  the  raw 
surface  left  by  the  division  of  the  neck  implanted  there.  The  plug  must 
be  changed  from  time  to  tiuie,  but  great  care  is  required  in  doing  this, 
and  it  slionld  be  put  otf  as  long  as  possible  after  the  operation  in  order 
to  leave  the  parts  quiet  till  the  edges  have  united  firmly. 

Tlie  same  operation  is  also  still,  I  believe,  sometimes  done  after  the 
method  of  Tagliacotius  by  transplanting  the  flap  from  the  patient's  arm. 
An  apparatus  must  first  be  manufactured  which  will  keep  the  arm  in  com- 
fortable apposition  with  the  face  ;  and  then  the  flap  is  to  be  marked  out 
and  raised,  much  as  in  the  Indian  operation  ;  but  here  the  surgeon  has 
the  advantage  that  he  can  take  a  neck  of  any  size  that  he  wishes,  so  that 
possibly  the'flap  is  less  liable  to  slough.  The  restrained  positio.u,  how- 
ever, is"^  a  great  inconvenience,  and  necessitates  the  section  of  the  neck 
as  early  as  possible. 

Rhinoplasty  is  very  liable  to  failure  from  sloughing  of  the  flap,  from 
want  of  union  of  the  edge  (especially  when  the  tissues  are  cicatricial  from 
old  lupus),  from  erysipelas,  and  from  secondary  haemorrhage.  It  is,  tliere- 
fore,  not  an  operation  which  the  surgeon  should  recommend.^  Mr.  Skey, 
who  had  much  experience  in  it,  says,  "Let  it  be  the  patient  who  urges 
the  operation."  And  in  the  present  day,  when  so  many  new  materials 
are  in  use  for  masks,  it  will  be  found  that  a  person  who  can  command  the 
necessary  assistance  will  derive  much  more  advantage  from  the  services 
of  the  mechanician  than  the  surgeon.  I  once  met  with  a  patient  who 
managed  to  make  for  herself  a  far  better  nose,  in  some  way  which  she 
would  not  explain,  than  any  which  rhinoplasty  could  have  provided. 

Contracted  Cicatrix. — The  contraction  of  scars,  especially  those  of 
burns,  frequently  leads  to  terrible  distortion,  particularly  in  the  neck  and 
at  the  flexures  of  the  joints,  as  the  axilla  and  the  fingers.  As  I  have  said 
above  (p.  135)  much  of  this  could  be  avoided  by  careful  extension  during 
the  healing  process,  and  by  promoting  rapid  union  ;  but  in  many  cases, 
especially  in  children,  some  amount  of  contraction  is  often  inevitable. 

It  is  very  diflicult  to  oi)ta'in  ]iermanently  satisfactory  results  by  oj^era- 
tion  in  these  cases.  Consequently  every  attempt  should  be  made  to 
stretch  the  cicatrix  by  mechanical  means  before  any  plastic  proceeding 
is  undertaken.  Wlieii,  however,  this  becomes  necessary,  several  dilferent 
measures  present  themselves  for  selection.  The  simplest  is  merely  to 
divide  the  cicatrix,  put  the  parts  forcibly  on  the  stretch,  and  let  the  gap 
fill  up  by  granulation,  keeping  the  apparatus  constantly  applied  till  the 
scar  is  completed,  whicli  may  be  hastened  by  skin-grafting.  I  have  seen 
this  method  succeed  in  deformity  from  scarring  in  the  limbs,  but  in  the 
neck  I  believe  it  always  fails.  The  gap  left  by  the  division  of  the  cicatrix 
may  be  filled  at  once  by  a  flap  cut  from  the  thorax  or  from  the  back  of 

1  Some  novel  attempts  have  recently  been  made  to  obviate  the  many  causes  of 
faiUiro  in  rhinoplasty  and  otlier  operations  by  trnn>pl!intalion.  Tlius  Dr.  Hardie,  of 
MsinehestiT,  has  transplanted  tlie  distal  phalanx  of  one  of  the  fingers  into  the  nose  in 
order  to  provide  a  bony  l)ase  for  the  transplanted  flaps  (lirit.  Med.  Journal,  Sept  25, 
1875)  and  Dr.  Wolf,  of  Glasgow,  has  even  gone  so  far  as  to  assert  tliat  no  vascular 
connection  with  its  original  neighburhdod  is  necessary  for  the  transplanted  fhip,  but 
that  the  skin  nniv  he  simjiiyeut  fnim  the  arm  or  other  part  and  inserted  into  the  face, 
and  will  adhere  and  grow  there  (ibid.,  Sept.  18,  1876), 


WEBBED    FINGERS    AND    TOES.  913 

the  neck  and  made  to  glide  on  its  base,  so  as  to  be  attached  to  the  edges 
of  the  divided  scar,  or  rather  to  the  line  of  division  which  is  carried  be- 
tween the  scar  and  the  integument  supposed  to  be  healthy.'  But  the 
olijection  to  this  plan  is  that  the  edges  of  the  cleft  left  by  such  divisions 
are  always  more  or  less  cicatricial  and  the  base  of  the  cleft  is  also  unnat- 
ural in  structure,  so  that  union  cannot  take  place  rapidly.  Now,  it  is  on 
the  occurrence  of  rapid  union  that  all  prospect  of  success  in  plastic  pro- 
ceedings depends,  A  somewhat  more  satisfactory  result  may  be  hoped 
for  if  all  the  cicatrix  can  be  extirpated,  but  this  is  usually  impracticable 
in  the  neck.  The  result  of  such  operations,  as  far  as  I  have  seen  (and  1 
have  performed  and  seen  man}'  such),  has  been  that  even  in  those  which 
seemed  most  successful  at  first,  where  almost  the  whole  flap  united  kindly 
and  the  deformit}'  was  at  first  greatly  lessened,  some  part  remained  long 
unhealed,  and  at  this  point  a  band  of  cicatrix  ultimately  formed  which 
subsequently,  in  spite  of  the  best  efforts  of  the  surgeon,  contracted 
slowly  and  to  a  great  extent  reproduced  the  deformity. 

Cheiloplody. — Again,  the  deformity  of  the  lip  is  a  very  difficult  feature 
in  contractions  of  the  neck.  The  lower  lip  gets  drawn  down,  presenting 
its  mucous  surface  externally,  and  causing  great  distress  from  dribbling 
of  saliva  as  well  as  distorting  the  other  features.  This  is  l)est  dealt  with 
by  freeing  the  reversed  lip  from  the  jawbone  as  well  as  possible  with  the 
knife,  refreshing  its  upper  edge,  and  drawing  over  it  two  pieces  taken 
from  the  cheek  and  corners  of  the  mouth.  These  pieces  are  cut  by  a  line 
sloping  away  on  either  side  from  the  centre  of  the  lower  lip  to  the  base 
of  the  jaw,  and  continued  along  that  bone  as  far  as  may  be  necessary, 
but  so  as  not  to  wound  the  facial  arter3^  These  two  pieces  are  movable 
enough  to  unite  with  each  other  in  the  middle  line,  while  their  bases  are 
sewn  into  the  refreshed  edge  of  the  lower  lip.  Similar  operations  may 
also  be  performed  in  cases  where  the  upper  or  lower  lip  has  been  destroyed 
by  cancer  or  injurj'. 

Webbed  Fingers  and  Toes. — A  somewhat  rare  deformity  is  that  in 
which  the  fingers  are  united  by  a  fold  of  skin  either  in  their  whole  extent 
or  for  some  distance  in  front  of  the  natural  cleft.  The  same  deformity 
is  found  in  the  toes,  but  is  of  no  consequence  there.  In  the  hand,  hovv- 
ever,  it  so  materially  limits  the  movements  that  it  is  of  great  importance 
to  remedy  it  if  possible,  but  it  is  very  difficult.  The  difficulty  consists 
in  the  great  tendency  to  cicatrization  commencing  at  the  posterior  angle 
of  the  wound,  in  the  situation  of  the  natural  cleft.  If  this  does  commence, 
it  will  surely  though  gradually  extend  forwards  till  the  web  is  reproduced 
and  tighter  than  before,  because  cicatricial.  Of  a  great  number  of  methods 
which  have  been  employed  in  the  treatment  of  webbed  fingers,  I  will  only 
mention  two.  One  is  to  procure  a  permanent  opening  in  the  situation  of 
the  natural  cleft  b}'  the  insertion  of  a  ring — much  as  the  hole  in  a  lady's 
ear  is  kept  open — and  when  this  opening  is  completely  and  permanently 
established  to  enlarge  it  by  the  insertion  of  tents  or  wedges  increasing 
in  size.  A  large  separation  being  thus  made  at  the  cleft,  the  web  in  front 
can  be  divided  gradually  by  elastic  pressure ;  or  else,  after  the  hole  has 
been  established,  the  web  in  front  is  divided  close  to  one  of  the  fingers, 
and  the  two  flaps  thus  obtained  are  united  together  to  cover  the  other 
finger,  for  which  they  are  amply  sufficient.  Then  a  covering  is  obtained 
for  the  denuded  finger  out  of  some  distant  part  of  the  body — say  the  outer 
side  of  the  thigh.     A  flap  is  dissected  up  and  left  attached  b^^  both  its 

'  Mr.  Butcher  has  shown  how  much  assistance  may  sometimes  be  afforded  in  these 
cases  by  subcutaneous  division  of  the  cicatricial  bands  around  the  chief  scar. 

58 


914  OPERATIVE    SURGERY. 

ends,  and  the  finger  is  thrust  in  below  it — much  as  the  hand  is  thrust 
into  the  pocket — and  tlie  edges  of  the  flap  united  to  those  of  the  cleft. 
When  union  has  taken  place,  the  ends  are  divided,  the  hand  released,  and 
the  cut  ends  implanted. 

AMPUTATIONS. 

The  chief  indications  in  amputation  are — 1.  To  remove  the  whole  of 
the  parts  whicli  are  diseased  or  injured  beyond  the  prospect  of  recovery. 
2.  To  avoid  all  unnecessary  loss  of  blood.  3.  To  cut  flaps  of  proper  shape 
and  long  enougli  to  cover  the  bones  without  any  tension.  It  might,  per- 
haps, be  added  that  the  main  nerves  ought  never  to  be  left  so  long  as  to 
be  exposed  to  pressure  by  the  ends  of  the  bones. 

The  (;hief  methods  of  amputation  are  as  follows  : 

The  circular,  in  which  a  cut  is  made  all  round  the  limb  through  the 
skin  and  fat,  which  are  thrown  back  from  the  muscles  something  like  the 
cutf  of  a  sleeve,'  then  the  muscles  are  divided  by  one  or  more  circular 
sweeps  down  to  the  bone,  then  all  the  soft  parts  are  retracted  from  the 
bone  or  bones,  and  the  latter  are  sawn  about  an  inch  above  the  part  first 
exposed  by  the  division  of  the  muscles. 

Retractors  are  sometimes  wanted  in  all  amputations,  but  more  gener- 
ality in  the  circular.  They  should  never  be  required  if  the  parts  are  health}'^, 
but  may  be  indispensable  when  they  are  stiff"  from  oedema  or  inflamma- 
tion. For  the  tiiigh  or  arm  the}'  are  usually  made  of  two  plates  of  metal, 
each  having  a  handle  at  each  end  and  a  semicircular  notch  in  the  upper 
edge.  One  of  these  is  placed  above  the  bone,  the  other  below.  The  two 
notches  form  a  hole  through  which  the  bone  passes,  and  the  soft  parts  are 
then  pulled  forcibly  upwards,  the  saw  being  applied  just  below  the  re- 
tractors. A  split  piece  of  stout  cloth  will  answer  the  same  purpose.  When 
there  are  two  bones,  a  tongue  must  be  torn  in  the  cloth  and  passed  between 
the  bones,  the  ends  are  then  crossed  and  the  cloth  drawn  upwards. 

Flap  amputations  are  now  more  in  use  than  circular.  Tiie  flaps  are  cut 
in  two  ways,  b}'  transfixion  and  by  incision.  In  the  former  plan,  when 
the  flaps  are  made  as  is  usual  in  front  and  behind  the  limb  (antero-pos- 
terior  flaps),  tlie  knife  is  passed  as  near  as  possible  in  front  of  the  bone, 
or  bones,  just  lielow  the  place  where  the  saw  is  to  be  applied.  Then  the 
knife  is  carried  downwards  and  outwards,  cutting  as  long  an  anterior 
flap  as  necessary  ;  the  same  thing  is  done  behind,  the  flaps  are  dr^iwn  up, 
the  bones  cleaned  a  little  higher  up,  and  the  saw  applied.  The  same 
operation  is  sometimes  done  on  either  side  of  the  bone  (lateral  flaps), 
chiefl}^  in  the  upper  arm.  In  this  way  the  flaps  must  be  formed  of  all  the 
tissues  of  the  limb ;  but  if  the  operator  wishes  to  take  skin  only,  or  in 
varying  proportion  to  the  muscles,  he  must  make  his  flaps  l)y  incision, 
carrying  the  knife  along  any  lines  which  he  may  find  suitable,  and  then 
raising  the  parts  from  without  inwards,  and  taking  care  to  take  an  ample 
allowance  of  fat  and  other  subcutaneous  tissues  along  with  the  skin.  The 
flaps  formed  by  transfixion  must  be  oval,  those  formed  by  incision  may 
be  of  any  shape.  Tliey  may  also  lie  formed  entirely  of  skin,  the  muscles 
being  divided  straight  down  to  the  bone;  or  the\'  may  include  all  the 
tissues  of  the  limb  (as  in  Teale's  amputation),  or,  as  is  now  very  com- 
monly done,  the  flaps  of  skin  having  been  thrown  l)ack,  the  muscles  may 
be  divided  as  in  the  circular  amputation — an  operation  usually  spoken 
of  as  '•  the  modified  flap  amputation."     I  shall  endeavor  as  well  as  my 

^  This  dis-oction  is  omiltHd  by  somi;  opcM-iitor?,  who  morel}' divide  all  IIk^  parts  down 
to  tho  bone  by  successive  circular  cuts,  while  an  assistant  retracts  the  parts  as  they 
are  divided. 


AMPUTATION    AT    THE    SHOULDER-JOINT.  915 

space  allows  to  illustrate  each  of  these  methods  of  oporatinp:  in  speaking 
of  the  amputations  of  different  members,  in  doing  which  I  shall  describe 
tlie  method  whicli  seems  best  adapted  to  each,  though  in  all  of  them  it  is 
quite  feasible,  naj^  is  necessary  sometimes,  to  adopt  a  method  the  farthest 
possible  from  the  one  here  recommended.  J'or  instance,  in  amputating 
at  the  hip  or  shoulder  the  flap  amputation  by  transfixion  is  the  best;  but 
it  is  often  necessary  to  cut  tlie  flaps  by  incision,  and  even  the  circular 
amputation  may  be  performed. 

Instruments  for  Amputation. — The  instruments  required  for  amputa- 
tion are  ver}'  simple.  In  the  present  day  many  amputations  are  per- 
formed with  a  simple  scalpel  rather  larger  than  a  dissecting  knife,  but 
generally  an  amputating  knife  is  employed.  This  should  have  a  sharp 
point  and  a  fine  narrow  blade,'  and  its  length  should  be  proportioned  to 
the  size  of  the  limb.  The  shorter  it  is  the  easier  is  it  to  manage,  but  for 
transfixion  operations  its  length  must  considerably  exceed  the  tliickness 
of  the  limb.  For  cleaning  the  bones  when  there  are  two  a  small  double- 
edged  catlin  is  convenient.  The  back  of  this  is  pressed  against  the 
farther  bone,  dividing  all  the  soft  tissues  and  periosteum,  then  the  point 
is  thrust  between  the  bones  until  their  periosteum  is  also  completely 
divided  where  their  surfaces  are  opposed,  then  the  point  is  disengaged 
by  pressing  the  front  of  the  blade  on  the  nearer  bone,  and  so  its  edge  is 
drawn  up  the  nearer  bone  till  it  comes  to  the  point  from  which  it  started. 
A  peculiar  manipulation  (called  the  figure  of  8)  is  sometimes  taught  for 
doing  this,  but  it  requires  really  no  special  instruction.  The  amputating 
saw,  a  stout  strong-backed  saw,  should  be  in  readiness,  and  a  pair  of 
sharp  bone-forceps  to  cut  off"  an}'  splinter  that  may  be  left  projecting,  and 
if  the  bone  is  fractured  the  lion-forceps  to  hold  it  while  it  is  sawed  smooth 
above.  A  common  scalpel,  tenacula,  ligatures,  and  the  contents  of  the 
pocket  case  complete  the  armamentarium. 

Dressing  the  Stumjy. — After  amputation  the  wound  is  to  be  dressed  as 
prescribed  in  Chapter  I,  a  piece  of  drainage-tube  being  passed  through 
the  deep  part  of  the  stump  in  order  to  drain  off  the  abundant  sero-san- 
guineous  discharge  which  usuall}'  collects  in  the  cavity  if  it  is  tightly 
sewn  up,  and  gives  rise  to  suppuration.  If  the  stump  is  long  enough  the 
patient  will  derive  much  comfort  from  its  being  placed  on  a  splint  and 
lightly  bandaged,  and  the  splint  may  be  slung  if  recpiired.  When  the 
flaps  are  necessarily  left  somewhat  deficient  in  length,  or  when  they  re- 
tract afterwards  so  as  to  threaten  to  leave  a  conical  stump,  much  benefit 
may  be  obtained  b}'  careful  bandaging,  the  parts  being  kept  well  drawn 
forward  while  the  bandage  is  being  applied  ;  and  still  more  advantage  is 
derived  from  the  application  of  continuous  traction  by  means  of  a  weight 
acting  on  a  stirrup  of  strapping,  which  has  been  secured  to  the  stump 
by  one  or  two  circular  strips,  a  few  inches  above  the  incision. 

Amputation  at  the  shoulder-joint  is  best  performed  by  transfixing,  and 
cutting  the  flaps  from  within  outwards.  The  situation  of  the  joint  having 
been  already  fixed  in  the  surgeon's  mind,  he  gets  an  assistant  to  compress 
the  subclavian  artery,  while  a  second  manages  the  arm  for  him,  holding  it 
at  first  at  right  angles  to  the  patient's  body.  The  operator,  standing  be- 
hind the  patient,  enters  the  knife  just  behind  the  posterior  flap  of  tlie 
axilla,  and  brings  its  point  out  close  to  the  coracoid  process.  It  is  quite 
easy  to  open  tlie  joint  with  the  point  of  the  knife  as  it  passes  across.  Then 
a  large  flap  is  cut  out  of  the  deltoid  muscle,  which  is  retracted  by  the 
second  assistant,  who  now  brings  the  arm  down  to  the  side  and  pushes  the 

1  The  old  "  cirouhir  "  knife  with  a  round  point  is  now  very  rarely  used. 


S16 


OPERATIVE    SURGERY. 


head  of  the  bone  up  out  of  the  joint  as  the  operator  passes  the  lieel  of  the 
knife  round  it.  The  knife  having  now  quite  severed  tlie  articulation,  the 
second  assistant  again  hohts  the  arm  perpendicular  to  the  body,  while 
the  surgeon  brings  his  knife  parallel  with  the  humerus,  and  cuts  a  short 
flap  out  of  the  parts  internal  to  it  in  the  axilla.  One  of  the  assistants  or 
himself  follows  the  knife  with  the  fingers  inside  the  flap  to  catch  the 
axillar}'  artery  between  the  fingers  and  thumb  in  case  the  pressure  on  the 
subclavian  is  insufficient.  On  an  emergency  (such  as  sometimes  occurs 
in  war)  the  pressure  on  the  subclavian  may  be  dispensed  with,  and  the 
operation  can  be  and  has  been  done  without  the  aid  of  any  trained  as- 

FlG.  391. 


The  stump  of  an  amputation  at  the  shoulder-joint,  a,  the  glenoid  cavity,  the  long  tendon  of  tlie 
biceps  seen  at  its  upper  part ;  b,  the  coracoid  process  with  the  coraco-brachialis  muscle  and  short  head 
of  the  biceps;  c,  the  posterior  eiroumflex  artery  and  circumflex  nerve;  d,  the  axillary  vessels  and 
brachial  plexus.  Above  the  letter  a  is  seen  the  mass  of  the  deltoid ;  above  the  letter  c  the  triceps 
muscle.  In  the  depression  between  the  deltoid  and  glenoid  cavity  are  the  tendons  passing  to  the  great 
tuberosity.  That  of  the  subscapularis  is  in  the  depression  between  the  glenoid  cavity  and  coracoid 
process.    Above  the  coracoid  process  is  seen  the  pectoralis  major. 

sistant  at  all,  the  operator  being  aided  only  b}'  a  man  who  manages  the 
arm  for  him  and  helps  him  to  tie  the  vessels.  If  it  is  found  more  con- 
A'-enient,  the  surgeon  in  operating  on  the  right  arm  may  stand  in  front  of 
the  patient,  and  cut  the  anterior  flap  by  entering  the  point  of  the  knife 
by  the  side  of  the  coracoid  process,  and  bringing  it  out  near  the  posterior 
flap  of  the  axilla.     The  flaps  are  shown  on  Fig.  393,  1. 

There  are  many  other  ways  in  which  this  amputation  can  be  performed, 
by  cutting  flaps  from  the  skin  inwards,  by  a  modified  circular  method,  or 
bj'^  using  any  tissue  left  uninjured  to  cover  the  glenoid  cavity.  I  have 
seen  cases  in  which  the  tissues  were  so  far  torn  off  the  arm  and  scapula 
that  even  this  was  impossil)le,  yet  which  healed  well  by  granulation,  and 
left  really  little  to  desire.  Amputation  at  the  shoulder-joint  is  by  far  the 
most  successful  of  all  the  major  operations;  but  it  should  not  be  performed 
except  in  cases  of  evident  necessity,  since  any  movable  stump  which  can 
be  formed  out  of  the  arm,  however  short,  will  be  of  some  use  to  the  patient. 

Amjmtalion  of  the  Arm. — Amputation  through  the  continuity  of  the 
humerus  can  be  performed  in  any  way  that  the  operator  fancies  or  that 
the  nature  of  the  disease  or  injury  points  out  as  advisable.  One  of  the 
best  methods,  I  think,  is  the  combination  of  skin-flaps  with  a  circular  in- 
cision of  the  muscles.  The  lines  of  incision  are  shown  on  Fig.  393,  2. 
The  tourniquet  may  be  put  on  near  the  axilla,  or  Esmarch's  bandage,  or 
the  axillary  artery  held  by  an  assistant.  The  operation  is  now  compara- 
tively rarei}'  performed,  being   reserved  mainly  for  cases  of  complicated 


AMPUTATION    OF    THE    ARM. 


917 


injur}'  in  which  it  is  impossibe  to  preserve  the  limb,  creases  of  malignant 
disease.  In  the  former  case  very  few  vessels  will  require  ligature,  proba- 
bly the  brachial  and  superior  profunda  will  be  the  only  ones  (Fig.  394). 
In  cases  of  rapidly  growing  tumor,  of  course  the  smaller  arteries  will  have 
become  enlarged,  and  must  be  tied. 


Fig.  392. 


Fig.  393. 


10 


Fig.  392. — The  front  of  the  arm,  showing  the  lines  of  incision  for  various  operations.  1.  One  of  the 
various  incisions  in  use  for  the  ligature  of  the  axillary  artery.  2.  The  incision  for  tying  the  brachial 
artery  in  the  middle  of  the  arm,  in  a  line  from  the  centre  of  the  bend  of  the  elbow  below  to  the  inter- 
val between  the  flaps  of  the  axilla  aliove.  3,  4.  The  lines  for  tying  the  radial  and  ulnar  arteries  high 
up.  5.  Flap  amputation  of  the  forearm.  6,  7.  Lines  for  tying  the  radial  and  ulnar  arteries  low  down. 
8.  Anterior  flap  for  amputation  at  the  wrist.  9.  Amputation  of  the  thumb  and  metacarpal  bone.  10. 
Amputation  of  a  finger  at  the  knuckle,  the  head  of  the  metacarpal  bone  being  removed. 

Fig.  393.— The  back  of  the  arm,  showing  the  flaps  for  various  amputations.  1.  Amputation  at  the 
shoulder-joint,  by  an  external  flap  cut  from  the  deltoid,  and  a  shorter  internal  flap  from  the  axilla. 
2.  Amputation  of  the  upper  arm  by  a  shorter  skin-flap  from  the  front,  and  a  longer  one  from  the  back. 
The  muscles  may  be  divided  in  the  same  lines  or  circularly.  3.  Teale's  amputation  in  the  forearm,  the 
longer  flap  from  the  front,  the  shorter  (here  shown  a  little  too  long)  from  the  back  of  the  limb.  4.  Am- 
putation at  the  radiocarpal  joint. 


918 


OPERATIVE    SURGERY. 


Through  the  Elbow. — In  some  rare  cases  amputation  has  been  per- 
formed through  the  elbow-joint.  I  have  never  seen  the  operation  done, 
thougli  I  liave  seen  the  stumps  of  such  operations,  and  very  useful  and 
good  ones.  There  would  be  no  difficulty  in  fashioning  the  flaps,  but  the 
opportunity  for  i)erforming  the  operation  must  be  very  rare,  for  any  part 
of  the  forearm  which  can  be  preserved  would  be  useful,  and  if  the  whole 
forearm  is  destroyed  the  humerus  is  also  probably  injured,  and  its  end 
must  be  removed. 

Amputation  of  the  forearm  is  a  ver}'  common  operation,  and  is  per- 
formed on  account  of  laceration  of  the  hand,  or  of  caries  of  the  wrist, 
or  malignant  tumor. 

I  have  placed  on  the  diagram  (Fig.  393,  3)  a  sketch  of  the  rectangular 
or  Teale's  amputation  in  this  part  of  the  limb,  and  it  is  a  ver}'  good 
method,  for  the  chief  difficult}'  in  amputation  of  the  forearm  is  caused 
by  the  numerous  tendons  (especiall}'  near  the  wrist)  which  are  liable  to 
be  cut  irregularly,  and  so  interfere  with  a  perfect  result.  In  the  rec- 
tangular operation  these  are  divided  straight  across,  and  the  flaps  formed 
are  more  regular.  But  many  other  plans  are  in  use  ;  a  modified  flap — i.  e., 
skin-flaps  with  circular  incision  of  the  muscles — or,  on  the  other  hand,  a 
circular  sleeve  of  skin  turned  back,  and  then  short  flaps  cut  out  of  the 
muscles  by  passing  the  catlin  in  front  of  the  bones,  below  the  two  main 
arteries,  and  cutting  outwards,  and  then  making  a  similar  small  flap  be- 
hind (as  recommended  by  Mr.  Hewett),  or  the  common  circular  operation. 

Fig.  394.  Fic;..395. 


Fig.  394. — Diagram  of  a  section  of  tlic  upper  arm,  showing  the  parts  as  they  would  be  seen  in  a  circu- 
lar amputation,  a,  The  brachial  vessels,  having  the  median  nerve  in  front  of  the  artery,  and  the  ulnar 
at  some  distance  below  it;  h,  The  basiliac  vein  with  the  internal  cutaneous  nerve;  c,  The  humerus, 
lying  close  to  which  are  seen  the  inusculo-spiral  nerve  in  the  substance  of  the  triceps  muscle  and  the 
superior  profunda  vessels  along  with  it.  In  front  of  the  liumerus  is  seen  the  nuisculo-cutaneous  nerve 
lying  between  the  biceps  and  hrachialis  anticus,  and  in  the  superficial  cellular  tissue  the  cephalic  vein. 
Muscular  vessels  will  probably  require  the  ligature,  lying  in  the  substance  of  thethree  muscles. 

Fig.  39.5. — Section  of  the  forearm  about  thi;  middle.  R,  Radius,  with  the  radial  vessels  and  nerve  in 
front  of  it;  m,  Median  nerve,  which  is  sometimes  acconipanied  by  a  vessel  requiring  the  ligature;  u, 
Ulna  overlapped  by  the  fl.  prof,  digitorum  and  having  the  ulnar  vessels  and  nerve  in  front  of  it.  The 
interosseous  membrane  is  seen  between  the  bones,  and,  lying  on  it,  the  anterior  interosseous  vessels. 
The  posterior  interosseous  vessels  are  seen  between  the  deep  and  superficial  layers  of  muscles  at  the 
back. 


AMPUTATION    OF    THE    FINGERS. 


919 


will  all  give  wood  results  when  carefully  executed.  If  any  tendons  project 
irregularly  they  must  be  trimmed  off  before  the  flaps  are  adjusted.  The 
position  of  tlie  vessels  can  be  seen  from  the  annexed  diagram  (Fig.  395). 

Amputation  at  the  W7'ist. — In  some  rare  cases  the  whole  hand  is  re- 
moved at  tiie  wrist.  This  is  best  done,  I  think,  by  cutting  two  tolerably 
equal  semicircular  flaps  back  and  front  from  the  skin  inwards.  (Figs. 
392,  8  ;  and  393,  4.)  If  the  pisiform  or  unciform  process  is  incon- 
veniently prominent  it  may  be  cut  off. 

Amputation  of  the  Fingei-x. — The  fingers  are  constantly  amputated  at 
any  of  their  three  joints,  sometimes  through  the  continuity  of  one  of  the 
phalanges,  and  more  frequently  through  the  metacarpal  bone,  the  head  of 
which  is  removed  along 
with  the  finger.  The 
two  terminal  phalanges 
are  best  amputated  by 
cutting  pretty  straight 
into  the  articulation  on 
its  dorsal  aspect,  cor- 
responding to  the  cen- 
tral fold  of  the  skin  on 
this  side  of  the  joint, 
and  then  passing  the 
knife  through  the  joint 
and  shaping  a  long  flap 
out  of  the  tissues  on  the 
palmar  surface.  In  am- 
putating at  the  knuckle 
it  is  important  in  a  labor- 
ing man  to  preserve  the 
head  of  the  metacarpal 
bone.  Those  who  study 
appearances  sometimes 
recommend  its  removal 
in  persons  who  are  not 
called  upon  for  manual 
labor  ;  but  this  weakens 
the  hand  so  much  by 
the  section  of  the  trans- 
verse ligament  and  other 
structures,  that  it  seems 
to  me  better  always  to 
preserve  the  iiead  of  the 
bone  if  possible,  though 
the  gap  between  the  two 
fingers  is  no  doubt  an 
ugly  deformity.     In  the 

T?  '       ,.                 "^        ,  Showing  the  incisions  for  various  operations,  viz. :  1.  The  incision 

UlSSeCting-rOOm  tlie  am-  ^^^  ty\u^  the  carotid  artery,  at  the  edge  of  the  sternomastoid  mus- 

putatlOn    (rig.    392,    10)  cle,  in  a  line  from  the  sternoclavicular  joint  to  the  point  between 

may      be      accomplished  *''^  angle  of  the  jaw  and  mastoid  process.    2.  That  for  tying  the 

with    a    sinole    sween   of  subclavian,  lying  just  above  the  clavicle,  in  the  space  between  the 

,  1  T  '^  rpi  1  'e  trapezius  and  sternoinastoid.  3.  The  incisions  for  the  removal  of 
LUe  Kniie.  lUe  Kniie  the  breast.  4.  The  incision  for  ovariotomy,  which  is  sometimes  ex- 
should  be  long,  thin,  but  tended  up  to  the  ensiform  cartilage.  The  dot  in  the  centre  of  this 
stout.  The  fino"er  to  be  i'^clsion  indicates  the  place  for  paracentesis.  5.  The  incision  for  the 
removed  fsaV  the  mid-  •'g'^*-'"''^"*'*'^^'^''''''"'^*^"''^-  in  tying  the  lower  part  of  the  externsl 
.  .  ^  *^ -^  iliac,  only  the  lower  part  of  this  incision,  lying  somewhat  parallel 
die)  IS  seized  and  drawn  to  Poupart's  ligament,  is  required. 


920  OPERATIVE    SURGERY. 

to  the  ulnar  sidts,  the  heel  of  the  knife  is  laid  on  its  radial  side,  at  the  an- 
terior end  of  the  incision,  and  carried  on  with  a  sawing  motion  backwards 
till  it  arrives  at  the  position  of  the  joint.  It  is  now  turned  transversely 
through  the  joint,  and  then  forwards  to  cut  out  the  flap  on  the  ulnar 
side.  The  various  exigencies  of  injur}-  and  disease  often  render  this 
operation  impracticable  on  the  living  subject,  and  tlie  flaps  must  be 
shaped  as  the  operator  best  can,  but  inclining  to  this  model.  If  the  head 
of  the  metacarpal  bone  is  to  l)e  removed,  the  incision  must  be  prolonged 
sufficiently  l)ackwards  to  allow  of  the  bone  being  cleaned  and  the  cutting 
forceps  applied. 

Amputalion  of  the  Thumb. — The  thumb  is  very  rarely  amputated,  since 
its  preservation,  or  that  of  any  part  of  it,  is  so  useful  as  a,  j^oint  d''appui 
to  the  fingers,  even  if  it  is  itself  immovable,  that  surgeons  generally  leave 
cases  of  injur_y  of  the  thumb  to  nature  ;  and  in  cases  of  diseased  joints  or 
phalanges  the  expectant  treatment  is  still  more  plainly  imperative.  The 
thumb  may  be  amputated  at  its  joint  with  the  trapezium  l)one  by  carry- 
ing an  incision  forward  on  the  dorsal  aspect  of  the  metacarpal  bone  from 
the  position  of  the  joint,  then  making  it  include  the  metacarpo-phalangeal 
joint  in  an  oval  manner,  as  shown  in  Fig.  392,  9,  and  so  returning  to  the 
point  from  which  it  started.  Thus  an  ample  covering  is  secured  for  the 
flap,  and  no  incision  made  in  the  palm.  The  thumb  being  freely  divided 
from  tlie  fold  uniting  it  to  the  forefinger,  is  lifted  up,  the  knife  passed 
below  its  metacarpal  bone,  separating  it  from  the  palmar  muscles,  and 
then  by  dividing  the  ligaments  which  unite  it  to  the  trapezium  the  whole 
member  is  removed ;  or  palmar  or  dorsal  flaps  maj^  be  formed  by  passing 
a  long  bistoury  in  front  of  the  thumb  from  near  the  situation  of  the  joint 
to  the  fold  between  the  thumb  and  forefinger,  and  then  cutting  out  a  large 
flap  from  the  mass  of  muscles  of  the  thumb.  The  joint  which  is  now  ex- 
posed is  divided,  and  a  smaller  flap  made  from  the  dorsum.  The  radial 
artery  is  sometimes  divided  in  the  operation,  though  by  carefully  keeping 
the  knife  close  to  the  bone  as  the  operator  passes  through  the  joint  this 
may  be  avoided. 

Amjnitation  at  the  HijyJoint. — The  operation  at  the  hip-joint  is  the 
most  formidable  of  all  the  amputations.  In  performing  it  it  is  often  essen- 
tial to  get  the  operation  over  as  rapidly  as  possible,  and  this  is  the  case 
especially  when  a  tourniquet  cannot  be  applied.  The  surgeon  will  require 
at  least  four  assistants:  one  to  administer  the  anaesthetic;  a  second  to 
attend  to  the  tourniquet,  and  if  needful,  compress  the  artery  in  the  groin  ; 
a  third  to  support  the  limb,  and  a  fourth  to  manipulate  it  so  as  to  facili- 
tate the  movements  of  the  knife.  The  tourniquet  which  is  in  use  in  this 
amputation  is  one  invented  by  Professor  Lister,  and  generall}'^  called  after 
his  name ;  but  he  has  pointed  out  that  Professor  Pancoast,  of  Philadel- 
phia, had  previously  designed  a  similar  instrument.^  It  is  a  large  horse- 
shoe tourniquet,  resting  by  a  broad  base  on  the  loins  and  somewhat 
steadied  by  a  strap  which  passes  from  its  expanded  end  to  its  arm.  The 
end  of  the  arm  carries  a  screw  and  pad.  The  pad  is  applied  over  the 
aorta,  just  above  the  umbilicus,  and  by  screwing  it  home  (if  the  tourni- 
quet is  of  the  proper  size)  the  pulse  in  both  groins  can  be  arrested,  which 
shows  that  the  aorta  is  commanded.  This  sometimes  produces  such 
dyspnfi'a  that  it  cannot  be  tolerated  even  under  anassthesia,  in  which  case 
the  second  assistant  must  be  charged  to  suppress  the  pulse  in  the  groin 
b}'  pressure  with  one  hand,  and  to  follow  tiie  surgeon's  knife  as  it  cuts 
out  the  anterior  flap,  and  seize  the  femoral  artery.     Other  assistants  (or 

1  Syst.  of  Surg.,  2d  ed.,  vol.  v,  p.  6'i2. 


DIAGRAMS. 


921 


Fig.  397. 


Fig.  897. — Diagram  showing  the  incisions  for  various  operations  on  the  lower  extremity.  1.  Ampu- 
tation at  the  hip-joint  by  a  short  anterior  and  long  posterior  flap.  2.  Amputation  of  the  thish  by  short 
anterior  and  long  posterior  flap.  3.  Teale's  amputation  of  the  log.  4.  Syrae's  amputation  at  the  ankle. 
5.  Chopart's  amputation.  6.  Ligature  of  the  femoral  artery  in  Scarpa's  triangle.  7.  Ligature  of  the 
femoral  artery  in  Hunter's  canal.  8.  Excision  of  the  knee.'  9.  Ligature  of  the  posterior  tibial  artery. 
10.  Ligature  of  the  anterior  tibial  artery.  11.  Ligature  of  the  posterior  tibial  artery  lower  down. 
12.  Lisfranc's  amputation.     13.  Amputation  of  the  great  toe. 

Fig.  398. — Lines  of  various  amputations  in  the  lower  extremity,  as  shown  on  the  back  of  the  limb. 
1.  The  posterior  or  short  flap  in  amputation  at  the  hip.  2.  The  posterior  or  long  flap  in  amputation 
of  the  thigh,  shown  in  Fig.  397,  2.  3.  Teale's  amputation  in  the  leg,  shown  rather  diagrammatically, 
the  long  anterior  incisions  being  placed  too  far  backwards,  in  order  to  render  the  position  of  the  poste- 
rior flap  intelligible.    4.  The  incision  at  the  outer  side  of  the  lower  flap  of  Syme's  amputation. 


922 


OPERATIVE    SURGERY. 


if  there  are  onl^'  four,  tlie  fourth)  will  press  sponsjes  on  the  vessels  in  the 
posterior  flap  as  they  are  cut.  Tiie  easiest  and  quickest  way  of  amputat- 
ing at  the  liip  is  by  antero-posterior  flaps.  The  knife  is  entered  midway 
between  the  anterior  superior  si)ine  and  the  great  trociiauter,  and  its 
point  is  brought  out  in  the  middle  of  the  fold  between  the  nates  and 
perineum,  in  doing  which  the  operator,  if  lie  knows  accurately  the  posi- 
tion of  the  joint,  will  probal)ly  open  it.  While  this  is  being  done  the 
fourth  assistant,  who  has  gently  flexed  the  limb  in  order  to  facilitate  the 
opening  of  the  joint,  brings  it  quite  straiglit,  and  the  operator  cuts  out  a 
long  anterior  flap,  reaching  about  four  or  five  inches  from  the  groin  if  the 
tissues  there  are  healthy.  The  second  assistant  draws  this  flap  upwards, 
the  operator  cuts  the  joint  freely  open  with  the  point  of  his  knife,  and 
the  fourth  assistant  by  strongly  extending  the  thigh  makes  the  bone  start 
out  of  the  socket.  Then  he  flexes  and  adducts  the  limb  so  that  the  tro- 
chanter may  become  prominent,  and  the  surgeon  passes  the  heel  of  his 
knife  round  the  trochanter,  and  gets  its  ]»lade  altogether  behind  the  femur. 
As  he  does  this,  the  fourth  assistant,  following  his  movements,  brings  the 
limb  straight  again,  and  the  posterior  flap  is  cut  out.  The  third  and 
fourth  assistants  are  now  free  to  attend  to  the  vessels  and  help  the  opera- 
tor in  securing  them.  The  long  anterior  flap  has  reached  below  the  bifur- 
cation of  the  femoral,  and  the  first  care  of  the  surgeon  is  to  tie  the  femo- 
ral and  profunda  arteries  (Fig.  399  a).     When  this  has  been  done  the 

Fig.  399. 


Amputation  at  the  hip  hy  tlie  long  anterior  and  short  posterior  flap.  a.  The  femoral  and  profunda 
vessels,  with  branchi  s  of  tlie  anterior  crural  nerve,  b.  The  great  sciatic  nerve  and  its  companion  ar- 
tery. A  large  branch  of  the  sciatic  artery  is  seen  in  front,  c.  The  muscular  mass  from  the  tuber  ischii 
and  tlie  obturator  externus  muscle.  Large  branches  are  seen  on  either  side  from  the  profunda  and 
gluteal.  D.  The  psoas  and  other  muscles  immediately  in  front  of  tlie  joint.  The  knife  must  be  passed 
beneath  this  mass  of  muscle  in  the  first  transfixion,  so  as  to  avoid  all  danger  of  puncturing  the  femoral 
artery. 

second  assistant's  hands  are  at  liberty,  and  then  the  large  vessels  in  the 
posterior  flap  should  be  secured,  while  any  smaller  bleeding  arteries  in 
the  anterior  are  compressed.  The  continuation  of  the  sciatic  artery  and 
the  comes  nervi  iscliiadici  will  be  found  near  the  sciatic  nerve,  large 
branches  from  the  internal  and  external  circumflex  on  either  side,  and 
some  branches  probably  from  the  gluteal.     When  all  the  vessels  are  tied 


AMPUTATION    OF    THE    THIGH. 


023 


Fig.  400. 


there  is  an  ample  covering  for  the  stump.  The  posterior  flap  is  shown  in 
Pig.  398,  1,  and  the  stump  in  Fig.  399.  If  from  the  grovvtli  of  a  tumor, 
or  any  other  cause,  this  method  is  impracticable,  the  flaps  can  he  made 
either  laterally  or  obliciuely,  or  one  of  the  flaps  may  be  lengthened  at  the 
expense  of  the  other  (Fig.  397,  1);  or  they  may  be  made  chiefly  of  skin, 
dissected  and  turned  back  before  the  deeper  incisions  are  made. 

Ampula/ion  of  (he  Thigh. — The  thigh  may  be  amputated  in  various 
ways,  and  at  any  level,  the  femur  being  divided  as  high  as  tlie  trochanter, 
or  as  low  as  the  condyles  ;  but  surgeons  are  always  anxious  to  go  as  low 
as  is  consistent  with  removing  the  disease,  remembering  Dietlcnbach's 
saying  that  "the  danger  rises  with  every  inch."  The  old  circular  am- 
putation, or  a  combination  in 
which  the  skin  is  cut  in  flaps, 
the  longer  anteriorly,  and  then 
a  circular  sweep  is  made  through 
the  muscles,  seems  to  me  the 
best  method.  For  the  amputa- 
tion close  on  the  knee-joint  Mr. 
Garden's  method  is  now  in  great 
favor.  Its  principle  is  that  of 
making  the  whole  stump  out  of 
one  long  anterior  flap  of  skin 
reaching  below  the  patella,  and 
cutting  the  posterior  skin  and 
muscles  straight  down  to  the 
bone  ;  then  raising  all  the  soft 
parts  somewhat  from  the  bone 

and      dividing      it      horizontallj'    show  the  flat  face  of  the  stump.     A  shows  the  femoral 

through  the  condyles,  l)elow 
the  medullary  canal.  This  is 
sufficient  in  most  cases  of  dis- 
ease of  the  knee,  and  leaves  a 
very  long  and  very  useful  stump. 
It  is  believed  also  to  be  less  ex- 
posed to  the  danger  of  osteo- 
myelitis than  the  operations  are 

in  which  the  medullary  canal  is  laid  open.  Flap  operations  can  also  be 
performed  in  any  part  of  the  thigh,  either  by  antero-posterior  (Fig.  397, 
2)  or  lateral  flaps.  Mr.  Teale's  method  by  rectangular  flaps  is  not  appli- 
cable to  the  thigh,  in  consequence  of  the  high  level  at  which  the  bone 
must,  on  this  method,  be  necessaril}'  divided. 

Amjjutation  through  the  knee-joint,  leaving  the  whole  cartilaginous 
surface  of  the  femur  and  patella  intact,  is  an  operation  of  wliich  I  am 
myself  rather  fond,  in  cases  where  the  whole  of  the  leg  is  destroyed  by 
accident,  or  where  malignant  disease  attacks  the  tibia,  yet  there  is  i)lenty 
of  sound  skin  below  the  knee.^  A  long  skin  flap  is  cut  out  of  the  front 
of  the  leg  by  an  incision,  convex  downwards,  starting  from  the  back  of 
either  condyle  and  reaching  four  or  five  inches  down  the  leg.  The  skin 
and  the  patella  having  been  raised  from  the  bones  and  the  lateral  liga- 
ments completely  divided,  the  surgeon  changes  the  scalpel  for  an  ampu- 
tating knife,  which  he  passes  behind  the  tibia  and  cuts  a  posterior  flap 

'  The  main  advantages  of  amputation  at  the  knee  are  the  lenj^th  and  power  of  the 
stump,  and  the  broad  unirritabhs  face  for  application  of  the  artificial  leg.  Its  disad- 
vantages are  the  tendency  to  sloughing  of  the  long  flap  and  to  abscess  extending  up 
the  thigh. 


Stump  of  circular  amputation  of  tliigh  bilow  the  mid- 
dle.   The  sleeve  of  skin  has  been  quite  turned  back  to 


artery,  its  vein  behind  it,  and  the  profunda  vein  and 
artery  behind  them.  The  sartorius  covers  the  vessels,  b 
shows  the  great  sciatic  nerve  audits  companion  aitery, 
the  semi-membranosus  muscle  lying  close  to  it  and  divid- 
ing the  mass  of  adductors  from  the  biceps  and  scmi-teu- 
dinosus.  c  shows  the  triceps  extensor  with  the  rectus 
aliovc  it.  Muscular  arteries  will  have  to  be  tied  in  all 
these  masses,  their  number  varying  witli  tlie  nature  and 
duration  of  the  disease. 


924 


OPERATIVE    SURGERY. 


outwards.'  This  flap  need  only  extend  a  very  short  distance  if  the  ante- 
rior flap  is  long  enough,  and  it  is  better  so,  as  the  wound  then  falls  com- 
pletely behind  the  femur.  The  popliteal  and  one  or  two  articular  branches 
are  probably  all  that  will  require  ligature. 

This  operation  is  variously'  modified.  Mr.  Butcher  describes  an  ope- 
ration as  "■  amputatiou  at  the  knee-joiut,"  in  which  the  end  of  the  femur 
is  cut  through  and  the  stump  made  chiefly  from  the  skin  and  muscles  of 
the  calf,  the  latter  being  hollowed  out  as  far, as  is  necessar}'  to  render  the 
flap  pliable  and  admit  of  its  being  attached  to  the  skin  in  front  of  the 
femur.  This  is,  as  it  were,  Garden's  method  reversed,  and  the  latter  is 
generally  preferred. 

Again,  there  is  an  operation  which  goes  usually  by  the  name  of"  Gritti's 
amputation,"  in  which  the  flaps  are  formed  as  for  the  amputation  through 
the  knee-joint,  but  either  in  consequence  of  disease  or  injur^'^  in  the  lower 
end  of  the  femur,  or  from  not  being  able  to  get  sufficient  sound  tissue  to 
cover  the  condyles,  the  operator  is  obliged  to  saw  through  them.  Then 
the  patella  is  sawn  perpendicularly,  so  that  all  its  cartilage  is  removed. 
The  anterior  flaj)  is  brought  over  the  sawn  end  of  the  femur,  and  the 
sawn  surface  of  the  patella  applied  to  that  of  the  femur. 

Or,  in  the  amputatiou  through  the  knee-joint,  the  chief  flap  can  be 
made  from  behind,  and  the  scar  brought  up  in  front  of  the  femur,  the 
patella  being  removed. 

Anipufation  of  the  leg  may  be  performed  on  the  circular  metliod,  which 

secures  a  somewhat  lower 
^^°-  '^^i-  section  of  the  bones  than 

any  of  the  flap  operations, 
or  by  skin-flaps  and  circular 
section  of  the  muscles ;  or 
by  flaps  formed  on  the  an- 
terior aspect  03^  section 
from  the  skin  inwards,  and 
on  the  posterior  by  trans- 
fixing the  parts  and  cutting 
outwards.  In  transfixing 
from  the  tibial  side  the  ope- 
rator must  be  careful  not  to 
pass  his  knifethrough  the  in- 
terosseous space  in  front  of 
the  fibula,  instead  of  behind 
it.  I  have  seen  this  twice 
done  on  the  living  subject. 
Mr.  Teale's  operation,  by 
rectangular  flaps,  is,  how- 
ever, a  very  good  method  in 
this  amputation,  when  the 
operator  has  no  objection 
to  dividing  the  bones  some- 
what higiier  up ;  and  this 
seems  a  convenient  place 
for  describing  it.  No  am- 
putating knife  is  required 
for   this    operation,   which 


Diagram  of  Teale's  amputation  of  the  leg,  performed  a  little 
below  the  centre  of  the  lirab.  The  anterior  long  flap  has  been 
bent  on  itself,  the  better  to  show  the  position  of  the  vessels. 
1.  The  anterior  tibial  vessels  and  nerve.  The  artery  is  shown 
expo.sed  throuybout  the  whole  length  of  the  tlap,  where  it  has 
been  peeled  off  the  interosseous  membrane.  The  tibialis  anti- 
cus  muscle  is  seen  on  its  tibial  side,  the  extensor  proprius 
pollicis  and  extensor  longus  digilorum  on  its  fibular  side,  ex- 
ternal to  which  is  the  mass  formed  by  the  peroneal  muscles, 
here  perhaps  rather  exaggerated  in  size.  2.  The  posterior 
tibial  vessels  and  nerve  lying  near  to  the  interosseous  mem- 
brane, but  separated  from  it  by  the  tililalis  posticus  muscle, 
and  from  the  tibia  by  tlie  flexor  longus  digitoruui.  3.  The 
peroneal  vessels  lying  close  to  the  fibula,  in  the  substance  of 
the  flexor  longus  pollicis.  In  the  cut  face  of  the  short  and 
thick  posterior  flap  are  seen  the  section  of  the  soleus,  and 
superficial  to  this  that  of  tbe  gastrocnemius  muscle,  each  con- 
taining the  mouths  of  several  muscular  vessels. 


'  Or  the  posterior  flap  ma}'  be  cut  from  the  skin  inwards  with  the  same  knife  as 
was  used  in  cutting  the  anterior  flaj),  or  the  whole  operation  performed  with  a  short 
amputating  knife. 


teale's   operation.  925 

is  performed  with  a  rather  large  scalpel.  Having  made  up  his  mind  where 
he  will  divide  the  bones,  the  surgeon  measures  (with  a  tape  or  with  his 
eye)  the  circumference  of  the  limb,  he  talces  a  horizontal  line  the  length 
of  half  this  circumference  with  its  extremities  lying  behind  the  tibia  and 
fibula,  and  from  the  ends  of  this  line  he  draws  two  incisions  of  the  same 
lengtii  as  the  base  vertically  downwards,'  and  unites  their  ends  by  an  inci- 
sion })arallel  to  the  base.  He  cuts  through  all  the  tendons  and  vessels 
straiglit  down  to  the  l)()nes  and  interosseous  meml)rane,  and  then  raises 
all  the  parts,  inclnding  tlie  anterior  tibial  vessels,  from  the  bones  and  inter- 
osseous membrane.  Much  care  must  be  taken  not  to  notch  the  artery  in 
doing  tliis,  the  edge  of  the  knife  being  kept  always  on  the  membrane.  Plav- 
ing  raised  the  anterior  flap  completely,  the  operator  cuts  the  posterior  flap 
by  a  transverse  incision  running  across  the  back  of  the  leg  down  to  the 
bones,  the  posterior  flap  being  a  quarter  the  length  of  the  anterior  (Fig. 
397,  3).  The  interosseous  membrane  being  divided  and  the  bones  per- 
fectly cleaned,  the  saw  is  api^lied.  For  this  purpose  the  leg  is  turned 
outwards,  so  that  the  fibula  is  first  presented  to  the  operator,  and  the 
division  of  the  fibula  completed  while  the  tibia  is  still  only  half  sawn 
through.  The  vessels  having  been  tied  (see  Fig.  401),  the  long  anterior 
flap  is  bent  over,  its  lower  edge  sewn  to  that  of  the  posterior  flap,  and  its 
doubled  lateral  edges  stitched  together.  If  the  flaps  have  been  cut  truly 
the  whole  fits  perfectly,  and  when  it  unites  kindly  it  makes  a  most  ex- 
cellent stump  ;  but  it  is  not  a  suitable  operation  for  weakly  i)ersons  on 
account  of  the  probability  of  sloughing  of  part  of  the  long  flap,  and  if 
secondar3'  haemorrhage  comes  on  it  is  very  troublesome. 

Mr.  H.  Lee  has  proposed  to  reverse  Teale's  proceeding,  making  the 
long  flap  from  behind  instead  of  in  front,  so  as  to  obtain  thicker  tissue 
for  the  lung  flap,  which  is  therefore  less  liable  to  slough,  and  to  avoid 
leaving  a  long  piece  of  nerve  (the  anterior  tibial),  which  has  to  be  bent 
on  itself  in  adjusting  the  flaps.'  I  have  seen  very  good  results  from  this 
operation  in  Mr.  Lee's  liands ;  but  it  is  somewhat  diflficult  to  be  certain 
of  the  position  of  the  posterior  tibial  vessels  in  performing  it,  and  the 
tendinous  part  of  the  gastrocnemius  muscle  in  the  lower  part  of  the  leg 
does  not  easily  lend  itself  to  the  bending  which  the  long  flap  has  to 
undergo. 

Teale's  method  provides  the  bones  with  a  thick  cushion  formed  in  great 
part  of  muscles.  These  muscles  ultimately  waste  away,  but  while  they 
are  undei'going  this  process  the  stump  becomes  consolidated,  and  the  skin 
does  not  adhere  to  the  bones,  so  that  the  face  of  the  stump  will  bear  the 
wooden  leg  to  press  directly  on  it. 

Li  performing  amputation  of  the  leg  when  the  tissues  are  at  all  con- 
solidated by  inflammation  it  is  often  dillicult  to  retract  the  parts  from  the 
bones.  In  such  cases  a  linen  retractor  is  required.  This  is  made  with  a 
long  piece  of  stout  linen,  in  one  end  of  which  a  tongue  is  cut  or  torn, 
leaving  this  end  to  consist  of  three  strips,  the  central  one  the  narrowest. 
This  tongue  is  passed  through  the  interosseous  sjiace,  the  broader  ends 
are  crossed  in  front  of  the  bones,  and  thus  the  parts  can  be  forcibly 
pushed  up  and  the  bones  exposed  much  higher  than  is  otherwise  possible. 

In  amjjutating  the  leg  the  posterior  tibial  artery  often  retracts  into 
the  corner  of  the  stump  (especially  when  it  is  made  b}'  transfixion),  and 
it  is  very  troublesome  to  tie  it,  or  any  of  its  branches  divided  near  the 
trunk. 

^  As  inn  limb  rapidly  decreases  in  size,  the  lower  end  of  the  flap  includes  much 
more  thnn  half  the  circnmferonoe  of  the  leg. 
2  Med.-Chir.  Trans.,  vol.  xlviii,  p.  195. 


926 


OrERATIVE    SURGERY. 


Fig.  402. 


Sii/me's  amputation  through  the  ankle-joint  is  thus  performed,  if  we 
follow  the  directions  of  its  author  :  the  anterior  flap  is  formed  b_v  drawing 
the  knife  from  the  jxjint  of  tlie  external  malleolus  to  the  corresponding 
point  on  the  opposite  aspect  of  the  foot,  /.  «.,  below  and  behind  the  in- 
ternal malleolus  (Fig.  897,  4).  The  anterior  flap  can  be  made  to  extend 
down  tlie  dorsum  of  the  foot  a  short  distance  if  the  surgeon  thinks  fit. 
The  i)()sterif)r  flap  is  made  by  drawing  the  knife  from  one  end  of  tlie 
anterior  flaj)  to  the  other  across  the  lower  surface  of  the  os  calcis,  inclin- 
ing it  rather  towards  the  heel,  so  that  the  incision  slopes  backwards. 
The  posterior  flap  is  then  dissected  back  and  thrown  round  the  end  of 
the  OS  calcis  until  the  tendo  Achillis  is  separated  from  that  bone  and  the 
knife  turns  round  the  upper  aspect  of  the  calcaneum.  In  doing  this  the 
operator  must  be  careful  to  keep  the  edge  of  the  knife  directed  towards 
the  bone,  so  as  not  to  score  the  skin  and  not  to  make  a  buttonhole.     It 

is  inipossil)le  to  do  this  satisfactorily  if  (as 
is  often  directed)  the  flaps  extend  from  one 
malleolus  to  the  other;  for  this  makes  the 
inner  part  of  the  flap  so  high  and  broad 
that  it  can  hardly  be  dissected  round  the 
heel  without  great  force.  When  the  os 
calcis  is  denuded,  the  anterior  flap  is  to  be 
thrown  up,  the  ankle-joint  opened,  the  knife 
passed  round  the  inner  and  then  the  outer 
malleolus,  and  the  foot  removed.  Next  the 
tibia  and  fibula  are  to  be  cleaned  for  about 
half  an  inch,  taking  care  by  keeping  the 
knife  close  to  the  bone  that  the  posterior 
tibial  arterj'  is  not  punctured,  and  a  thin 
horizontal  slice  of  the  tibia  with  both 
malleoli  sawn  oflT.  The  arteries  are  then 
secured  (Fig.  402),  and  the  flaps  sewn  up. 
Man}^  surgeons  think  it  best  to  pass  a 
drainage-tube  from  one  angle  of  the  wound 
through  an  opening  made  at  the  back  near 
the  tendo  Achillis,  so  as  to  avoid  the  bag- 
ging of  matter  in  the  posterior  flap.  Other- 
wise it  is  almost  always  necessary  when 
suppuration  sets  in  to  make  an  opening  in 

B.  Tlie  suction  of  tlictiliia.    D.  Tluit  of  the    the  flap.^ 

fibula,   r.  The  posterior  tiiiiai artery  and       The  operation,  howevev,  is  much  morc 
its  bifurcation    Kxternai  to  this  is  seen   ^^^jj    performed  in  the  reverse  manner  to 

th<!  teiiilon  ofthe  fle.\o.  proprius  pollicis,  -'    '  •,       i    i         -iir        n  u 

an<]  in  thr  middle  line  the  tendo  Achillis.   that  prescribed  by  Mr.  Syrae.      Ihe  flaps 

are  marked  out,  the  anterior  one  formed, 
the  joint  opened,  and  then  the  |)osterior  flap  dissected  from  the  u[)per 
part.  In  this  way  the  difliciilty  of  dissecting  the  posterior  flap  rouiul  the 
heel  is  quite  avoided,  and  it  is  a  matter  of  indirterence  to  what  exact 
points  the  incisions  are  drawn. 

The  great  recommendation  of  Syme's  amputation  is  the  excellence  of 
the  stump  which  it  forms,  the  tissues  of  the  heel  being  capalde  of  sustain- 
ing an}'  pressure,  so  that  the  i)atient  walks  about  easily  with  a  kind  of 


The  stump  of  Syme's  amputation,  a. 
The  anterior  tibial  vessils  and  nerve, 
divided  below  Ihe  point  where  the  ex- 
tensor proprius  pollieis  passes  over  them. 


•  The  rpasf)n  why  Mr.  Symfi  was  no  oinphatic  in  di recti Dtj  the  operator  to  avoid 
making;  a  "buttonhole"  was  not  so  niucli  Ix-cause  the  hole  i.s  in  itself  a  di.^ailvantage 
as  hocaiise  it  sliows  that  the  knife  is  directed  towards  the  skin  and  is  dividinij  its 
nutrient  vessels. 


chopart's  amputation.  927 

elephant's  foot  apparatus,  which  can  be  made  to  resemhle  the  natural 
foot  to  a  <>reat  extent  liy  liaving  a  foot-piece  put  on  to  it,  and  he  can  walk 
a  short  distance  well  enouyli  without  any  ai)[)aratus  at  all.  The  opera- 
tion is  available  in  most  cases  of  disease  of  the  ankle  and  tarsus,  and  in 
many  cases  of  injury. 

Pir'ociojpx  amputation  is  a  modification  of  Syme's,  in  which  the  extrem- 
ity of  the  OS  calcis  is  saved  and  is  applied  to  the  cut  end  of  the  til)ia,  in 
order  that  it  may  unite  with  that  bone  and  form  a  longer  stump.  The 
flaps  being  marked  out  in  the  same  M'ay  as  in  Syme's  amputation,  the- 
saw  is  applied  to  the  incision  across  the  under  surface  of  the  os  calcis 
and  that  hone  is  savvn  in  a  direction  sloping  upwards  and  backwards  to 
its  ni)per  surface  behind  the  ankle.  Then  the  joint  is  opened  and  the 
malleoli  and  under  surface  of  the  tibia  i-emoved  just  as  in  Syme's  ampu- 
tation. The  section  of  the  os  calcis  is  then  i)laced  in  apposition  with 
that  of  the  tiiiia,  and  the  wound  united.  When  all  goes  well  Pirogoff's 
amputation  forms  a  very  good  stump  ;  but  it  is  not  very  often  available, 
for  in  cases  of  disease  requiring  ami)utation  the  os  calcis  is  usually,  or 
very  often,  involved,  and  in  cases  of  injury  either,  on  the  one  hand,  more 
of  the  foot  can  be  preserved,  or,  on  the  other,  the  surgeon  finds  himself 
obliged  to  amputate  througii  the  leg. 

Syba.strar/alo'id  Amjnitation. — In  some  cases  it  may  be  that  the  os 
calcis  and  the  bones  of  the  front  of  the  tarsus  are  diseased  or  injured, 
but  the  astragalus  is  healthy  ;  and  then  a  very  good  stump  may  be  made 
by  forming  a  heel  and  a  dorsal  flap  long  enough  to  meet  beneatli  the  as- 
tragalus, severing  that  bone  from  its  connection  to  the  calcaneum  and 
scaphoid,  and  leaving  it  in  the  ankle,  while  the  rest  of  the  foot  is  re- 
moved, but  1  have  not  had  any  opportunity  of  seeing  this  operation 
practiced.  It  does  not  seem  of  much  importance  by  what  precise  inci- 
sions the  flaps  are  formed,  so  that  they  are  suflBciently  ample,  and  that 
the  lower  flap  is  formed  chiefl}'  of  the  tissues  of  the  heel,  as  in  Syme's 
amputation.  I  must  refer  the  reader  for  the  details  of  the  published 
eases  of  this  rare  operation  to  Mr.  Hancock's  Lecturei<  on  the  Anatomy 
and  Snrge7^ti  of  the  Foot^  p.  191  et  seq.,  where  he  will  find  described  also 
a  modification  of  the  subastragaloid  amputation  devised  and  performed 
by  Mr.  Hancock  himself,  and  bearing  the  same  relation  to  the  ordinary 
subastragaloid  amputation  as  Pirogoff's  does  to  Sj'me's  amputation. 
Mr.  Hancock  preserves  a  portion  of  the  back  of  the  os  calcis  in  the  heel- 
flap,  saws  off'  the  head  of  the  astragalus  and  its  lower  articulating  sur- 
faces, and  then  adapts  the  cut  surface  of  the  os  calcis  to  that  of  the  as- 
tragalus. The  result,  as  figured  in  Mr.  Hancock's  work,  is  an  excellent 
stump,  almost  as  long  as  the  sound  limb,  and  quite  capable  of  bearing 
any  amount  of  pressure. 

The  distinguishing  recommendation  of  the  suliastragaloid  amputation 
is  the  increased  length  of  the  stump,  even  as  compared  with  Pirogoff"'s, 
and  still  more  with  Syme's  amputation,  and  this  advantage  attaches  still 
more  strongly  to  Hancock's  amputation. 

Chopart^s  anvputation  is  performed  througii  the  transverse  tarsal  joint 
(Fig.  403).  The  tuberosity  of  tlie  scaphoid  is  easily  felt,  and  the  position 
of  the  calcaneo-cuboid  joint  halfway  between  the  external  malleolus  and 
the  point  of  the  fifth  metatarsal  bone  is  known.  An  incision  is  di'awn 
across  from  one  of  these  points  to  the  other  with  a  scalpel,  and  a  short 
dorsal  fiap  is  cut  (Fig.  397,  5),  the  transverse  tarsal  joint  opened,  and 
the  bones  fairly  separated  from  one  another.  Then  I)y  means  of  an  am- 
putating knife  a  long  plantar  flap  is  cut  outwards,  or  towartls  the  skin. 


928 


OPERATIVE    SURGERY. 


Fui.  403. 


This  flap  can,  of  course,  be  cut  with  the  scalpel  by  incision  from  the 

skin  almost  equally  readily. 

One  objection  often  made  to  Chopart's  am- 
putation is  that  the  tendo  Achillis  is  liable  to 
displace  the  bones  upwards,  being  no  longer 
antagonized  by  the  tendons  in  front,  so  that 
the  scar  is  brought  downwards  and  the  stump 
becomes  too  irritable  to  bear  the  pressure. 
This  defect  is  not  always  noticed,  nor  is  it 
eas}'  to  see  exactly  on  what  its  occasional  ab- 
sence depends.  It  may  be  avoided,  according 
to  some,  by  subcutaneous  section  of  the  tendo 
Achillis  at  tlie  time  of  the  operation,  a  com- 
plication which,  however,  it  is  desirable  to 
avoid.  The  plan  of  passing  the  sutures  through 
the  tibial  tendons,  so  as  to  attach  them  to  the 
cicatrix  (due,  I  believe,  to  the  late  Mr.  Dela- 
garde,  of  p]xeter)  is  worth  bearing  in  mind. 

Lixfranr/s  operation  consists  in  removing 
the  whole  metatarsus  with  the  toes,  and  leav- 
ing the  tarsus  intact.  Hey's  amputation  is  the 
same,  except  that  the  second  metatarsal  bone 
is  divided,  and  its  head  left  in  the  articulation 
between  the  cuneiform  bones.  The  projection 
of  the  second  metatarsal  bone  backwards  (Fig. 
403)  is  the  only  ditliculty  in  this  operation. 
The  position  of  the  articulation  of  the  great 
toe    with  the  internal   cuneiform,  and  of  the 

amputation  is   perronnrd  at  the  little  toe  with  the  cuboid  being  fixed,  a  curved 

transverse  tarsal  joint,  where  the   incision   is   drawn  from  the  onc  point  to  the 

bones  are  separated  from  each  other    ^+i,„„     /t?;„.      oot       i  ci\  j  \      a 

behind.     Lisfranc's  at    the    tarso-    "^^''^l    ^     ^^\    ^^^ ^     l^)     and     as     much     flap     aS 
metatarsal  articulations,  where  they    pOSSlblc    taken     from    the     dorSUm.      The     flap 

are  separated  in  front.  being   tlirown    back,   the    joiut    bctwecu    the 

great  toe  and  cuneiform  bone  is  divided,  then 
the  point  of  the  knife  is  carried  directly  backwards  till  it  is  slopijed 
by  the  middle  cuneiform  bone,  when  it  is  directed  outwards,  and  then 
forwards  again,  so  as  to  cut  entirely  round  the  head  of  the  second 
metatarsal.  Then  by  pulling  the  metatarsus  forcibly  downwards,  while 
the  knife  is  passed  along  the  line  of  the  articulations,  which  slope  back- 
wards, the  disarticulation  is  completed,  and  the  plantar  flap  may  be  cut 
by  transfixion  or  incision,  as  in  Chopart's  amputation.  This  operation 
is  used  almost  exclusively  in  cases  of  injury,  so  that  as  much  flap  as  pos- 
sible must  lie  taken  on  both  sides  to  compensate  for  any  possible 
sloughing. 

Finally,  aMi[)utation  may  be  performed  through  the  tarsus  in  any  situa- 
tion, by  simply  fashioning  flaps  and  sawing  through  the  bones;  and  this 
proceeding  is,  in  the  opinion  of  Mr.  Hancock,  the  highest  authority  on 
these  operations,  superior  to  the  amputations  performed  through  the  artic- 
ulations. 

The  toes  may  be  amputated  exactly  as  the  fingers  arc,  l)ut  here  it  is 
still  moi-e  un(lesii'al)le  than  in  the  hand  to  remove  the  heads  of  any  of  the 
central  metatarsal  bones.  If  any  of  tlie  smaller  toes  require  removal  the 
whole  to(;  sliould  be  amputated,  since  the  portion  left  would  be  useless, 
and  might  lie  in  the  way.  'V\h\  heads  of  the  first  and  fifth  metataisal 
bones  should  always  be  cut  off  in   amputating  those  toes,  the  incision 


Skeleton  of  the  foot.    Chopart's 


EX(;i??ioNS.  929 

througli  the  bones  being  sloped  off  if  possible.  The  great  toe  with  the 
head  of  its  metatarsal  bone  can  be  removed  by  a  V-shaped  incision  as 
shown  in  Fig.  897,  13.  If  the  whole  n)etatarsal  bone  is  to  be  removed, 
the  point  of  the  Y  must  be  extended  backwards  as  far  as  the  situation  of 
the  incision  (12)  on  the  same  dingram,  and  the  toe  having  been  removed 
the  metatarsal  bone  is  dissected  out  from  the  incision,  care  being  taken, 
in  dividing  its  head  from  the  cuneiform  bone,  to  keep  the  knife  so  close 
to  the  bone  as  not  to  wound  the  plantar  arch. 

EXCISIONS. 

Excisions  of  joints  and  bones  are  operations  which  are  quite  of  modern 
date,  and  wliich,  in  I'act,  could  hardly  be  practiced  freely  before  the  inven- 
tion of  aniifsthesia.  They  are  performed  chiefly  on  account  of  disease  of 
the  articular  surfaces  or  of  the  tissue  of  the  bone  excised,  sometimes  (as 
in  excision  of  the  scapula  and  clavicle)  on  account  of  the  grovvth  of  tu- 
mors from  the  bone,  sometimes  as  primary  or  secondary  operations  after 
injury. 

The  operations  resemble  to  a  certain  extent  the  dissections  by  which 
tumors  are  removed.  The  diseased  joint  or  bone  may  be  regarded  as  a 
tumor  to  be  exposed  by  appropriate  incisions,  tlie  soft  parts  turned  aside 
without  injuring  the  main  vessels  and  nerves,  all  its  connections  severed, 
and  the  whole  of  the  morbid  tissue  removed.  But  there  is  this  furtlier 
consideration  in  performing  an  operation  of  this  kind,  that  the  morbid 
structure  removed  is  an  important  part  of  the  skeleton,  and  that  the 
operation  must  be  so  performed  as  to  make  provision  for  the  subsequent 
stability  or  mobility  of  the  limb  as  may  be  recpiired.  Thus,  in  the  ex- 
cision of  the  knee,  it  is  im[)ortant  that  the  bones  should  be  firmly  anchy- 
losed,  a  result  which  is  especially  to  be  deprecated  in  the  elbow.  The 
instruments  required  in  excisions  are,  in  addition  to  the  usual  dissecting 
instruments,  saws  of  various  sizes,  from  the  amputatbig  to  the  "key- 
hole" saw,  retractors,  the  lion  forceps,  and  the  cutting  bone  forceps.  In 
subperiosteal  excisions  the  operator  must  have  various  raspatories,  ?'.  e., 
semi-blunt  chisels  or  rasps,  as  well  as  the  chain-saw,  and  a  combination 
of  a  rasjjatory  and  director  for  the  purpose  of  detaching  the  periosteum 
from  the  bone  and  carrying  the  chain  around  it.  For  some  excisions  a 
combination  of  a  staff  and  a  director  is  very  useful — the  "excision  di- 
rector." This  is  shaped  like  a  lithotomy  statf,  and  mounted  on  a  jointed 
handle.  Its  convex  side  is  grooved.  It  is  glided  under  the  bone  to  be 
removed — say  the  neck  of  the  femur — and  then  by  reversing  its  position 
its  grooved  surface  is  turned  towards  the  bone  and  lifts  it  out  of  tlie 
wound,  while  its  concave  part  lies  over  and  protects  the  soft  parts. 

The  use  of  Esmarch's  bandage  is,  as  I  have  said  above  (page  909), 
very  advantageous  in  most  of  these  operations. 

In  late  years,  the  advantages  of  preserving  the  periosteum  ("subperi- 
osteal excision")  have  been  much  insisted  on  by  Oilier  and  Langenbeck; 
and  in  some  excisions  they  are  incontestable,  while  in  others  ilie  advan- 
tage of  the  new  method  is  at  any  rate  not  as  yet  proved.  I  shall  refer 
to  the  subject  in  speaking  of  each  several  excision. 

Excision  of  the  ahoulder  is  perhaps  as  successful  as  any,  even  that  of 
the  elbow,  considered  merely  as  an  operation,  and  is  equally'  applicable 
in  cases  of  injur}'  and  disease  ;  but  it  differs  from  excision  of  the  elbow 
in  the  inij)ortant  particular  that  its  results  at  their  best  are  probably  in- 
ferior— certainly  not  superior — to  those  of  natural  anchylosis,  and  there- 

59 


S80  OPERATIVE    SURGERY. 

fore  that  it  should  never  be  practiced  when  there  is  any  good  prospect  of 
ohtaiiiing  a  cure  by  natural  ancliylosis.  As  tiiis  cure  is  very  often  obtained 
in  cases  of  disease  of  the  slioulder,  excision  is  but  rarely  practiced  in 
civil  life.  In  gunshot  injuries,  wiien  the  missile  has  not  penetrated  be- 
yond the  bones  of  the  joint,  as  in  the  cases  figured  on  pages  344,  345,  it 
is  a  very  successful  operation.  In  tumors  springing  from  the  head  of  the 
bone  it  might  be  justihaltle  to  excise  the  atlected  portion  of  bone,  if  it 
could  be  clearly  diagnosed  that  the  tumor  is  not  malignant,  but  this 
could  very  rarely  be  the  case. 

Tiie  operation,  as  usually  jiracticed,  consists  merely  in  removing  the 
head  of  tiie  humerus.  This  may  he  done,  if  there  is  not  much  thicken- 
ing over  tlie  joint,  by  a  single  incision  running  downwards  as  far  as  may 
be  judged  necessary  from  the  up|)er  part  of  the  acromion  process,  over 
the  most  prominent  part  of  the  liead,  where  it  is  most  plainly  felt  beneath 
the  skin.  This  line  of  incision  corresponds  pretty  nearly  to  the  direction 
of  the  long  tendon  of  the  biceps  muscle.  In  some  cases  it  is  necessary 
to  make  a  flap  out  of  the  deltoid  muscle,  of  a  somewhat  triangular  shape, 
with  its  base  upwards.  The  precise  position  of  the  incisions  which  bound 
this  flap  is  a  matter  c>f  secondary  imi)ortance,  and  is  usually  determined 
by  that  of  the  sinuses  or  wounds.  The  head  of  tlie  bone,  having  thus 
been  exposed,  is  to  be  rotated  (when  the  shaft  is  entire)  first  outwards, 
in  order  to  stretch  the  tendon  of  the  subsca[)ularis,  then  inwards,  to  make 
tense  those  attnched  to  the  gretiter  tuberosity  ;  these  tendons  are  to  be 
divided,  and  the  capsule  thus  freely  opened,  and  then  the  head  of  the 
bone  is  to  be  tiirust  out  of  tlie  wound  and  sawn  off.  If  the  case  is  one  of 
injury,  and  the  head  of  the  bone  is  severed  from  the  shaft,  it  must  be 
seized  with  the  lion-forceps  and  dissected  out.  The  bleeding  is  usuall}' 
free  from  the  posterior  circumflex  artery  or  its  branches.  If  the  long 
tendon  of  the  biceps  can  be  distinguished  it  should  be  spared.  In  both 
disease  and  injury  the  glenoid  cavity  often  escapes;  but  if  it  should  be 
found  affected,  it  may  be  thought  necessary  to  remove  it.  This  is  best 
done  with  a  large  chisel  or  with  hone-nippers  of  appropriate  shape.  The 
parts  should  l)e  lightly  put  together  by  means  of  a  few  sutures,  and  the 
patient  confined  to  bed  for  the  first  few  days,  until  the  consecutive  fever 
has  passed  over.  He  may  then  be  allowed  to  move  about,  the  elbow 
being  carefully  su|)ported.  The  tendency  of  the  muscles  which  form  the 
flaps  of  the  axilla  to  displace  the  bone  may  be  counteracted  by  a  pad  in 
the  arm])it. 

The  ^iibperioi<teal  method  should  undoubtedly  be  adopted  if  the  surgeon 
finds  iiimself  obliged  to  remove  a  great  extent  of  the  bone.  M.  Oilier' 
directs  that  tlie  incision  should  be  made  as  far  forwards  as  possible  with- 
out wounding  the  cephalic  vein,  in  order  to  preserve  the  greater  part  of 
the  deltoid  muscle  in  its  natural  connection  with  the  circumflex  nerve,  b}' 
which  he  hopes  to  preserve  tlic  action  of  that  muscle.  The  joint  is  then 
to  be  cut  into,  and  tlien  all  the  tendons  and  periosteum  [jeeled  off  the 
bones  with  raspatories  of  the  proper  shape,  the  iiumerus  being  gradually 
pushed  out  of  the  wound  till  the  pi'oper  level  is  reached  for  its  section. 

I  have  never  seen  a  case  iu  which,  after  this  excision,  the  arm  could  be 
elevated  above  a  horizontal  line,  and  this  seems  to  me  to  depend  more  on 
the  loss  of  the  joint,  and  the  consequent  want  of  a  point  of  support  for 
the  humerus,  than  on  any  supposed  loss  of  function  of  the  deltoid.  In 
fact,  I  believe  that  the  atrophy  iA'  tiie  deltoid  is  secoudary  on  the  loss  of 
its  function,  and  that  if  the  machinery  for  raising  the  arm  could  be  re- 

1  Trailc  des  Kcgcncrationcs  des  Os,  vol.  li. 


EXCISION    OF    THE    CLAVICLE.  981 

produced — that  is  to  say,  if  the  head  of  the  Imnienis  could  1)0  regenerated 
along  with  a  perfect  capside,  so  that  the  ball  coidd  be  tiinily  applied  to 
its  socket  as  in  the  natural  condition — the  deltoid  would  soon  regain  its 
bulk  and  power.  But  there  is  no  |)roof  given  by  M.  Ollier's  cases  that 
this  is  ever  doue ;  and  the  mere  ligamentous  union  which  generally  en- 
sues furnishes  no  such  fulcrum.  At  the  same  time,  the  shorter  the  liga- 
ment the  more  jjower  of  motion  will  there  be  in  the  humerus  ;  and  to  this 
end  it  is  very  important  to  preserve  the  periosteum  if  the  bone  is  to  be 
divided  much  below  the  tuljerosities.  Many  histories  show  the  extensive 
excisions  which  may  be  i)racticed  on  the  humerus  with  preservation  of  a 
very  useful  arm.  One  pul>lished  in  the  Lancet  for  July  18,  1874,  by  Dr. 
Donovan,  records  a  case  in  which  the  whole  bone  from  the  head  to  a  point 
just  above  the  condyles  was  excised  subi)eriosteally,  in  a  case  of  acute 
periostitis  in  a  boy,  with  good  results. 

The  excision  of  the  scapula  on  ai:;count  of  a  tumor  is  a  formidable 
operation,  the  advantages  of  which  should  be  maturely  weighed  before 
its  dangers  are  encountered.  Oi)crations  on  this  bone  for  necrosis  are 
much  more  likely  to  be  permanently  successful,  but  they  rather  resemble 
the  common  operations  for  extraction  of  a  sequestrum  than  formal 
excisions. 

The  total  excision  of  the  scapula  for  a  tumor  should  be  thus  performed. 
The  patient  being  brought  under  the  influence  of  chloroform,  an  assistant 
should  be  charged  with  the  comi)ression  of  the  subclavian  artery,  for 
which  purpose,  if  the  projection  of  the  tumor  makes  compression  dilii- 
cult,  the  incisions  may  be  so  managed  as  to  enable  him  to  put  his  flnger 
directly  down  upon  it.  This  precaution  much  diminishes  the  h.iemor- 
rhage  from  the  subscapular  artery  and  its  branches,  which  otherwise 
might  be  formidable.  The  surgeon  then  proceeds  to  denude  the  tumor 
of  its  outer  coverings  by  turning  dovvn  appropriate  skin  flaps,  taking 
great  care,  however,  not  to  open  the  capsule  of  the  tumor  itself  When 
the  whole  tumor  is  thus  exposed  tiie  muscles  inserted  into  the  vertebral 
border  of  the  bone  should  be  rai)iilly  divided,  as  also  those  whieh  ai'e 
attached  to  the  spine  of  the  scapula.  The  tumor  being  now  movable 
should  be  lifted  well  up,  and  freed  from  its  other  attachuients  by  rapid 
strokes  of  the  knife,  commencing  from  its  lower  angle.  The  subscapular 
artery  is  divided  near  the  end  of  the  operation,  and  can  be  caught  hold 
of  by  the  surgeon  or  his  assistant,  and  held  till  the  tuinor  is  removed,  or 
can  be  at  once  tied.  The  ligaments  of  the  shoulder  are  then  easily 
divided  and  the  mass  removed.  The  acromion  process,  if  not  diseasccl, 
may  be  divided  with  bone-nippers,  and  left  behind  to  preserve  the  shape 
of  the  parts  and  protect  the  head  of  the  humerus. 

Excision  of  the  Clavicle. — Excisions  of  any  part  of  the  clavicle  should 
be  undertaken  with  the  greatest  care  on  account  of  the  close  relations 
which  the  bone  has  to  important  structures,  and  on  account  of  the  risk 
of  diffuse  inflammation  below  the  deep  fascia  of  the  neck  ;  and  the  total 
extirpation  of  the  bone,  for  a  tumor  springing  from  its  sultstance,  is  one 
of  the  gravest  operations  in  surger}'.  In  Mott's  case  the  operation  lasted 
four  hours^  and  thirty  vessels  were  tied.  Mott  says,  "■  Tliis  operation 
far  sur|)assed,  in  tediousness,  difticulty,  and  danger,  anything  whieh  I 
have  ever  witnessed  or  perfcn'med."  If  it  be  decided  to  remove  the 
whole  claviele  along  with  a  tumor,  the  incisions  should  be  made  very 
free,  one  over  the  long  axis  of  the  bone,  joined  by  otliers  in  appropriate 

1  See  Polluck,  in  St.  George's  Hospital  Keports,  vol.  iv,  p.  2'il. 


932  OPERATIVE    SURGERY. 

places  for  turning  down  such  flai)s  as  may  appear  necessary,  and  the 
parts  to  be  oi)erated  on  should  be  brought  fairly  into  view  before  the 
bone  is  meddled  with.  After  having  freely  divided  all  the  superficial 
attachments  of  the  bone  and  tumor,  the  next  step  is  to  divide  the  outer 
end  of  the  clavicle  from  the  scapula,  either  by  cutting  through  the  joint 
or  by  severing  the  bone  with  a  small  saw  or  ni[)pers.  Then  the  part 
which  is  to  be  removed  can  be  raised,  and  must  be  separated  with  great 
care  from  the  imi)ortant  parts  whicii  lie  below  it,  so  as  to  reach  the 
sternal  part,  which  is  last  divided,  and  which  serves  during  the  opera- 
tion as  a  pivot  on  which  the  bone  can  be  moved  and  supported  ;  or,  in 
other  cases,  it  may  be  found  more  convenient  to  divide  tiiis  part  of  the 
bone  also  at  an  earlier  period  of  the  operation.'  It  ajipears  that  very 
useful  motion  ma}'  be  recovered  after  the  removal  of  a  large  part,  or  even 
the  whole,  of  the  shaft  of  the  clavicle. 

Excitiion  of  the  elbow  is  a  most  useful  and  a  most  successful  operation. 
It  is  practiced  on  account  of  injury  and  of  disease  with  equal  relative 
success,  though  the  absolute  success  is,  as  in  all  operations,  much  greater 
in  cases  of  disease  tiian  those  of  injury.  Any  disease  which  does  not  ex- 
tend far  from  the  articulating  surfaces,  and  wliich  is  otherwise  incurable, 
is  a  clear  indication  for  excision.  As  caries  of  the  joint-ends  of  the  elbow 
hardly  ever  involves  any  extensive  intlainmalion  of  the  shafts  of  the 
bones,  this  comprises  most  cases  of  serious  disease  of  this  joint.  I'here 
are  even  cases  in  which  the  disease  is  not  incurable,  but  where  the  cure 
would  involve  long  disuse  of  the  liml)  and  ultimate  loss  of  motion  from 
anchylosis,  where  it  may  be  justifiable  to  resort  to  excision,  if  the  patient 
be  young  and  healthy,  in  the  hope  of  cutting  short  the  disease  and  pro- 
curing a  more  movable  limb.  And  other  cases  are  also  met  with,  though 
rarely,  in  which  the  limb  has  been  allowed  to  become  anchylosed  in  an 
extended  or  otherwise  useless  position,  and  where  the  surgeon  may  be 
justified  in  excising  the  joint  at  the  request  of  iiis  patient  after  the  risks 
and  the  probalile  advantages  of  tlie  operation  have  been  explained  to  iiim. 

It  must  always  be  borne  in  mind  in  this  operation  that  the  oliject  is  to 
procure  such  union  as  shall  be  sutliciently  firm,  on  the  one  hand,  to  atford 
a  fixed  centre  of  motion  for  the  bones  of  the  forearm,  and  thus  give  pre- 
cision and  strength  t(;  the  movements  of  the  hand,  and  yet  shall  not  be  so 
close  as  to  abolish  any  of  the  motions  of  tlie  joint.  In  the  most  successful 
cases  these  indications  are  perfectly  fulfilled,  so  that  the  motions  of  the 
hand  are  as  extensive  as  on  the  sound  side,  and  no  case  of  excision  of 
the  elbow  is  to  be  reckoned  as  perfectly  successful  in  which  this  is  not 
the  case.  Such  perfect  success  is  n)ore  probable  in  childhood  than  in 
mature  life,  though  even  tlien  it  is  often  obtained,  and  if  it  be  not,  an 
amount  of  motion  ought  at  any  rate  to  l)e  insured  which  leaves  the  patient 
a  very  useful  arm  even  in  cases  which  do  not  quite  come  up  to  the  ideal. 

The  operation  is  now  abnost  always  performed  by  means  of  a  single 
straight  incision  running  parallel  to  the  course  of  the  ulnar  nerve,  Imt  a 
little  (;xterilal  to  it — i.  e.^  over  tlie  inner  side  of  the  olecranon  and  for 
about  two  inches  above  and  itelovv  it,  This  incision  is  made  fairly  down 
to  tlie  Ijone,  dividing  the  triceps  muscle  and  t!ie  periosteum.  The  oper- 
ator prf)ceeds  dilferently  in  tlie  common  and  in  the  subperiosteal  opera- 
tion. In  tlie  ordinaiy  operation  he  opens  the  joint  freely  by  cutting 
round  the  olecranon,  <livides  the  external  lateral  ligament,  dissects  the 
paits  off  the  humerus  l)etvveen  the  olecranon  and  internal  condyle  with 
much  care,  keei)ing  the  edge  of  tlie  knife  constantly  on  the  bone,  and 


'  See  Truver.s,  Mcd.-Cliir.  Trans.,  vol.  x.xi. 


EXCISION    OF    THE    ELBOW.  933 

pressing  the  parts  away  from  the  bone  with  tiie  left  thumVi-nail.  cantions]}^ 
so  as  not  to  endaiii>er  the  nlnar  nerve  wliich  lies  amongst  these  parts.' 
Then  the  internal  lateral  ligament  is  cut  away  from  the  luimerus,  and 
novv  tlie  joint  is  qnite  destroyed.  Tf  the  end  of  the  lunnerns  can  he  thrust 
out  of  the  wound  without  interfei'ing  with  the  bones  of  tlie  foi-earm  it  is 
to  be  sawn  across  just  above  the  condyles,  or  the  olecranon  may  be  cut 
away  for  this  j)nrpose  l)efore  tlie  rest  of  the  disease  is  removed  from  tlie 
forearm.  Tlien  the  bones  of  the  forearm  are  to  be  thrust  out  of  the 
wound  and  sawn  off  on  the  same  level — i.  «.,  just  below  the  coroiioid  pro- 
cess, the  head  and  neck,  but  not  the  bicipital  tubercle  of  the  radius  being 
removed.  It  is  far. better  to  remove  l)otli  liones  together  by  a  clean  cut 
with  the  saw  than  to  divide  the  neck  of  the  radius  with  bone  nippers. 
And  it  is  often  convenient  to  reverse  the  usual  order,  by  removing  the 
bones  of  the  forearm  before  dealing  with  the  humerus.  When  tlie  sur- 
geon is  satisfied  that  all  the  disease  is  removed,  the  bandage  is  relaxed 
(if,  as  is  generally  advisable,  Ksmarch's  bandage  has  been  employed), 
and  the  vessels  tied  with  catgut  ligature.  Then  a  kw  minutes  are  to  be 
given  for  exposure  and  cold  bathing  to  stay  any  residual  oozing,  the 
wound  is  to  lie  united  with  silver  sutures,  a  drainage-tube  being  inserted 
into  it,  and  the  arm  put  on  a  splint  and  dressed. 

SubperioH/eal  Method. — If  the  operator  decide  to  proceed  suliperioste- 
ally  he  must  first  take  care  that  his  incision  has  really  divided  the  whole 
periosteum  down  to  the  bony  structure,  then  by  working  with  the  raspa- 
tory on  the  back  of  the  olecranon  he  will  find  it  very  easy  to  detach  the 
periosteum  there,  and  he  must  use  all  possible  care  to  clean  tlie  back  of 
the  humerus  completely  of  all  soft  structure — periosteum,  capsule  of  joint, 
and  tendons — and  especially  to  detach  as  completely,  and  with  as  little 
injury  as  possible  to  their  structure,  all  the  tendons  and  other  soft  parts 
wliicli  adhei'e  to  both  condyles.  The  end  of  the  olecranon  may  now  be 
removed  in  order  to  obtain  access  to  the  front  of  the  ulna,  detach  the 
tendon  from  the  coronoid  process,  and  tlius  complete  the  denudation  of 
the  portion  of  ulna  which  is  to  be  sawn  off.  If  the  attachments  of  the 
orbicular  ligament  can  l)e  recognized  and  i)reserved,  it  may  be  possible 
to  remove  the  head  of  the  radius  without  interfering  with  them.  Now 
comes  the  most  difficult  i)art  of  the  operation,  viz.,  how  to  clean  the  fron*". 
of  the  humerus  of  its  periosteum.  M,  Oilier  attempts  this  by  gliding  a 
curved  instrument  between  the  bone  and  periosteum  and  conveying  a 
chain  saw  in  its  course,  but  this  curved  raspatory  is  very  apt,  when  act- 
ing in  the  dark,  to  pass  through  the  periosteum.  It  seems  better  to  divide 
the  bone  with  the  keyhole  saw  from  behind  incomiiletely,  and  then  frac- 
ture it,  as  is  done  by  some  operators  while  removing  the  end  of  the  femur 
in  excising  the  knee.  The  periosteum  will  remain  untorn,  and  the  sur- 
geon can  then  proceed  to  detach  it  from  either  side,  commencing  from 
the  part  exposed  in  the  wound.  The  advantages  of  the  subperiosteal  ex- 
cision of  the  elbow,  which  is  far  more  lal»orious  and  involves  more  violence 
to  the  tissues  than  the  common  operation,  are,  I  must  say,  as  3'et  un- 
proved. 

After  the  operation,  the  limb  should  be  placed  lightly  on  a  si)lint.  The 
precise  form  of  splint  is  of  no  importance  ;  in  fact,  the  splint  itself  is  not 


1  Tho  ulnar  nerve  is  seen  in  operiitions  on  tlie  dejid  subject,  but  in  flisease  it  is  sel- 
dom visible,  heinij  hidden  by  the  intliuiimutory  products  around  the  diseased  joint. 
I  have  seen  it  in  |)rirnnry  excision  for  injury  in  the  living,  and  in  excisions  in  which 
Esmarch's  bandage  is  used  it  may  sometimes  be  seen. 


934 


OPERATIVE    SURGERY. 


absolntel}'  necessary,  for  some  surgeons  of  much  experience  use  only  a 
bandaiie.  But  I  think  the  support  and  confidence  which  the  splint  gives 
(especially  if  startings  of  the  linili  take  place,  as  they  are  rather  apt  to 
do)  are  a  great  conil'oit  to  the  patient.  In  about  a  week,  when  the  parts 
are  beginning  to  consolidate,  the  splint  should  be  so  arranged  as  to  per- 
mit the  hand  to  reacli  tiie  month,  and  when  the  wound  has  nearly'  healed 
))assive  motion  and  then  active  motion  is  to  be  enforced.  'IMie  precise 
time  at  which  active  motion  is  to  begin  cannot  be  fixed.     If  the  quantity 

Fl(i.40t. 


The  method  of  slinging  the  limb  after  excision  of  the  elbow. 


of  bone  prescril)ed  above  has  been  removed,  there  will  very  likely  never 
lie  occasion  for  any  passive  motion  at  all,  and  in  no  case  ought  it  to  be 
used  until  all  active  inflammation  has  passed  over  and  the  wound  is  almost 
healed.  While  the  ijatient  is  in  bed  it  is  a  comfort  to  sling  the  arm  from 
a  pole  over  the  bed,  as  shown  in  Fig.  404. 

The  repair  after  exciHion  is  in  rare  cases  b}'^  bony  anchylosis.  This  is 
undoubtedly  to  be  reckoned  as  a  failure,  and  ought  hardly  ever  to  occur. 
It  depends  geneially  on  the  I'emoval  of  too  little  bone,  and  on  the  neglect 
of  passive  motion  afterwards.  Commonly  the  repair  is  by  means  of  filirous 
bands  which  tie  the  ends  of  the  dilferent  bones  to  each  other.     In   rare 


EXCISION    OF    THE     WRIST. 


935 


¥[(-..  4(15. 


cases  there  is  considerable  reproduction  of  bone  and  a  complete  joint  is 
formed.  Tiiis  was  the  case  in  a  remarkable  instance  described  and  figured 
by  Mr.  Syme,  in  which  a  considerable 
reproduction  of  bone  had  taken  place 
from  either  side  of  tiie  end  of  the  lui- 
meriis,  and  these  two  newly  produced 
condyles  locked  in  the  two  bones  of 
the  forearm,  forming-  a  complete  hinge 
joint,  in  which  tl>e  radius  played  in  a 
newly  formed  orbicular  ligament  'The 
patient,  who  was  a  railway  guard,  had 
been  able  to  use  the  excised  elbow  as 
well  as  the  sound  one  for  the  purpose 
of  swinging  himself  from  one  carriage 
to  another  of  the  train  in  motion. 
This  rei)roduction  is  quite  as  perfect 
as  any  which  has  been  proved  to  take 
place  after  subperiosteal  resection.  In 
fact  the  reproduced  bone  after  the  lat- 
ter operation  is  often  exuberant  and  is 
detrimental  to  the  motion  of  the  joint.' 

Excision  of  the  ivrist  as  a  formal 
operation  is  not  often  practiced,  since 
in  cases  of  disease  which  are  suffici- 
ently serious  to  justify  so  very  severe 
a  proceeding,  the  affection  has  gener- 
all}'  extended  too  far  ;  while  in  slighter 
cases,  tiie  surgeon  thinks  that  the  pa- 
tient will  ultimately  do  better  if  only  "^  'he  lii.nieius  locking  in  the  bones  of  the 
the  diseased  portions  of  bone  be  dealt  f:"'^''™  /"  the  n.w  joint ,/  new  orbicular 
,  .    '  liL;;nnent  iiround  the  head  of  the  radius ;   (;,  a 

With   from   time  to   time  as  may   be  nee-     portion  of  the  ligamentous  union  between  the 
essary,  and  passive  motion   be  kept  ll[)    ulna  and  humeras;  A,  tendon  of  the  biceps;   i, 
sedulously.       In  cases  of  injury  I   have    a,  n^w  lateralligaments  attached  below  to  the 
.     ,  ,        „  .    .  ,      .  end  of  the  ulna  on  Olio  side,  and  to  the  orbicu- 

never  as  yet  heard  of  excision  being   u,,  ligament  on  the  other. 
practiced. 

The  two  chief  objects  in  the  operation  of  excision  of  the  wrist  are  not  to 
divide  any  tendons  which  can  be  spared,  and  to  remove  the  whole  joint, 
i.  e.,  the  ends  of  the  bones  of  the  forearm,  all  the  bones  of  the  carpus 
(except  perhaps  the  pisiform),  and  the  ends  of  all  the  metacarpal  bones. 
This  is  best  done  according  to  Professor  Lister's  method,  which  is  thus 
effected.  The  patient  is  put  under  auiiesthesia,  and  then,tlie  bandage  or 
tourniquet  being  securely  adapted,  an  incision  is  made  commencing  in 
front  over  the  second  metacarpal  l)one  internal  to  the  tendon  of  the  ex- 
tensor secundi  internodii  pollicis,  and  running  along  the  back  of  the 
carpus,  internal  to  the  same  tendon,  as  high  as  to  the  base  of  tiie  styloid 
process  of  the  radius.  The  soft  parts,  iiududing  tlie  extensor  secundi 
internodii  and  the  radial  artery,  being  cautiously  detached  from  the  bones 
external  to  this  incision,  and  the  tendons  of  the  radial  exten.sors  of  the 
wrist  being  also  severed  from  their  attachments,  the  external  Itones  of  the 
carpus  will  be  exposed.  When  this  has  been  done  sutHciently,  the  next 
step  is  to  sever  the  trapezium  from  the  other  bones  with  cutting  pliers, 


Mr.  Synic's  case  of  reproduction  of  the  joint 
after  excision  of  the  elbow.  From  the  Lan- 
cet, vol.  i,  1855.  o.  the  humerus;  6,  the  ulna; 
c,  the  radius;  d,  e,  projections  from  the  shaft 


'  A  very  intere.sting  account  of  the  dissection  of  a  Ciist!  four  years  al'ter  suhperios- 
teal  resection  will  be  found  in  Langenbeck's  Archiv,  vol.  x,  by  Dr.  Doutrelepont. 


936 


OPERATIVE    SURGERY. 


in  Older  to  facilitate  the  removal  of  the  latter,  which  should  be  done  as 
freely  as  is  found  convenient.  The  operator  now  turns  to  the  ulnar  side 
of  the  incision  and  cleans  tlie  carpal  and  metacarpal  bones  as  mucli  as 
can  be  done  easily.  The  ulnar  incision  is  now  made.  It  should  be  very 
free,  extending-  from  al)out  two  inches  above  the  styloid  process  down 
to  tlie  middle  of  the  (iftli  metacarpal  bone,  and  lying  near  the  anterior 
edge  of  the  ulna.  The  dorsal  line  of  this  incision  is  then  raised  along 
with  the  tendon  of  the  extensor  carpi  ulnaris,  which  should  not  be  isolated 

Fig.  40(). 


Diagram  of  the  excision  of  the  wrist  (after  Lister),  a,  the  radial  artery;  b,  tendon  of  the  extensor 
sccundi  internodii  iiollicis;  c,  indicator  ;  d,  Ext.  conuu.  digitornni  ;  k,  Ext.  niin.  dig.  ;  K,  Ext.  prim. 
inl.  pol. ;  <;,  Ext.  oss.  met.  pol. ;  il  i,  Ext.  carp.  rad.  long,  and  brev. ;  k,  E.xt.  carp.  iiln. ;  L  l,  line  of  ra- 
dial incision.— From  the  System  of  Surgery. 


from  the  skin  and  should  be  cut  as  near  its  insertion  as  possible.  Then 
the  common  extensor  tendons  should  be  raised,  and  the  whole  of  the 
])osterior  aspect  of  the  carpus  denuded,  until  the  two  wounds  communi- 
cate quite  freely  together;  but  the  radius  is  not  as  yet  cleaned.  The 
next  stej)  is  to  clean  the  anterior  asi)e(;t  of  the  ulna  and  carpus,  in  doing 
wliicli  tlie  pisiform  bone  and  the  hooked  process  of  the  unciform  arc 
severed  from  the  rest  of  the  carpus,  the  former  with  the  knife,  the  latter 
with  the  cutting  pliers.  In  cleaning  tlic  anterior  aspect  of  the  carjius, 
care  must  be  taken  not  to  go  so  far  forwards  as  to  endanger  the  deep 
palmar  arch.  Now,  the  ligaments  of  the  internal  carpal  bones  being  suf- 
liciently  divided,  they  are  to  be  removed  with  l)lunt  bone  forceps.  Next 
the  end  of  tlic  ulna  is  made  to  protrude  from  the  incision,  and  is  sawn  off, 


EXCISION    OF    THE    HIP,  937 

as  low  down  ns  is  eoiiKistent  with  its  condition,  but  in  any  case  above  its 
radial  articulation.  Tlie  end  of  the  radius  is  then  cleaned  sufficiently  to 
allow  of  its  beiiifj;  protruded  and  removed.  If  this  can  he  done  without 
disturbing  the  tendons  from  their  grooves,  it  is  far  better.  If  the  level 
of  the  section  is  below  the  ui)])er  part  of  the  cartilaginous  facet  for  the 
ulna,  the  remainder  of  the  cartilage  must  be  cut  away  with  the  pliers.  The 
operator  next  attends  to  tlie  metacarpal  bones,  wliieh  are  pushed  out  from 
one  or  the  other  incision  and  cut  off  with  the  pliers  so  as  to  remove  the 
whole  of  their  cartilage-covered  portions.  Tlie  trapezium  bone,  which 
was  left  in  the  early  stage  of  the  operation,  is  now  carefully  dissected 
out,  so  as  to  avoid  any  injury  to  the  tendon  of  the  flexor  carpi  radialis  or 
to  the  radial  artery,  and  the  articular  surface  of  tlie  first  raetacar[)al  bone 
is  tlien  exposed  and  removed.  Lastly,  the  cartilaginous  portion  of  the 
pisiform  bone  is  taken  avvay  ;  but  the  nonarticular  part  is  left  behind  un- 
less it  is  diseased,  in  which  case  it  should  be  removed  entire.  The  same 
remark  applies  to  the  hooked  process  of  the  unciform. 

The  operation  is  one  of  the  most  tedious  and  difficult  in  surgery,  but 
it  appears  to  me  to  give  very  satisfactory  results,  and  therefore  should,  I 
think,  always  be  ado[)ted  in  such  cases  as  are  favorable  for  any  operation 
at  all.  It  is  advisable,  if  not  necessary,  to  put  on  the  tourniquet,  so  that 
the  view  of  the  parts  should  not  be  obscured  by  Idood.  It  is  also  very 
desirable  to  break  down  freely  any  adhesions  which  the  tendons  may 
have  formed,  while  the  patient  is  under  chloroform  previous  to  the  oper- 
ation. 

No  tendons  are  divided  in  this  operation  except  the  extensors  of  the 
wrist,  for  the  flexor  carpi  radialis  is  inserted  lower  down  than  the  point 
at  which  the  metacarpal  bone  is  usually  divided. 

In  order  to  insure  motion,  particularly  in  the  fingers,  passive  move- 
ments should  be  performed  from  a  very  early  period  after  the  operation. 
For  this  purpose,  Mr.  liister  places  the  limb  on  a  splint  with  the  palm  of 
the  hand  raised  by  a  large  wedge  of  cork,  fixed  below  it ;  so  that  the 
joints  of  the  fingers  can  be  moved  without  taking  the  limb  off  the  appa- 
ratus. S[)ecial  arrangements  are  made  for  keeping  the  splint  steady  and 
for  preventing  displacement  of  the  hand  to  either  side.  Careful  and 
methodical  passive  motion  should  be  used  to  each  several  joint — ^to  those 
of  the  fingers  and  thumb  almost  from  the  day  of  operation,  and  to  the 
wrist  as  soon  as  the  parts  have  acquired  some  firmness,  each  movement, 
pronation  and  supination,  flexion  and  extension,  abduction  and  adduc- 
tion, being  separately  exercised  ;  and  the  patient  should  be  encouraged 
to  make  attempts  at  voluntary  motion  as  early  as  possible.  In  order  to 
exercise  the  fingers,  the  portion  of  the  splint  which  supports  them  may 
be  removed  while  that  on  which  the  wrist  is  received,  is  stili  left.  Fin- 
ally, when  the  rigid  splint  is  left  ofl^  some  flexible  support  is  still  to  be 
worn  for  a  long  time. 

Excision  of  the  hip  is  performed  almost  exclusively  on  account  of 
strumous  disease  (so  called)  of  the  joint.  The  few  cases  in  which  this 
operation  has  been  practiced  for  gunshot  injuries  have,  I  believe,  all  oc- 
curred in  military  practice,  and  they  have  been  exceedingly  fatal. 

I  have  spoken  in  the  appropriate  place  (p.  480)  of  tlie  indications  for 
performing  this  operation  in  morbus  coxarius,  and  have  now  only  to  deal 
with  the  operative  details.  Some  operators  content  themselves  with  re- 
moving only  so  much  of  the  femur  us  is  diseased;  others  (as  Dr.  Sayre, 
of  New  York)  consider  it  necessary  to  remove  the  whole  of  the  trochanter 
major.     The  latter  plan  seems  to  me  to  involve  an  unnecessarily  exten- 


dS8  OPERATIVE    SURGERY. 

sive  removal  of  bone  ;  but  if  it  is  preferred  I  have  no  doubt  that  the  sub- 
periosteal method  should  be  followed,  as  recommended  by  Dr.  Sayre. 
The  ordinary  operation  is  thus  performed.  A  free  incision  is  made,  of  a 
semilunar  shape  with  the  convexity  backwards,  over  the  posterior  part 
of  the  trochanter,  which  should  go  boldly  down  to  the  bone.  Then  by 
cuttino-  along  the  neck  of  the  femur  the  joint  is  reached,'  and  it  should 
be  freely  opened  ;  the  head  of  the  bone  twisted  out  of  the  joint,  and  the 
neck  divided,  with  a  keyhole  saw,  as  low  down  as  the  surgeon  thinks 
necessary.  If  the  operation  is  performed  for  injury,  and  the  neck  of  tlie 
bone  is  fractured^  the  incisions  must  lie  more  extensive,  the  fi'actured 
jiart  must  be  freely  exposed,  seized  with  the  lion  forceps  and  dissected 
out,  and  then  search  must  be  made  for  bullets,  fragments  of  bone,  and 
other  foreign  i)odies.  Finally,  the  surgeon  must  carefully  examine  the 
acetabulum  and  remove  by  the  gouge,  trephine,  chisel,  and  forceps  all 
portions  of  diseased  bone.  In  the  subperiosteal  resection,  the  periosteum 
is  divided  just  below  the  great  trochanter,  and  that  process  is  denuded 
from  all  librous  tissue  (periosteum  and  tendons)  inserted  into  it,  and  this 
l)roceeding  is  carried  on  upwards  till  the  joint  has  been  laid  freely  open. 
Tlien  the  common  tendon  of  the  psoas  and  iliacus  is  divided  with  a  knife 
and  the  deep  ix)rtions  of  the  neck  of  the  bone  separated  fi'om  the  fibrous 
strictures  as  well  as  it  is  possible. 

It  is  usual  in  Europe  to  dress  the  wound  lightly,  and  either  put  up  the 
liml)  in  a  bracketed  splint,  or  in  a  plasterof  Paris  case,  or — which  I  have 
found  easier  and  quite  as  satisfactory — with  a  weight  and  pulley.  None 
of  these  plans  aim  at  restoring  the  length  of  the  limb.  Dr.  Sayre's  plan 
consists  in  screwing  the  limb  down  by  means  of  an  extending  apparatus 
to  the  same  length  as  the  other,  and  he  asserts  that  in  some  cases  after 
removing  a  great  length  of  bone,  the  limb  has  regained  its  normal  length, 
and  all  its  natural  movements. 

The  operation  is  a  dangerous  one;  at  least  a  great  many  patients  die 
after  it ;  many  it  is  true,  not  from  the  operation  l)ut  from  previous  disease. 
Still  the  number  who  have  died  from  the  direct  sequehe  of  the  operation 
has  not  been  small,  in  my  experience.  Nearly  half  of  the  published 
cases  seem  to  have  proved  fatal^  from  one  cause  or  another. 

Union  is  almost  ahvays  b}^  ligament;''  in  some  rare  cases,  chiefly  those 
which  have  been  neglected,  osseous  anchylosis  has  taken  place  ;  in  others 
no  union  has  cvccurred,  or  the  femur  has  been  so  loosely  connected  to  the 
j)elvis  that  tiie  limb  is  useless, 

Ex(dtiion  of  the  knee  is  an  operation  which  has  afforded  excellent  re- 
sults in  the  less  severe  cases  of  disease  of  the  synovial  membrane  and 
articular  surfaces  of  that  joint,  for  which  amputation  used  to  be  per- 
formed. B}'^  "the  less  severe  cases"  I  mean  such  as  occur  in  young 
persons  of  a  tolerably  healthy  constitution,  from  chronic  action,  not 
spreading  to  any  great  extent  into  the  bone,  and  not  accompanied  with 
very  great  distortion  or  atrophy  of  the  limb.  It  is  quite  true  that  in 
many  of  these  cases,  if  no  operation  be  performed,  tiie  abscesses  will 
dry  uj)  and  the  diseased  bone  exfoliate  ultimately;  l)ut  it  is  also  true 
that  tliis  action  often  takes  many  years  to  accomplish,  during  the  whole 


1  Thoiiy;Ii  tlie  joint  in  sidvanced  stages  of  disease  is  iisuall}'  spoken  of  as  "  dis- 
locatiid,"  it  really  hardly  ever  is  so.  Ibiving  excised  the  lii(i-joint  between  twenty 
and  thirty  times  1  cannot  remember  to  have  come  across  a  case  in  which  the  head  ot 
the  bone  (or  its  remains)  was  not  in  the  aeetabulum,  and  Dr.  Sayre  says  that  in  fifty- 
two  cases  of  excision  he  hjis  only  found  one  of  dislocation. 

2  Syst.  of  Surgery,  vol.  v,  p.  694,  2d  ed. 


EXCISION    OF    THE    KNEE.  939 

of  which  time  the  patient  is  unfit  for  any  active  employment,  and  that 
often  at  tiie  end  of  it  the  limb  is  more  an  incnmbrance  than  anytliing 
else,  and  frequently  requires  amputation.  However  this  may  be  it  is 
certain  that  we  used  some  years  ago  to  see  amputation  practiced  in  many 
of  the  same  class  of  cases  as  are  now  treated  most  successfully  by  ex- 
cision, and  so  far  excision  of  the  i<nee  has  been  a  great  gain.  But  the 
atteinpt  to  show  that  it  is  in  itself  a  safer  and  more  successful  operation 
than  amputation  has  failed,  and  all  judicious  surgeons  now  agree  that 
excision  cannot  be  snccessfidly  performed  above  the  middle  period  of 
life  (say  al)out  forty,  varying,  however,  of  course  with  the  constitution) 
or  in  phthisical  patients,  or  in  acute  or  extensive  disease,  or  for  tumors, 
in  all  vvhich  conditions  amputation  though  dangerous  is  often  successfid. 

Excision  is  also  very  dangerous  when  performed  as  a  primary  opera- 
tion for  injury,  and  especiall}'  those  complicated  injuries  which  follow  on 
gunshot  wounds  ;  so  that  in  these  cases  amputation  is  usually  preferred, 
unless  under  exceptional  circumstances,  tliat  is  to  say  in  persons  of  re- 
markal)ly  sound  constitution,  or  at  early  periods  of  life,  and  in  whom  the 
injury  can  be  ascertained  to  be  strictly  limited  to  the  immediate  neigh- 
borhood of  tiie  articulation. 

The  operation  is  thus  performed.  An  incision  should  be  made  from 
the  back  part  of  one  condyle  to  the  back  part  of  the  other  (Fig.  381,  8), 
passing  across  the  front  of  the  limb  below  the  patella,  and  slightly  convex 
downwards.  It  is  seldom  necessary  to  make  any  other  incision  into  the 
skin  ;^  but  if  there  is  much  thickening  about  the  soft  parts,  perpendicular 
incisions  may  be  made  at  the  ends  of  this,  so  as  to  form  the  H- shaped 
incision,  which  used  always  to  be  employed  in  this  operation.  The 
ligamentum  patelliB  is  to  l)e  divided  in  the  first  incision  ;  then  the  soft 
parts  are  to  be  thrown  back  from  the  patella  and  the  end  of  the  femur, 
and  the  patella  is  to  be  removed."  The  joint  is  now  to  be  freely  opened 
by  cutting  at  the  sides  of  the  condyles,  so  as  to  sever  completely  both 
lateral  ligaments ;  and  then  the  knife  is  to  be  carried  round  the  posterior 
surface  of  the  end  of  the  femur,  care  being  taken  in  doing  this  to  thrust 
the  femur  oiit  of  the  wounds  as  much  as  possible,  by  an  assistant  forcibly 
flexing  the  limb,  and  to  keep  the  edge  of  the  knife  directed  towards  the 
bone,  and  guided  by  the  finger,  so  as  to  avoid  the  popliteal  artery,  which 
here  is  separated  from  the  bone  only  by  some  fat  and  loose  tissue ;  and, 

^  Some  surgeons  prefer  to  make  a  long  elliptical  flap  from  the  front  of  the  limb, 
including  the  patella.  I  myself  do  not  ordinarily  use  this  method,  as  it  makes  a 
larger  wound,  and  renders  it  somewhat  moi-e  difficult  to  deal  with  the  patella.  It 
may,  however,  be  necessary  when  there  is  much  swelling. 

2  It  is  my  invariable  rule  to  remove  the  patella,  and  this  is,  I  believe,  the  usual 
practice.  1  can  see  no  use  in  the  bone  if  left,  and  much  risk  of  recurrence  of  disease. 
(Set!  also  Swain,  On  Excision  of  the  Knee-joint,  p  73.)  Dr.  Patrick  Heron  Watson, 
on  the  other  hand,  counsels  its  preservation,  when  possible,  for  the  following  reasons: 
"  (1)  That  its  removal  is  unnecessary  in  most  cases  ;  (2)  that  its  presence  in  the  flap 
bears  up  the  soft  parts  from  the  lino  of  incision,  and,  without  preventing  consolida- 
tion, helps  to  keep  them  away  from  the  cut  margin  t.f  either  osseous  surface  ;  (3)  that 
its  removal  occasions  more  bleeding;  and  (4)  that  the  hollow  left  after  its  removal 
from  the  centre  of  the  long  fla[)  leaves  a  hollow  cavity,  in  which  matter  bags,  and 
requires  a  separate  incision  to  drain  it  efficiently."  (On  Excision  of  the  Knee,  p. 
76.)  If  the  latter  assertion  be  well  founded,  it  constitutes  to  mj'  mind  an  additional 
objection  to  the  use  of  the  long  flap  in  excision,  rather  than  an  argument  for  the 
preservation  of  the  patella.  None  of  the  other  supposed  inconveniences  of  removing 
the  patella  will  he  found  to  be  of  any  practicsil  importance  if  the  operation  be  per- 
formed with  the  simple  transverse  incision.  As  to  the  first  assertion,  it  is  a  matter 
of  experience.  In  my  own  practice,  the  removal  of  the  patella  has  seemed  in  the 
great  majority  of  cases  not  merely  advisable,  but  necessary. 


940 


OPERATIVE    SURGERY. 


in  sawing  the  bone,  it  nia^'  be  advisable,  if  the  femur  have  not  been  very 
completely  cleaned,  not  to  pass  the  saw  entirely  through  the  osseous 
tissue,  but  rather  to  break  than  to  cut  the  outer  lamella  at  the  back,  by 
using  the  saw  as  a  lever.  The  level  at  which  the  femur  is  to  be  divided 
should  be  carefully  borne  in  mind  in  operating  on  children.  I  have  re- 
peatedly seen  the  surgeon  take  away  the  whole  epiphysis  and  a  i)art  of 


Fig  407. 


Fig.  408. 


Fig.  407. — A  section  niadu  through  the  femur 
and  tibia  in  a  child  aged  five  years,  to  show  the 
position  of  the  epiphysial  lines  and  the  point  at 
which  the  section  ought  to  be  made  in  excision. 
If  the  seclion  be  made  above  the  trochlear  sur- 
face of  the  femur,  the  whole  epiphysis  will  bi'  re- 
moved. In  the  tibia,  the  whole  articular  surface 
may  be  removed  without  risk. — From  the  System 
of  Surgery. 

Fig.  408. — The  same  femur,  shown  in  an  an- 
terior view,  to  mark  the  level  at  which  the  saw 
ought  to  be  applied. 


the  shaft  from  mere  want  of  care,  having  forgotten,  or  omitted  to  ascer- 
tain, whereabouts  this  line  is  situated.  Figs.  407,  408  show  its  true 
position,  and  will  prove  that  in  any  case  of  excision  in  which  the  whole 
cartilaginous  surface  of  the  femur  is  removed,  the  shaft  will  be  trenched 
upon.  The  end  of  the  femur  having  been  removed  the  head  of  the  til)ia 
is  to  be  cleaned  and  sawn  horizontally,  care  being  taken  in  young  persons 
to  keep  close  below  the  cartilaginous  surface,  so  that  the  epii)hysial  line 
be  not  interfered  with.  In  cases  where  there  has  been  no  dislocation, 
nor  much  alteration  in  the  shape  of  the  bones  from  previous  disease, 
there  is  now  usually  no  impediment  to  placing  the  limb  in  a  straight 


EXCISION    OF    THE    KNEE. 


941 


position,  with  the  bones  in  accurate  adjustment.  Otherwise  they  must 
be  adjusted  by  taking  of!"  successive  i)ieces  from  the  end  of  tlie  femur  or 
tibia  (if  possilile  without  going  beyond  the  epiphysis);  and  in  cases  of 
old  dislocation  it  is  often  necessary  to  sever  one  of  the  hamstring  tendons. 
Tiie  parts  should,  in  all  cases,  be  adjusted  in  perfect  position  upon  a 
splint,  and  the  bandages  firmly  ajjplied  before  the  patient  is  moved  or 
allowed  to  recover  from  the  chloroform.  If  the  femur  appears  at  all 
prominent,  a  short  splint  should  be  applied  in  front  in  order  to  counteract 
the  tendency  of  the  leg  to  gravitate  backwards  (which  is  also  assisted  by 

Fig.  409. 


Splint  for  excision  of  the  knee. 

the  action  of  the  flexor  tendons) ;  and  it  is  at  an}^  rate  a  useful  precau- 
tion to  apply  a  long  side-splint  to  the  outer  side  of  the  limb,  which  can 
be  discarded  after  the  first  few  days,  if  it  appears  superfluous.  I  have 
found  much  comfort  to  the  patient  from  suspending  the  whole  apparatus 
in  a  "Salter's  swing."  It  will  of  course  be  understood  that  the  spliuts 
are  interrupted  and  bracketed  with  iron  at  the  seat  of  operation,  so  as  to 
give  access  to  the  wound. 

There  are  many  other  methods  of  dressing  the  wound  and  limb  in 
cases  of  excision  of  the  knee.  Dr.  I'atrick  Heron  Watson  warmly  recr 
ommends  the  use  of  plaster  of  Paris  (or  plaster  coated  with  paraffin 
externally,  to  render  it  less  permeable  to  discharges),  which  he  thus  ap^ 
plies.  Fig.  410  represents  an  iron  rod,  which  extends  from  the  groin  to 
the  foot,  the  upper  straight  end  being  at  the  groin,  the  arch  at  the  site  of 
the  wound,  the  hook  (for  swinging  the  limb)  near  the  ankle-joint,  and  the 

Fig.  410. 


Dr.  P.  H.  Watson's  suspension-rod  for  excision  of  the  knee. 

raised  part  running  along  the  dorsum  of  the  foot.  Fig.  411  shows  two 
forms  of  "  Gooch  "  splint,  the  former  merely  hollowed  out  on  each  side  at 
the  level  of  the  wound  and  cut  out  at  the  lower  part  in  a  horseshoe  or 
stirrup  form,  to  relieve  the  heel  and  tendo  Achillis  from  pressure;  the 
latter  having  also  a  piece  above  to  be  adapted  to  the  innominate  bone. 

"In  application,  the  limb  is  first  laid  and  carefully  adjusted  upon  the 
posterior  splint,  which  should  preliminarily  be  padded  with  lint,  and 
covered  with  gutta-percha  tissue,  or  hot  paraffin,  in  the  position  which 
corresponds  to  the  site  of  operation.  The  iron  rod  is  then  placed  in 
front,  and  folded  lint  laid  between  it  and  the  limb  at  the  groin,  at  the 
upper  part  of  the  tibia,  and  at  the  bend  of  the  ankle.  Those  two  parts  of 
the  apparatus  are  then  retained  in  contact  with  the  limb  by  means  of  aa 


942 


OPERATIVE    SURGERY. 


open  wove  roller  bandage  applied  from  the  toes  upwards,  the  site  of  the 
incision  being  alone  left  uncovered.  The  whole  is  tlien  rendered  immov- 
able by  means  either  of  plaster  of  Paris  applied  by  the  hand,  of  the  con- 
sistence of  thick  cream,  or  of  parattin,  which,   having    been  rendered 


Fi(^.4n. 


Dr.  H.  P.  Watson's  splints  for  excision  of  the  knee. 


temporarily  liquid  b}'  heat,  is  applied  b}'  a  large  painter's  brush.  When 
the  application  has  solidified,  the  patient  may  be  removed  to  bed,  and 
the  limb  suspended  from  the  running  pulley  of  a  Salter's  swinging  cra- 
dle, or  from  the  roof-bar  of  the  common  iron-wire  cradle."  (Op.  cit.^ 
p.  19.) 

The  advantages  claimed  for  this  metliod  are  the  comfort  tlie  patient 
derives  from  being  able  to  shift  his  position  ;  the  ease  of  transporting 
him  from  place  to  place  (a  great  consideration  in  military  practice) ;  the 
facilit}-  of  applying  dressings  to  the  wound ;  the  permanence,  simplicity, 
and  facilit}'^  of  construction  of  the  apparatus  itself.  The  plaster  of  Paris 
dressing  is  in  general  use  in  this  and  other  excisions  by  the  German 
surgeons. 

Mr.  Butcher  has  recommended'  a  "box-splint"  for  the  after-treatment 
of  tins  operation.  This  consists  of  two  side-splints,  the  outer  one  ex- 
tending iVom  the  axilla  to  below  tiie  foot,  the  inner  from  the  groin  to 
below  the  foot,  jointed  on  to  a  back-piece.  The  sides  are  let  down  to 
dress  the  wound.  This  is,  as  far  as  I  have  seen,  a  convenient  apparatus 
when  all  goes  well,  but  is  less  handy  when  complications  occur,  and  is, 
on  tlic  whole,  I  think,  infci'ior  to  tlie  above-meniioned  methods  of  treat- 
ment. 

It  is  an  essential  element  in  the  success  of  this  operation  not  to  be 
forced  to  disturb  the  limb  at  all  for  several  days  ;  hence  the  dressings 
should  l)e  most  carefully  applied  at  first.  And  for  the  same  reason  all  bleed- 
ing vessels  should  be  carefully  secured,  so  as  to  avoid  secondary  luemor- 
rhage.  The  l)leeding  during  the  opeiation  is  often  very  free,  from  the  en- 
larged articular  vessels;  and  secondary  luvmorrhage  is  by  no  means  rare, 
and  is  a  very  unfavorable  occurrence.  The  opeiation,  especially'  when  it 
has  been  a  protracted  one,  which  in  cases  of  old  dislocations  it  often  is, 
is  usually  followed  by  a  considerable  amount  of  fever,  subsiding  with  the 

^  Operative  and  Conservative  Surgery,  p.  142. 


EXCISION    OF    THE     ANKLE-JOINT.  dAZ 

establisliiTient  of  a  free  sn])purntion  ;  and  then,  in  favorabie  eases,  tlie 
work  of  repair  eommences  by  grannlation  and  osseous  union,  as  in  eoni- 
ponnd  fraeture.  In  unfavorable  eases,  tiie  bones  become  denuded  and 
ulcerated  in  the  supi)uratiug  cavity,  the  discharge  is  offensive,  tiie  wound 
unhealthy,  fresh  abscesses  probai)ly  form,  and  the  patient's  health,  in- 
stead of  ini[)roving  from  the  removal  of  the  disease,  shows  a  tendency  to 
decline.  Under  these  circumstances,  cidoroform  should  be  administered 
and  amputation  performed,  if  on  examination  it  proves  necessary. 

The  process  of  recovery  is  usually  a  slow  one.  In  Dr.  Hodges's  tal)les 
the  average  duration  of  the  treatment  in  48  cases  in  which  the  patella 
was  removed  is  stated  to  have  been  225  days;  and  in  88  cases  in  which 
that  bone  is  believed  to  have  been  left,  255  days;  or,  roughly  speaking, 
the  average  duration  of  treatment  was  about  eight  months;  and  in 
many  of  the  cases  which  afterwards  turn  out  the  most  suecessfid,  sinuses 
remain  open,  and  the  limb  is  in  a  state  which  cannot  but  cause  anxiety 
for  many  months  after  formal  treatment  is  discontinued.  In  some  ex- 
ceptional cases,  indeed,  matters  go  on  much  more  rapidl}'  than  this,  and 
the  recoveiy  is  completed  as  soon  as  (indeed,  it  may  be  that  one  or  two 
have  recoveied  sooner  than)  after  amputation;  but  as  a  general  rule,  the 
time  required  for  recovery  after  excision  may  be  taken  at  about  four 
times  as  long  as  after  amputation.  In  fact,  I  think  we  are  taking  a  view 
very  favorable  to  excision  if  we  say  that  every  month  after  the  operation 
advances  the  cure  onl^'  as  far  as  a  week  would  after  amputation. 

Kei)air,  when  the  case  does  perfectly  well,  is  by  osseous  anchylosis, 
and  this  ought  to  be  com[)lete,  so  that  the  tibia  and  femur  form  one  solid 
mass  of  bone,  in  a  perfectly  straight  line.  There  is  a  great  tendency  to 
1)0W  outward  at  the  junction,  and  this  must  be  carefully  watched  and 
counteracted  during  the  process  of  healing  and  for  some  time  after  the 
patient  begins  to  put  his  leg  to  the  ground.  In  rarer  cases  the  limb 
l)ends  l)ackwards'  or  inwards,  but  the  outward  bend  is  the  more  com- 
mon. In  some  cases  small  portions  of  bone  remain  long  exposed,  and 
the  wound  cannot  be  brought  to  heal.  Such  cases  may  often  be  treated 
successfully  by  gouging  or  by  treating  the  exposed  bone  with  snlphurLc 
acid. 

Excisum  of  the  anJde-jowt  is  an  operation  which  is  not  often  prac- 
ticed, since  in  injury  it  is  usually  sufficient  to  take  away  the  loose  or 
comminuted  portions  of  bone,  and  in  disease  the  affection  is  seldom  so 
limited  to  the  ankle  as  to  justify  the  surgeon  in  removing  only  that  joint. 

Cases  suitable  for  excision  of  the  ankle  are  those  in  which  the  lesion 
(whether  traumatic  or  from  disease)  is  limited  to  the  ends  of  the  bones 
of  the  leg  and  to  the  astragalus.  When  the  disintegration  extends  far  into 
the  bones  of  the  leg  am|)utation  ought  undoubtedly  to  be  practiced,  and 
although  in  some  cases  a  considerable  amount  of  the  bones  of  the  tarsus 
has  been  successfully  removed  along  with  the  ankle-joint,' yet  the  advisa- 
bility of  such  an  operation  must  always  be  very  doubtful.  Again,  the 
patient  ought  not  to  be  laboring  under  any  general  constitutional  ca- 
chexia ;  and  further,  those  cases  are  best  suited  for  this  excision  in  which 
the  disease  is  the  direct  result  of  a  somewhat  recent  injury.  Witli  all 
these  limitations,  the  range  of  application  of  this  operation  will  be  but 
small  in  cases  of  disease,  and  in  tlu.se  of  injury,  as  above  stated,  partial 
resections  have  hitherto  been  more  common,  but  the^■e  is  much  reason  to 


'  As  in  a  separation  in  the  Museum  of  the  College  of  Surgeons  where  bony  anchj'- 
iosis  has  taken  place  at  a  right  angle. 

2  See  my  essay,  On  Excision  of  Bones  and  Joints,  in  the  5th  vol.  of  Syst.  of  Surg. 


944  OPERATIVE    SURGERY. 

believe,  nitli  Mr.  H.  Lee,  tliat  in  these  cases  a  more  useful  limb  would 
otten  be  obtained  l\y  a  more  formal  excision  of  the  whole  joint.' 

The  operation  is  not  an  easy  one,  and  it  is  rendered  more  difficult  in 
some  cases  by  partial  ancliylosis.  The  best  way  of  performing  it  is,  I 
think,  to  make  a  I'ree  incision  behind  the  posterior  border  and  external 
malleolus  of  tlie  fil)nla,  extending  about  two  inches  along  the  outer  side  of 
the  foot,  and  a  smaller  incision,  as  recommended  by  Mr.  H.  Lee  {op.  cit.) 
round  the  internal  malleolus.  The  inner  malleolus  having  been  carefully 
cleaned  of  soft  parts  is  to  be  partially  sawn  through  with  a  Hey's  saw, 
and  clipped  off  with  bone-nippers.  Then  the  extei'ual  malleolus,  having 
been  dissected  clear  of  the  tendons  and  other  fibrous  structures,  is  to  be 
sawn  through,  and  now  liy  clearing  the  bones  of  all  their  fibrous  adhesions, 
the  tibia  may  be  pushed  out  of  the  wound  on  the  outer  side  of  the  foot, 
and  its  articular  end  sawn  off.  Next,  the  astragalus  is  to  be  dealt  with. 
In  all  cases  where  the  bone  is  much  inflamed  it  is  far  more  satisfactory 
(as  I  thiidv  I  have  jjroved '■)  to  remove  the  whole  bone,  for  which  pui'pose 
the  astragalo-scaphoid  joint  should  first  be  freely  oi)ened  ;  then  the  knife 
passed  between  the  astragalus  and  os  calcis,  dividing  the  interosseous 
ligament;  and,  finally,  the  bone  twisted  out  with  the  lion-forceps.  But 
if  the  affection  of  the  astiagalns  be  very  superficial,  a  keyhole  saw  may 
be  passed  into  the  wound,  either  in  front  of  or  l)ehind  the  articular  sur- 
face, and  the  whole  of  this  surface  removed  by  a  hoi'izontal  section.  No 
large  vessels  should  be  wounded  in  this  operation,  nor  are  any  tendons 
necessarily  divided. 

A  much  easier  operation  is  to  make  an  anterior  flap  through  all  the 
tendons,  nerves,  and  vessels  in  front  of  the  joint,  as  in  Syme's  amputa- 
tion, and  then  remove  all  the  diseased  parts  of  bone  ;  but  as  this  involves 
needless  injury  to  the  anterior  tibial  vessels,  and  division  of  several  ten- 
dons, it  is  not  often  resorted  to.  At  the  same  time,  I  have  excised  the 
astragalus  in  this  way  several  times,  and  the  use  of  the  foot  has  been 
very  good,  notwithstanding  the  injur}-  to  the  tendons  and  vessels. 

A  well  fitting  splint  should  have  been  previously  provided,  and  the 
limb  should  be  kept  at  rest  till  the  parts  have  become  quite  consolidated. 
It  is  then  to  l>e  put  into  a  plaster  or  other  immovable  apparatus,  and  the 
patient  is  to  be  allowed  to  walk  about  on  a  wooden  leg. 

The  use  of  the  leg  is  often  almost  as  good  as  ever.  Two  lads  on  whom 
I  performed  this  operation,  removing  the  astragalus  wholly  in  one  and 
partially  in  the  other,  were  heard  of  some  years  afterwards  doing  the 
ordinary  work  of  agricultural  laborers,  and  able  to  walk  all  day  ;  but 
recovery  is  much  slower  than  after  amputation. 

Exciaion  of  the  os  calcia  is  an  operation  which  may  often  be  practiced 
with  great  advantage.  Disease  of  the  tarsus  very  commonly  begins  in 
the  joint  l)ctween  the  calcaneun)  and  astragalus,  and  frequently  spreads 
into  the  former  bone;  the  afliection  of  the  latter  being  so  superficial  that 
the  carious  spot  can  be  gouged  away  when  the  greater  mass  of  disease 
has  been  removed,  in  these  cases  the  central  part  of  the  calcaucum 
often  perishes,  leaving  a  large  mass  of  necrosis  inclosed  in  a  thin-walled 
cavity  of  inflamed  and  sol'tened  [)one.  If  now  the  whole  bone,  including 
this  shell  of  softened  bone,  be  removed,  the  patient  makes  a  certain  and 
speedy  recovery  with   a  useful  foot  ;  while  if  the  loose  portion    be  re- 


'  Soe  a  paptM-  by  Mr.  H.  Lee,  in  Mi-d.-Cliir.  Trans.,  vol.  Ivii,  p.  137. 
*  See  St.  George's  Hospital   Keports,  vol.  iv.     A  Note  on  Excision  of  the  Anide- 
ioint. 


EXCISION    OF    THE     ASTRAGALUS.  945 

moved,  and  the  shell  scooped,  he  may,  it  is  true,  recover,  and  the  heel 
ma}'  possibly  be  more  firm,  Ijut  the  recovery  is  at  least  doubtful,  and  in 
the  course  of  a  tedious  convalescence  the  health  may  give  wav,  fresh 
disease  be  lighted  up,  and  amputation  become  necessary. 

Excision  of  the  os  calcis  is  tiius  peiformed.  An  incision  is  commenced 
at  the  inner  edge  of  the  tendo  Achillis,  and  drawn  horizontally  forwards 
along  the  outer  side  of  the  foot,  somewhat  in  front  of  the  calcaneo-cuboid 
joint,  which  lies  midway  between  the  outer  malleolus  and  the  end  of  the 
fifth  metatarsal  bone.  Tliis  incision  should  go  down  at  once  upon  the 
bone,  so  tiiat  the  tendon  should  be  felt  to  snap  as  the  incision  is  com- 
menced. It  sliould  be  as  nearly  as  possible  on  a  level  witli  the  upper 
bordei'  of  the  os  calcis;  a  point  wliich  the  surgeon  can  determine,  if  the 
dorsum  of  the  foot  is  in  a  natural  state,  by  feeling  tlie  pit  in  which  the 
extensor  brevis  digitorum  arises.  Another  incision  is  then  to  be  drawn 
vertically  across  the  sole,  commencing  near  the  anterior  end  of  the  former 
incision,  and  terminating  at  the  outer  border  of  the  grooved,  or  internal, 
surface  of  tlie  os  calcis,  beyond  which  point  it  should  not  extend,  for  fear 
of  wounding  the  posterior  tibial  vessels.  If  more  room  be  required,  this 
vertical  incision  may  be  prolonged  a  little  upwards,  so  as  to  form  a  +.^ 
The  bone  being  now  denuded,  by  throwing  back  the  flaps,  the  first  point 
is  to  find,  and  lay  open,  the  calcaneo-cuiioid  joint;  and  then  the  joints 
with  the  astragalus.  The  close  connections  between  these  two  bones  con- 
stitute the  principal  difticulty  in  the  operation  on  the  dead  suliji^ct ;  but, 
as  has  been  already  stated,  these  joints  will  frequently  be  found  to  have 
been  destroyed  in  cases  of  disease.  The  calcaneum  having  been  sei)arated 
thus  from  its  bony  connections  by  the  free  use  of  the  knife,  aided,  if 
necessary,  by  the  lever,  lion-forceps,  etc.,  the  soft  parts  are  next  to  be 
cleaned  otf  its  inner  side  with  care,  in  order  to  avoid  the  vessels,  and  the 
bone  will  then  come  avvay.  The  flaps  are  to  be  closed  lightly,  with  one 
or  two  points  of  wire  suture,  over  the  large  gap  left  by  the  excision. 

Suhpei'iosteal  Excision. — M.  Oilier  describes  an  operation  by  which  the 
OS  calcis  can  be  removed  sulijieriosteally  without  the  division  of  any  ten- 
dons, except  the  tendo  Achillis.  An  angular  flap  is  made  by  an  incision 
running  horizontally  along  the  lower  outer  border  of  the  bone,  and  ver- 
tically along  the  outer  border  of  the  tendo  Achillis.  Then  the  periosteum 
and  the  parts  above  it,  including  the  peronei  tondons,  are  peeled  off  the 
bone.  Next  the  attachment  of  the  tendo  Achillis  and  the  periosteum  are 
detached  from  the  tuberosity  of  the  os  calcis.  Then  the  joints  are  opened, 
and  the  inside  of  the  hone  is  cleaned,  and  so  its  removal  is  completed.  I 
have  only  practiced  this  operation  once,  and  then  the  result  seemed  to 
me  less  perfect  than  after  the  ordinary  operation. ' 

After  recover}',  the  only  mark  of  deformity  in  the  foot  is  an  elevation 
of  the  heel  proportionate  to  the  size  of  the  bone  removed. 

Excision  of  the  Astragalus. — The  astragalus  is  easily  removed  by 
making  a  curved  incision  from  one  malleolus  to  the  other,  something 
like  that  made  at  tlie  beginning  of  Syme's  amputation.  The  ankle-joint 
is  then  to  be  laid  freely  open,  and  the  whole  upper  part  of  the  diseased 
bone  tlius  exposed.  Then  the  ligaments  connecting  it  to  the  scaphoid 
are  to  be  severed,  and  the  bone  is  to  be  levered  up,  when  the  interosseous 

1  I  have  always  divided  the  tendons  of  the  peroneus  longus  and  brevis.  They  can, 
of  course,  be  dissected  oat  and  held  aside  with  a  bhmt  hook,  but  I  have  not  observed 
any  bad  effects  from  their  division. 

-  See  Clin.  Soc.  Trans.,  vol.  viii. 

60 


946  OPERATIVE    SURGERY. 

ligament  connecting  it  witli  the  os  calcis  will,  if  entire,  be  felt,  and  can 
be  readily  divided.  All  that  is  then  necessary  to  complete  the  operation 
is  to  clean  the  back  part  of  the  bone,  which  should  be  done  with  care,  in 
order  to  avoid  injury  to  the  tendons  and  vessels  which  lie  near  it.  I  have 
had  several  cases  in  children,  and  have  seen  one  in  an  adult  in  whom  a 
very  useful  foot  was  left. 

The  bone  might  also,  no  doubt,  be  removed  by  two  lateral  incisions 
similar  to  those  used  in  excision  of  the  ankle.  This  would  avoid  the  injury 
to  the  tendons  and  vessels  incidental  to  the  above  method,  but  vpould  be 
more  laborious. 

Other  Excisions  in  the  Foot. — No  formal  directions  are  required  for 
excising  the  other  tarsal  bones.  The  soft  parts  are  to  be  thrown  aside 
by  crucial  incisions,  radiating  from  the  sinuses  wliich  lead  to  the  diseased 
bone,  and  the  latter  removed  ;  care  being  taken,  in  all  cases  where  it  is 
possible,  to  excise  the  whole  bone  with  the  articulating  surfaces. 

The  metatarsal  bone  of  the  great  toe  is  very  often  diseased  ;  and  from 
its  large  size  disease  may  go  on  in  its  substance  for  a  long  period  without 
affecting  any  other  bone.  In  such  cases,  after  a  sufficientl_y  patient  trial 
of  the  appropriate  constitutional  treatment,  with  rest,  it  is  proper  to  ex- 
pose the  disease  ;  and  if  this  is  found  to  include  the  greater  part  of  the 
bone,  then  the  best  course  is  to  remove  the  whole,  with  both  its  articular 
surfaces.  This  may  be  readily  done  by  making  an  incision  over  the 
whole  length  of  the  bone,  joined  by  shorter  perpendicular  cuts  in  front 
and  behind,  and  thus  turning  back  small  rectangular  flaps  including  the 
whole  length  of  the  bone.  It  is  better  to  commence  b}'  severing  it  from 
the  cuneiform  bone,  as  in  dividing  it  from  the  phalanx  the  plantar  arch 
will  most  likely  be  wounded,  and  the  bleeding  may  prove  somewhat  em- 
barrassing; wliereas  if  the  artery  be  not  divided  till  the  bone  is  removed, 
there  is  no  dilTiculty  in  tying  it.  No  splint  is  required.  The  great  toe 
sinks  down  somewhat  towards  the  tarsus,  but  the  foot  is  as  useful  in 
progression  as  lie  fore. 

It  seems  hardl}-  worth  while  to  expend  space  on  the  description  of  such 
rare  operations  as  the  excision  of  the  tarso-metatarsal  joints,^  or  of  por- 
tions or  the  whole  of  the  shaft  of  the  long  bones  (see  p.  425),  or  of  the 
ribs  or  sternum.  They  are  very  rarely  practiced,  and  in  the  latter  case 
especially  the  indications  for  their  performance  should  be  narrowly  scru- 
tinized, since  they  are  by  no  means  free  from  danger,  nor  at  all  certain 
to  attain  the  end  in  view,  which  is  to  remove  the  whole  disease  and 
therein*  take  awa}'  permanentlj^  what  must  always  be  a  source  of  irritation 
to  the  subjacent  viscera. 

'  See  a  case  reported  by  me  in  the  Clin.  Soc.  Trans.,  vol.  v,  p.  207. 


INDEX. 


Abdomen,  gunshot  wounds  of,  342;  injuries 
of,  2:^0;  wounds  of,  235  ;  p.ariicentesis  of,  617 

Abdominiil  iineurisiu,  616 

Abscess,  ,54;  .alveolar,  685;  cold,  55;  intra- 
cr.iniiil,  160;  ischiorectal,  658;  lacunar, 
388;  lumbar,  487;  periosteal,  425;  post- 
ph.'irynfreal,  490;  p.soas.  487;  residual,  57; 
spinal,  484;    subpectoral,  218 

Abscess  of  bone,  429 ;  breast,  859  ;  joints, 
461;  labium,  393;  prostate,  776;  scrotum, 
841  ;  septum  nasi,  599  ;   tongue,  609 

Abscess  in  perinseo,  785,  793 

Abscess,  bleeding  from,  57  ;  inflammation  of, 
57 

Abscess  knives,  56 

Absorbents,  inflammation  of,  566 

Acarus  foUiculorum,  883  ;  scabiei,  877 

Accumulation  of  wax,  757 

Acetabulum,  fracture  of,  243;  impaction  of 
femur  in,  244,  292 

Aehores,  878 

Acne,  882  ;   rosacea,  594  ;  syphilitic,  883 

Acquired  hernia,  618 

Acromial  end  of  clavicle,  fracture  of.  254 

Acromion,  dislocation  of,  271  ;  fracture  of,  257 

Active  congestion,  33 

Actual  cautery,  901  ;   in  haemorrhage,  126 

Acupressure,  122 

Acute  laryngitis,  672  ;  periostitis,  425 

Additamentary  bones,  472 

Adenitis,  566 

Adenoma,  or  adenoid  tumor,  861 

Adhesion,  primary,  41  ;  secondary,  45 

Adhesions,  peritoneal,  producing  strangula- 
tion. 612 

Adhesions  of  iris.  712;  of  labia,  844;  in  ova- 
rian tumor,  856 

Adhesive  syphilitic  inflammation,  396 

Air,  entrance  of  into  veins.  111 

Air-passages,  foreign  bodies  in,  208 

Albinism,  886 

Allarton's  operation  for  stone,  814 

Alopecia,  875  ;  syphilitic,  403 

Alternating  calculi,  805 

Alveolar  abscess,  685  ;  cancer,  376  ;  sarcoma, 
366 

Amaurosis,  730;  from  abscess  of  antrum,  589 

Ametropia,  764 

Amputation  in  burns,  136;  destruction  of 
joints,  469;  fractures,  142;  gunshot  wounds, 
345  ;  osteomyelitis,  428 

Amputation,  914;  circular,  914;  flap,  914; 
instruments  for,  915  ;  of  arm,  916  ;  at  el- 
bow, 918  ;  at  shoulder,  917  ;  of  breast,  860; 
of  fingers,  919  ;  of  forearm,  918  ;  at  wrist, 
919  ;  of  foot.  925  ;  partial,  926,  927  ;  sub- 
astragaloid,  927;   of  leg,  924;  of  penis,  843; 


of  thigh.  923;  at  hip,  921;  at  knee,  923; 
of  thumb,  920  ;  of  toes,  928  ;  Butcher's, 
924;  Garden's,  923;  Chopart's.  927;  Grit- 
ti's,  924  ;  Hancock's,  927  ;  Hey's,  928  ;  Lis- 
franc's,  928  ;  PirogofT's,  927  ;  Syme's,  926  ; 
Teale's,  924 

Amygdaloid  glands,  396 

Anassthetics,  905 

Anastomosis,  aneurism  by,  357 

Anatomical  neck  of  humerus,  fracture  of,  268 

Anchylosis,  bony,  473  ;  extra-articular,  472  j 
false  or  fibrous,  472 

Anchylosis  of  spine,  494 

Anel's  operation  for  aneurism,  533 

Aneurism,  623;  arteriovenous,  627;  cirsoid, 
627  ;  consecutive,  525  ;  diffused,  625  ;  dis- 
secting, 626  ;  false,  52()  ;  fusiform,  526  ; 
true,  525  ;  tubular,  526  ;  varicose,  627.  See 
also  the  names  of  individual  arteries,  as 
Popliteal.  Recurrence  of,  634  ;  rupture  of, 
531  ;  spontaneous  cure  of,  6.'51 

Aneurism  by  anastomosis,  359 

Aneurism  of  bone,  462 

Aneurism  needle,  114 

Aneurismal  sac,  relations  of,  to  artery,  530 

Aneurismal  varix,  627 

Angeioleucitis.  566 

Angular  curvature,  485 

Ankle,  amputation  at,  926  ;  diseases  of,  481  ; 
dislocation  of,  328;  compound,  329;  exci- 
sion of,  943 

Annular  stricture,  784 

Annular  syphilitic  ulceration  of  bone,  441 

Ante-scrotal  urinary  fistula,  794 

Antiseptic  dressing,  50 

Antrum,  cysts  and  dropsy  of,  588;  tumors  of, 
591 

Antyllus.  operation  of.  for  aneurism,  532 

Anus,  artificial,  638  ;  imperforate,  665  ;  fistula 
in,  657  ;  prolapsus  of,  657  ;  pruritus  of,  661  ; 
ulcer  or  fissure  of,  660 

Aorta,  abdominal  aneurism  of,  550  ;  ligature 
of,  551  ;  compression  of,  561 ;  thoracic  aneu- 
rism of,  639 

Aphonia,  nervous  or  hysterical,  678  ;  paralytic, 
679 

Apparatus  for  fracture,  142 

Arch,  palmar,  wound  of,  251 

Arm,  amputation  of,  916  ;  aneurism  in  the, 
648 

Arsenic  as  cautery,  884 

Arterial  hsemorrhage,  112 

Arterial  varix,  527 

Arteriovenous  aneurism,  527  ;  in  orbit,  543 

Arteries,  aneurism  of,  523  ;  atheroma  of,  521  ; 
calcification  of,  621;  division  of.  110;  em- 
bolism of,  522;  inflammation   of,    521;  in- 


948 


INDEX, 


juries  of,  107;  laceration  of,  109;  licrnture 
of,  113;  occlusion  (if  522;  partiiil  lacer- 
ation, 107:  subcutaneous  rupture  of,  108; 
wound  of  1119 

Arteriotomy.  902 

Arteritis,  523 

Artery.  Sei-  the  individual  names,  as  Femo- 
ral, Carotid. 

Arthritis,  rheumatic,  471 

Articular  ends,  diseases  of  463 

Artificial  anus,  638  ;  membrana  tyn>pani,  759; 
pupil,  733 

Aspintor,  the,  229  ;  puncture  of  the  bladder 
by,  792 

Assalini's  fracture  box,  314;  tenaculum,  121 

Astigmatism.  755 

Astragalo-calcanean  joint,  diseases  of,  481 

Astragalus,  dislocation  of,  330  ;  disease  of, 
481  ;  excision  of  945;   fracture  of,  315 

Atheroma,  521 

Atony  friitn  distension  of  bladder,  799 

Atrophy  of  bone,  458;   of  breast,  859 

Atropine  in  iritis,  712,  714 

Aural  polypi.  7ti3 

Auricle,  malformations  of,  756  ;  eruptsions  of, 
756  ;   tumors  of  756 

Autoplastic  par  gli.'sement,  911 

Aveling's  apparatus  for  transfusion,  127 

Avulsion  of  toenail.  893 

Axilla,  dislocation  of  shoulder  into,  271 

Axillary  artery,  aneurism  of,  546  ;  ligature  of, 
548 

Back,  sprains  of  the,  185 

Bacteria,  in  blood-poisoning,  63;  in  erysipelas, 
71 

Baker  Brown's  needle,  848 

Balanitis,  388 

Ball-and-socket  truss,  627 

Bandages.  893  ;  capelline,  895  ;  compound, 
895  ;  four-tailed,  895  ;  many-tailed,  896  ; 
T,  896  ;  spica,  895  ;  spiral,  894  ;  starched, 
898  ;  suspensory,  896 

Bandaging.  893  ;  of  wounds,  21 

Barbadoes  leg.  885 

Base  of  skull,  fracture  of  170  ;  union  of  175 

Bath,  warm,  in  strangulated  hernia,  622 

Bedsores,  SO  ;  from  fractured  spine,  191 

Bellocq's  sound  for  plugging  the  nose,  5&6 

Bending  of  hones  of  forearm,  266.  See  also 
"  Greenstick  fracture.'' 

Bichloride  of  methylene,  908 

Bilateral  lithotomy.  815 

Biliary  fistula  at  umbilicus,  616 

Bird's-nest  cells  in  epithelioma,  373 

Bistouri-cache.  665 

Bladder,  calculus  in,  806;  cancer  of  771  ; 
contraction  of,  in  cystitis,  775  ;  dilatation 
of,  in  cystitis,  775  ;  diseases  of,  768  ;  dis- 
tension of  786  ;  foreign  body  in,  249  ;  re- 
moval of  from,  823;  gunshot  wound  of,  343 
hypertrophy  of,  773  ;  inflammation  of  773 
malformation  of  768;  paralysis  of,  799, 
puncture  of  above  the  pubfs,  780  ;  from  the 
rectum,  791  :  rupture  of  244  ;  from  disten- 
sion, 786  ;  wound  of  249 

Bleeding,  902  ;  in  wound  of  lung,  341  ;  in 
head  injuries.  182 

Blepharitis,  685 

Blind  fistula.  657 

Blisters,  900  ;   in  treatment  of  ulcers,  418 

"  Bloc,  reduction  en."  622,  636 

Blood,  organization  of,  39 


Blood-cysts,  350  ;  within  the  skull,  165 

RIood,  state  of,  in  inflammation,  48 

Bodies,  loose,  in  joints,  469;  in  tunica  vagin- 
alis, 831 

Boils,  888 

Bone,  diseases  of,  422.  See  also  its  various 
affections,  as  Caries,  Necrosis  ;  wounds  of, 
143 

Bony  anchylosis,  473 

Bougies  in  stricture  of  oesophagus,  611 

"  Boutonniere,  la,"  792 

Bowel,  rupture  of  231.     See  also  Intestine. 

Brachial  artery,  ligature  of,  549 

Brain,  compression  of,  178;  concussion  of 
177  ;  traumatic  lesion  of,  176,  180  ;  by  gun- 
shot, 338;   traumatic  inflammation  of  181 

Brain,  implicated  in  disease  of  the  ear,  764 

Brasdor's  operation  for  aneurism,  540 

Breast,  diseases  of,  858  ;  abscess  of  859  ;  am- 
putation of,  866  ;  cancer  of,  864  ;  functional 
disorders  of,  861  ;  inflammation  of.  859  ; 
hypertrophy  of,  858  ;  lobular  induration  of, 
860;  neuralgia  of  861;  tumors  of,  861  ; 
male,  diseases  of,  867 

Bridle  stricture,  784 

Broad  ligament,  cysts  of,  852 

Brodie's  lithotrite,  818 

Bronchocele,  endemic,  868  ;  exophthalmic, 
809;  pulsating,  869;  sporadic,  868;  re 
moviil  of  869 

Bronchotomy,  680 

Bronzed  skin.  886 

Bryant's  test  for  displacement  of  femur,  291  ; 
tracheotomy  canula,  682 

Bubo,  gonorrhoeal,  389  ;  syphilitic,   395 

Bubonocele,  643 

Ballets,  lodgment  of,  335 

Bullous  eruptions,  877 

Bunion,  501 

Burns,  131  ;  degrees  of  132  ;  of  larynx,  214 

Bursa  of  psoas  enlarged,  478 ;  patellae,  en- 
largement of,  498 

Burste,  enlarged,  500 

Bursal  abscess,  499  ;  tumors,  347 

Busk's  splint  for  fractured  femur,  298 

Butcher's  amputation,  924  ;  splint  for  excision 
of  knee,  942 

Buttock,  wounds  and  contusions  of,  240 

Calcaneum,  see  Os  Calcis. 

Calcification  of  arteries,  521 

Calculus,   804  ;  prost:itic,   824  ;  salivary,   583  ; 

urethral,  824  ;  vesical,  803  ;  vesico-prostatic, 

824 
Calculi,  tests  for.  805 
Calculous  nephralgia,  766  ;   pyelitis,  766 
Callous  ulcers,   1 16 
Callus,  144;  provisional,  145 
Calomel  vapor  bath.  400 
Canaliculi,  obstruction  of  750 
Cancer,  368 ;   colloid,   375;  epithelioma,   374; 

medullary,    372;     melanotic,   373;    osteoid, 

373;  pulsatile,  452;  scirrhous,  370;  villous, 

376 
Cancer  of  bladder,   771  ;   bone,   442  ;    eyeball. 

735  ;   lip,  583  ;   oesophagus,  613  ;   ovary,  852  ; 

p-^nis,    842;    prostate.    781;    rectum,     663; 

scars,  420  ;  scrotum,  842  ;  spine,  494  ;  testis, 

837  ;    thyroid,    869 ;    tongue,    605  :    uterus, 

852;   vulva,  847 
Cancerous  ulcers,  417 
Cancroid  tumors,  348 
Cancrum  oris,  85 


INDEX. 


949 


Capelline  bandage,  895 

Capivi  rash.  ;^89 

Carbdlic  dressing  for  wounds,  51 

Carbolizeil  lijratures  for  arteries,  119 

Carbonate  of  lime  calculus,  805  j  deposit  in 
urine.  803 

Carbuncle,  889  ;  facial,  890 

Carcinoma,  MS;  «(;«  Cancer. 

Garden's  amputation,  92.'^ 

C.-iries,  -l-^l  ;  strumous,  481  ;   of  the  spine,  551 

Carotid  artery,  aneurism  of,  540  ;  compression, 
of,  541  ;  ligature  of  common,  641  ;  of  ex- 
ternal, 54;! 

Carpus,  dislocation  of,  285  ;  diseases  of,  483  ; 
fracture  of,  2ii9 

Carte's  compressor  for  aneurism,  636 

Cartilages,  degeneration  of,  4(59;  injuries  of, 
155  ;   loose,  4fi9  ;    ulceration  of,  4(ifi 

Cartilages,  costal,  fracture  of,  222 

Cartilaginous  stricture,  784  ;  tumor,  see  En- 
chondrom:!. 

Castration,   837 

Cataract,  717;  congonital,  7  I  7  ;  laminar,  718  ; 
pyramidal  or  punctated,  718;  senile,  721 

Cataract  glasses,  727 

Catarrh  of  the  tympanum,  762 

Catarrhal  conjunctivitis,  689 

Catgut,  carbolized  for  ligature  of  arteries,  119 

Catheter,  tying  in  a,  790 

Catheter,  Eustachian,  760 

Catheterization,  787;  forced,  780,  791 

Catheter-sound.  808 

Caustic  treatment  of  caries,  433;  naevus,  361  ; 
rodent  ulcer,  416  ;   syphilis,  395 

Cauterisat'on  en  fleches,  902 

Cautery,  actual,  866  ;  in  ovariotomy,  856  ;  in 
hfemorrhage,  126 

Cautt-rv.  galvanic,  901  ;  in  fistula,  659  ;  poten- 
tial,'90  I 

Cautery,  operations  for  piles  by,  656 

Cerebral  diseases  spreading  from  the  ear.  764 

Cervix  femoiis,  fracture  of,  289 

Chancre,  h.ird,  396  ;  sloughing,  395  ;  soft,  394, 
oflip,  409,  582 

Charbon,  891 

Charriere's  guillotine,  585 

Chassaignac's  tubercle,  541 

Cheiloplasty,  913 

Chest,  gunshot  wounds  of,  340;  injuries  of,  217 

Chilblains,  891 

Childcrowing.  674 

Chimney-sweep's  cancer,  842 

Chloasma,  876 

Chloroform,  871 

Chopart's  amputation,  927 

Chordee.  387.  389 

Choroiditis.  734 

Chronic  .'ibscess  of  bone,  429  ;  mammary  tu- 
mor, 861  ;  rheumatic  arthritis,  471  ;  ulcers, 
418 

Cicatrices,  44,  419;  contraction  of,  420,  912; 
excess  of,  4l9  ;  keloid  of.  419  ;  neuralgia  of. 
419  ;   tumors  of,  420  ;   ulceration  of,  419 

Cicatrices  of  cornea,  708 

Cicatrization,  44 

Cilia,  m.'ilposition  and  redundancy  of,  686 

Cili;iry  body,  injuries  of.  738 

Circumcision.  843 

Cirsoid  aneurism,  527 

Civiale's  lithutrite,  817  ;  urethrotome,  797 

Clamp,  Mr.  Lee's,  606;  for  ovariotomy,  856 

Clamp  and  cautery,  operations  for  piles  with, 
666 


Clavicle,  dislocation  of,  270  ;  of  both  ends  of, 
271;  excision  of.  931;  fr.icture  of,  262; 
greenstick  fracture  of,  138 

Clemot's  operation  for  harelip.  572 

Clergyman's  sore  throat,  675 

Clitoris,  hypertrophy  of,  846 

Cloacas  in  bon*,  435 

Clots,  "active  and  passive,"  in  aneurism,  533 

Clove-hitch,  900 

Clover's  crutch  for  lithotomy,  809;  lithotrity 
syringe,  820 

Clubfoot,  605;   relapsed,  613;  see  (/hoTiiUnes. 

Clubhand,  514 

Coagulating  injections  in  aneurism,  538 

Coccyx,  fracture  of.  244 

Cold  abscess,  65  ;   ulcers,  412 

Cold  for  arresting  haeaiorrhage,  125;  for  local 
anajsthesia,  905 

Coles's  artery  compressor,  557 

Collapse,  128 

Collar,  treatment  of  fracture  of  thigh  by,  302 

Colles's  fracture.  267 

Colloid  tumor,  375 

Colotomy,  614,  665 

Complications  of  fracture,  143 

Compound  cysts,  351 

Compound  fracture,   136 

Compound  di>location,  153;  of  elbow.  284  ;  of 
shoulder.  279 

Compression  of  the  brain,  178 

Compressi(m  treatment  of  aneurism,  535 

Concussion  of  the  brain.  176;   of  the  spine,  191 

Condyles  of  femur,  fracture  near,  303  ;  of  hu- 
merus, fracture  of,  261 

Condylomata,  662.  887;  of  meatus  of  ear,  758 

Congenital  cataract.  7l7;  cysts,  352;  of  blad- 
der. 769;  dislocMtion  of  hip,  478;  hernia, 
618;  hydrocele,  829  ;  inguinal  hernia,  640  ; 
syphilis,  407;   tumors  of  the  tongue,  609 

Congestion,  33 

Conical  ooriieii,  710 

Conjurieiiva.  dise.ises  of,  688 

Cotijunclival  tumois,  697 

Coijun-etivitis,  catiirrhal.686  ;  contagious. 693  j 
diphtheritic.  696;  EL'ypiian,  693  ;  epidemic. 
693;  gonorrhoe:il,  690  ;  inf.mtile.  689;  phlvc- 
tenular.  696  ;  purulent,  689,  690  ;  simple, 689 

Consecutive  aneurism.  625 

Contagious  ophthalmia,  693 

Continuous  suture.  899 

Contracted  cicatrix,  420,  912;  palmar  fascia, 
514 

Contraction  of  bowel  .ifter  «trangulation,  637 

Contre  coup,  fracture  by,  169 

Contusion,  39;  of  arteries,  107;  of  buttock, 
240  ;   of  scrotum.  247 

Copaiba,  admini-^tTiiti(m  of,  392 

Goracoid  process,  fracture  of,  257 

Cord,  scrotal,  affections  of  830  ;  hsematocele 
of.  831  ;  hydrocele  of.  830 

Cord,  spinal,  impli-eation  of,  in  disease,  486 

Corns,  886 

Cornea,  diseases  of.  698  ;  abscess  of.  706  ;  acute 
ulcers  of.  707  ;  cicatrices  of,  708  ;  conical, 
710  ;  flattening  of,  in  ophthalmia.  693  ;  im- 
plication of.  in  ophth.-ilmia,  690,  692  ;  opacity 
of,  703;   suppuration  of  70.t;    wound  of,  740 

Coronoid  process  of  jaw,  fracture  of,  198 

Coronoid  process  of  ulna,  fracture  of,  266  ;  in 
dislocation  of  elbow,  281 

Coryza,  chronic,  597 

Costal  cartilages,  fracture  of,  222 

Coxeter's  extractor,  337 


950 


INDEX. 


Cracks  of  lips,  6S1 

Craiiiutu,  tuinnrs  of,  580  ;  sec  uho  Skull. 

Crepitus  of  fracture,  140 

Oripps's  splint  for  fractured  femur,  300 

Croup,  6~-y 

Cruiie  tubercle,  '-^TS 

Crutch,  Clover's,  for  lithotomy,  809 

Cubebs  in  gonorrhoea,  392 

Cupping,  903 

Curvature,  angular.  485  ;   lateral,  491 

Cutaneous  cysts,  351  ;   congenital,  H52 

Cut  throat.  203 

Cyanche  tonsillaris,  584  ;   trachealis,  673 

Cyst,  congenital,  of  bladder,  7fi9 

Cystic  disease  of  breast,  862,  863  ;   testicle,  835 

Cystic  enchondroma.  35S 

Cystic  tumors,  349  ;  compound,  351  ;  of  bone, 

4^0;   of  broad  ligainent,  852  ;  of  jaws,  589; 

of  labia,  846  ;  of  ovary,  852 
Cystigerous  cysts,  353;   of  ovary,  853 
Cy.^tic  oxide.  802,  804 
Cystiti.s  773 
Cystoeele,  vaginal.  849 

Deafness,  diagnosis  of  its  source,  761  ;  syphil- 
itic, 764 

Degeneration  of  muscles,  502 

Delirium  tremens,  91 

Demarcation,  line  of,  76 

Deposits,  secondary,  61  ;  urinary,  801 

Depressed  fracture  of  skull,  167;  trephining 
for,  170 

Dermal  cysts,  353 

Dermal  tumors  of  ovarj',  853  ;  testis,  838 

Default's  splint  for  fractured  femur,  299 

Diaiihragm,  gunshot  wound  of,  342 

Diaphragm.'itie  hernia,  652 

Diffuse  inflammation,  70 

Diffused  iineurism,  526  ;  bony  tumor,  450 

Digital  compression  in  amputation,  909  ;  of 
aneurism,  535 

Dilataticm  of  stricture,  788;  rapid,  788;  for- 
cible, 796 

Diphtheritic  conjunctivitis,  696 

Direct  iriguinal  lieinia,  646 

Diieet  ophth;ilmo.«copic  examination,  727 

Discission  of  the  lens,  719 

Dislocation,  general  pathology  of,  154;  of 
acromion,  271  ;  of  ankle,  328;  of  astragalus, 
330  ;  of  carpus,  285  ;  of  clavicle,  270  ;  of 
elbow,  280;  of  fingers.  287;  of  hip,  315;  of 
humeru.s,  271  ;  partial,  279  ;  compound,  279  ; 
complicated  wiih  fracture,  276;  of  knee, 
325;  of  lens,  740;  of  metatarsus,  333;  of 
patella,  326  ;  of  pelvis,  243  ;  of  phalanges 
of  foot,  333;  of  radius,  upper  end,  283; 
lower  end.  284;  of  ribs.  292;  of  semilunar 
cartilages.  327  ;  suhastragaloid,  331  ;  of  tar- 
sus, 333  ;  of  thumb,  286  ;  of  tibio-fibular 
joint,  327  ;  of  ulna,  283  ;  of  vertebrae,  188  ; 
of  wri.st.  284 

Dislocation,  congenital,  of  hip,  478 

Dislocation  in  hip  di.sease,  477 

Dislocation,  partial,  and  osteoarthritis,  472 

Displacement  of  fracture,   140 

Dissecting  aneurism,  527 

Dissection  warts,  8>S8  ;   wounds,  93 

Distal  ligature  in  aneurism,  540 

D>.g.  hydrophobia  in  the,   102 

Dolbeaii's  perineal  lilhutrity,  816 

Dorsum  ilii,  dislocation  in,  315 

Double  vision,  741 

Double-headed  roller,  895 


Drilling  ununited  fracture,  151 

Dropsy,  ovarian,  854;  of  joint,  462 

Dry  gangrene,  76 

Duchenne's  disease,   504 

Duodenum,  ulceration  of,  in  burns,  134 

Dupuytren"s  clas»ification  of  burns,    131  ;    en- 

terotome,  639 
Dura  mater,  fungous  tumor  of,   580 
Durnam's  tracheotomy  canula,  682 
Dysphagia,  nervous,  611 
Dysphonia  clerinorum,  675 
Dyspnoea  in  wound  of  lung,  341 

Ear,  diseases  of  the,  756  ;  foreign  bodies  in,  196 

Eir-ring,  tumors  in  puncture  of,  766 

Earle's  bed,  295 

Eburnation  of  joint  ends,  471 

Ecraseur,  the,  606  ;   in  fistula,  659 

Echthyma,   879 

Ectropium,  687 

Eczema,  872:  impetiginodes,  879;  syphilitic, 
872 

Eczematous  ulcer,  413 

Elastic  ligature  in  fistula,  659 

Elbow,  amputation  at,  918  ;  excision  of,  932  ; 
subperiosteal,  933  ;  diseases  of,  483  ;  disloc.i- 
tion  of,  2«0  ;  fractures  near,  262  ;  inflamma- 
tion of  bursa  of,  500 

Electrolysis  in  ntevus,  361 

Electro-puncture  of  aneurism,  538 

Elephantiasis,  Arabum,  885;  Grajcorum,  884; 
of  scrotum,  841 

Elevated  fracture  of  skull,  168 

Elevator,  184 

Embolism,  79,  522 

Emigralion  of  leucocytes,  36 

Emmetropia,  754 

Emotional  contractions,  516 

Emphysema,  220  ;  in  wound  of  Umg,  341 

Encephalitis,  traumatic,   181 

Eiicephalocele,  580 

Eneephaloid  cancer,  372 

Enchondroma,,  357,  446  ;  ossifying,  449;  of  jaw, 
691;   of  septum  nasi,  599  :  of  testicle,  836 

Encysted  hernia,  642  ;  hydrocele,  830 

Endoscope,  the,  809 

Enlarged  prostate,  779  ;   tonsils,  584 

Enterocele,  617 

Entero-epiplocele,  617 

Enteiotome,  the,   689 

Entrance  and  exit  wounds,  gunshot,  333 

Entropium,  686 

Enucleation  of  eyeball,  739;   of  ncevus,  361 

Enuresis,  800 

Eperon,  the,  in  artificial  anus,  639 

E|)ididymiiis.  83". 

Epigastric  artery,  wound  of,  in  paracentesis, 
616 

Epiphyses,  separation  of,  139 

Epiphysis,  lower,  of  femur,  sepiration  of,  303  : 
upper,  of  femur,  disjunction  of,  295  ;  lower  of 
huinei  us,  separation  of.  263  ;  upper  of  hu- 
merus, separation  of,  251 

Epiplocele,   617 

Epi.scleritis,  697 

Epispadias,  781 

Epi.-taxis,  596 

Epithelioma,  374;  of  bone,  444 

Epulis,  590 

Eiininia  mitis,    100 

Erethism,  mercurial,  399 

Eruptions,  bullous.  877;  exanthematous,  870; 
bacmorrhugic,  871  ;  papular,  880  ;  parasitic, 


INDEX. 


951 


874  ;  pustular,  878  ;  secondary  syphilitic, 
401  ;  siiuiiiiKius,  882;  tertiary  syphilitic, 
405  ;  tuhiTcular,  882  ;  vesicular,  872  ;  xero- 
derinatous,  88(5 

Erysipelas,  67  ;  phlegmonous,  70  ;  of  scalp,  159 

Erythema.  (57  ;  laeve,  (57  ;  intertrigo,  67  ;  fugax, 
67  ;  nodosuna,  68 

Esmarch's  bandage,  909 

Ether,  906  ;   as  local  anocsthetic,  905 

Eust:ichian  catheter,  the,  760 

Eustnchiiin  tuhe,  tx:imin;ition  of,   760 

Exanthematous  eruptions,  870;  jaw-necrosis, 
687 

Excisions,  929  ;  subperiosteal,  930  ;  of  niilile, 
943  ;  of  astragalus.  945  ;  of  clavicle,  9.31  ; 
elbow.  932;  hip,  937;  knee,  938;  raelatar 
sal  bones,  910;  os  calcis,  946;  os  uteri,  852; 
sciipula,  931  ;  shoulder,  929  ;  wrist.  935 

Excision  in  osteoarthritis,  472 

Exclusion  of  pupil,  713 

Exfoliation,  435 

Exostosis,  358,  447  ;  ivory,  447  ;  cancellous, 
449;  diffused,  451  ;  of  external  meatus,  758; 
of  j'lw,  591 

External  hfcmorrhoids,  654  ;  urethrotomy,  795 

Extra-capsular  fracture  of  femur,  289  ;  of  hu- 
merus, 259 

Extr.'iction  of  cataract,  722;  haemorrhage  after, 
726 

Extra-peritoneal  operation  for  hernia,  631 

Extraviisation  in  scalp,  157  ;  below  the  skull, 
162  ;  in  arachnoid  cavity,  165  ;  in  the  brain, 
166 

Extravasation  of  urine,  785 

Extremity,  lower,  injuries  of,  288  ;  upper,  in- 
juries of.  250 

Extremities,  gunshot  wounds  of,  343 

Exuberant  sciirs,  419;    ulcers,  418 

Eye,  contusion  of,  739  ;  diseases  of,  683  ;  enu- 
cleation of,  739  ;  injuries  of,  737  ;  paralysis 
of  mu.-cles  of,  748  ;  tumors  of,  735 

Eyeball,  rupture  of,  740;  tension  of,  729 

Eyeliishes,  malposition  and  redundance  of,  686 

Eyelids,  diseases  of,  684  ;  wounds  of,  687 

Face,  gunshot  injuries  of,  339  ;  injuries  of,  195 
Faci.il  bones,  fr^icture  of,  196 
Faecal  flstuhi  in  herni.i,  635,  638  ;  from  imper- 
forate anus,  666  ;   at  umbilicus,  616 
Fseees,  impaction  of  613 
False  iineuris-.u,  526  ;  joint  after  fracture,   149; 

passage  (urethral),    788 
Farcy,  98 

Fascia  (if  piilm,  contraction  of,  514 
Fatty  tumors,  354 
Favus,  875 
Female,    lithotomy    in    the,    816  ;    diseases  of 

organs  of  gener.ition,  845 
Femoral  artery,  aneurism  of,  654  ;  ligature,  of 

common,  565;  of  supei  ficial,  556,  556 
Femoral  hernia,  647 
Femur,  fracture  of  neck  of,   289  ;  of  upper  end 

of,  295  ;  of  lower  end,  303  ;  of  shaft,  298  ;   in 

childhood,  302 
Femur,  impaction  of,   in  acetabulum,  244 
Fenestrated  lithoirite,  8  17 
Fergusson's  knot  for  strnn2;ulation  of  naevi,  362 
Fever,     hectic,     64;     infl.inimatory,     35,    46; 

miliary,  872;    urethral,  795 
Fibrinous  calculus,  806 
Fibrocellular  tumor,   356 
Fibrocystic  tumor,  356  ;  of  bone,  451 
Fibroplastic  tumor,  367;  of  breast,  863 


Fibrous  anchylosis,  472 

Fibrous  polypus  of  nose,  601 

Fibrous  tumor,  366  ;  of  uterus,  851  :  diagnosis 
from  ovarian  tumor,  854 

Fibula,  dislocation  of  head  of,  327  ;  fracture 
of,  3  1 1 

Figure  of  8  bandage,  895 

Fingers,  amputation  of,  919  ;  dislocition  of,  287 

Fissure  of  anus,  660;  of  lip,  581 

Fissured  palate,  574 

Fistula,  58  ;  ante-scrotal,  794  ;  in  ano,  657  ; 
fee^'al,  in  hernia,  635,  638  ;  fajcal,  from  im- 
perforate anus,  666  ;  lachrymal.  750  ;  lym- 
phatic, 566  ;  in  perinaso,  785,  794  ;  recto- 
urethral,  814;  recto-vaginal.  814;  salivary, 
195  ;  umbilical.  616  ;  urinary,  785,  794  ; 
vesico-intestinal,  776;  vesicovaginal,  849 

Fit,  hysterical,  383 

Flatfoot,  512 

Flexion  in  aneurism,  537;  in  reduction  of  dis- 
location of  hip,  316,  323,  325 

Fluctuation.  65 

Focal  illumination  for  detection  of  cataract, 
723 

Foetal  tumor  of  testis,  838 

Follicular  granulations  in  epidemic  ophthal- 
mia, 693 

Follicular  Laryngitis,  675 

Foot,  amputation  of,  926  ;  dislocation  of,  from 
astragalus,    331 

Forced  catheterization.  780,  791 

Forcible  taxis,  dangers  of,  621 

Forcipression,   125 

Forearm,  amputation  of,  918;  aneurism  in  the, 
649  ;  dislocation  of,  backwards  at  elbow, 
281  ;  fractures  of  264 

Foreign  bodies  in  abdomen,  235  ;  in  air-paa- 
s;ige,  208  :  in  bladder,  249  ;  removal  of,  823  ; 
in  ear,  196  ;  in  eyelids,  737  ;  in  hand,  251  ; 
in  intestine,  23S  ;  in  nose,  196  ;  in  oesopha- 
gus, 214  ;  in  rectum,  249  ;  in  stom.ach,  237  ; 
in  thorax,  225;  in  urethra,  249  ;  in  vagina, 
249  ;  introduction  of,  for  cure  of  aneurism, 
538 

Fourtailed  bandage,  895 

Fractures,  general  pathology  of,  137  ;  simple, 
138;  compound,  138;  transverse,  138;  ob- 
lique. 138;  dentated,  138:  greenstick,  138; 
impacted,  110 

Fraciures  of  the  astragalus,  316;  carpus,  269; 
clavicle,  252  ;  coccyx,  244  ;  costal  cartilages, 
222;  facial  bones,  196;  femur,  296;  fibula, 
311  ;  foot,  3 '4  ;  forearm.  264  ;  humerus,  258; 
jaw,  196  ;  larynx,  207  ;  leg,  310  ;  malar  bone, 
197;  metacarpus,  269:  met.itarsus,  315; 
neck  of  femur,  289;  union  of,  294;  olecranon, 
264  ;  OS  calcis,  314  ;  ossa  nasi,  196  ;  p.itella, 
306  ;  pelvis.  241  ;  phalanges  of  hand,  269: 
foot,  314;  radius,  266;  ribs,  218;  .'^capula, 
256  ;  skull,  167;  spine,  186;  sternum.  222; 
tibia,  311  ;  trochanter  major,  295;  ulna,  266; 
zygoma.  197  ;  CoUes's,  267;  Potfs,  325 

Fracture-box.  314 

Fr.icture  of  exostoses.  450 

Fr.icture  from  necrosis,  438 

Fracture,  union  of,   144;   ununited,   148 

Fracture,  spontaneous,  459 

Fr.igilitas  ossium,  458 

Fragments,  impaction  of,  after  lithotrity,  821 

Framboesia,  886 

Frontal  sinus,  fracture  of,  168 

Frostbite,   81 

Fulminating  glaucoma,  728 


952 


INDEX. 


Fundus  of  herniiil  sac,  618 
Fungous  tumor  of  dura  mater,  681 
Fungus  hscmatodes,  372 
Funicular  canal,  patency  of,   726 
Fu.-ible  calculus,  805 
Fusiform  aneurism,  526 

Gag,  Hutchinson's,  606 
Galaetoeele.  864 
Galactorrhcea,  861 
Gallbladder,  rupture  of,    2:V.] 
Galvanic  cautery,  I'Ol  ;   in  fistula,  659 
Galviino-puncture  of  aneurism,  5;-;8 
Ganglion,  501  ;  compound  palmar,  502 
Gangrene,  75  ;  dry,  76  ;  moist,  76  ;  traumatic, 

75  :  from  embolism,  79  ;  hospital,  81  ;  senile. 

84;    of   hernia,  619;    treatment  of,  6;H  ;    of 

penis,  844  ;  after  ligature  of  artery,  118 
Garters,  lithotomy,  809 

Gastrotomy,  2;i8  ;  for  obstruction  of  bowel,  614 
Gastrostomy,  239 
Gelatinous  polypus,  599 
Genuflexion  in  popliteal  aneurism,  558 
Giant  celled  sarcoma,  365 
Giraldes's  operation  for  harelip,  573 
Glands,    inflammation    of,    666  ;     sympathetic 

afifections  of,  567  ;  strumous,  667  ;  syphilitic, 

404:  cancerous,  568 ;  inguinal,  diagnosis  of, 

from  hernia.  649 
Glanders,  98 
Glaucoma,  728 
Gleet,  388  ;  treatment  of,  384 
Gliome,  735 
Globus  hystericus,  383 
Glossitis,  610. 
Glue  splint,  897 
Gluteal  aneurism,  55'! 
Goitre,  Sfe  Bronchocele. 
Gonori  hoea,  387  ;  in  female,  392  ;  treatment  of, 

391 
Goaorrhoeal    ophthalmia,    690;    orchitis,    833; 

rheumatism,  389 
Gordon's  splints  for  fracture  of  radius,  268 
Gout,  rheumatic,  471 
Gouty  ulcer,  414 
Grafting  of  skin,  421 
Granuhitions,  44 
Granubitions   of  conjunctiva,    follicular,    693 ; 

papillary,  695 
Graj'  tubercle,  377 
Greenstick  fracture,  138 
Griiti's  ampul;ition,  924 
Guillotine,  tonsil,  585 
Gum-and-chalk  splint,  897 
Gum  boil,  586 

Gumraata,  4(i6  ;  of  the  tongue,  609 
Gunshot  wounds,  334 
Gutta  percha  splints,  898 

Hsematocele,  831  ;  of  the  cord,  831 

Htem;itoma.  39;  auris,  756 

Htematuria,  767;  in  gonorrhoea,  389 

UaJinofihilia,   105 

iliemopiy>is  in  wound  of  lung,  311 

Hasinorrhage,  105  ;  habitual,  107  ;  arterial, 
112;  venous.  112;  recurrent,,  118;  prostatic, 
778;  secondary,  after  ligature  rjf  artery,  115, 
534 

Ha-'Miorrhage,  means  of  restraining,  909 

Hictnorrhiigi;i,  871 

Hainonhagic  diathesis,  105 

Hie  norihagic  ulcers,  418 

Hemorrhoids,  654;  urethral,  846 


Hemostatics.   126 

Hemothorax,  221 ,  341 

Hainsby's  harelip  truss,  574 

Hand,  foreign  bodies  in,  261 

Hani  chancre,  396 

Harelip,  669  ;  double,  573  ;  complicated,  573 

Harelip  suture,  899 

Head,  gunshot  wounds  of,  338  ;  injuries  of,  157 

Healthy  ulcer,  412 

Heart,  wounds  of,  225  ;  rupture  of,  228 

He.it.  in  inflammation,  34 

Hectic  fever,  66 

Hernia,  617;  gangrene  of,  619;  inflammation 
of,  619;  incarcerated,  618;  strangulated, 
618;  radical  cure  of.  .629;  sre  also  the 
various  forms,  as  Inguinal,  Femoral. 

Hernia  cerebri,  182;  of  the  lung,  224;  testis, 
836 

Hernia  knife,  631 

Herni.il  sac,  hydrocele  of,  830 

Herniotomy,  630 

Herpes.  873;  zoster,  873;  of  lip,  581 

llesselhach,  triangle  of,  646 

Ht-terologous  tumors,  348 

Hey's  saw,   184 

Hide's  felt  splint,  898 

Hilton's  nasal  snare,  600 

Hip.  amputation  at.  922  ;  disease  of,  475  ;  con- 
genital dislocation  of,  478;  dislocations  of, 
313  ;  excision  of,  937  ;  subperiosteal,  938 

Hddgkin's  disease,  568 

Holt's  instrument  for  forcing  a  stricture,  796 

Homologous  tumors,  348 

Horns,  888 

Horsehair  probang  for  oesophagus,  216 

Hospital  gangrene.  82 

Housemaid's  knee,  498 

Hum"rns.  disloc.ition  of.  271  ;  fracture  of,  258 

Hunierian  chancre,  396  ;  operation  for  an- 
eurism, 632 

Hutchinson's  gag,  606 

Hydatids  in  bone,  452;  breast,  864  ;  liver,  617 

Hydrencephalocele,  580 

Hydrocele.  726  ;  congenital,  829  ;  infantile, 
829  ;  of  the  cord.  830  ;  encysted,  830 

Hydrocele  of  hernial  sac,  830 

Hydrocele  of  the  neck,  349 

Hydrophobi.i,  100 

Hydrops  aiticuli,  462 

Hydrosarcocele,  830 

Hymen,  imperforate,  844 

Hyoid  bone,  dislocation  and  fracture  of,  206 

Hyperiiietropia,   754 

Hy  |)ertro[)hy,  congenital,  of  the  tongue,  609 

Hypertrophy  of  bone,  457 

Hyp(ichondri:isis,  sexual,  839 

Hyponarthetic  apparatus,  143 

Hypospadias,  781 

Hysteria,,  382 

Hysterical  aphonia,  678  ;  contractions,  616  ; 
fit,  383  ;  disease  of  joints,  474 

Hysterotomy,  851 

Ice.  application  of,  in  strangulated  hernia,  622 

I  e  and  salt  as  an  anesthetic,  905 

Ichthyosis,  886;  lingue,  608,  609 

Iliac  arteries.  Iig;iture  of,  551 

Iliofemor.il  aneuri,<m,  554 

Ilium,  fracture  of,  241 

I  iipicted  fracture,   140 

lm|iaciion   of  feces,    613;   of  fragment?   after 

lithutrity,  H2  I 
Impassable  stricture,  790 


INDEX. 


953 


Imperforate  iinus,  6fi5  j  hymen,  844  ;  vagina, 
845 

Impetigo.  878  ;  syphilitic,  879 

Inc.'ircenited  herni:i,  618 

Incision  of  ineiuhrana  tyinpani,  7fi2 

Incomplete  fr;icture,  sen  Greenstick  Fracture. 
Hernia,  see  Bubonocele. 

Incontinence  of  urine,  799 

Incurvation  of  tarsal  c.irtilage,  686 

Indian  operation  of  rhinoplasty,  911 

Indirect  of)hthalmoscopic  examination,  728 

Indolent  ulcer-ii,  418 

Indurated  annular  stricture,  784 

Infiintile  hernia,  642;  hydrocele,  829;  leucor- 
rha3i,  398;  paralysis,  60.'{  ;  purulent  oph- 
thalmia, 689;  sypiiilis,  407 

Infants.  non-con>.'enital  syphilis  in,  409 

Infiltrating  cancer  of  bone,  442 

Inflamed  bowel  in  hernia,  treatment  of,  634  ; 
hernia.  619;  ulcers,  418 

Inflamm;ition,  33 

Infl;imm.itory  ulcer.  412 

Inflition  of  tympanum,  760 

Infra  and  supra-condyloid  fractures  of  humerus, 
263 

Ingrowing  toenail,  892 

Inguinal  aneurism,  554  ;  hernia,  congenital, 
640;  direct,  646;  encysted,  642;  infantile, 
642  ;  oblique,  640,  645  ;  in  the  female  646  ; 
truss,  625 

Injections,  coagulating,  in  aneurism,  638  ;  in 
naevus,  361;  in  gonorrhoea,  391;  of  hydio- 
cele,  828  ;  of  bone,  their  diagnosis,  443 

Innoniin:ite  artery,  aneurism  of,  539;  ligature 
of,  546 

Inoculation  for  pannus,  698  ;  of  secondary 
syi'hilis,  404  ;  syphilitic,  410 

Insufflition  for  polypi,  601  ;  of  invaginated 
bowel,  615 

Intention,  first,  41  ;  second,  42  ;  third,  45 

Intercostil  artery,  wound  of,  227 

Internal  ear,  afiffctions  of,  764  ;  hasmorrhoids, 
654;  operations  for,  655;  mammary  artery, 
wound  of,  227  ;  strangulation,  612  ;  urethrot- 
omy, 797 

Interrupted  suture,  899 

Intertrigo,  67 

Interstitial  cancer  of  bone,  443  ;  keratitis,  704 

Intestine,  gangrene  of,  in  hernia,  619  ;  perfora- 
tion of,  in  hernia,  619;  protrusion  of,  from 
wound,  236  ;  internal  strangulation  of,  612; 
rupture  of,  231,  622  ;  suture  of,  237  ;  ulcera- 
tion of,  in  hernia,  6  19 

Intracapsular  fracture  of  feiuur,  289  ;  of  hu- 
merus, 258 

Intracoracoid  dislocation  of  shoulder,  273 

Intnicranial  suppuration,  160 

Intussusception,  614 

InvMgination  of  dead  bone,  434  ;  of  intestine, 
614 

Iodide  of  potassium  in  syphilis.  400,  405 

Iodine,  injection  of,  in  hydrocele,  829 

Iridect..my.  701,  703,  709,  715,  725,  731 

Iridectomy  forceps,  725 

Iridochor.iiditis,  716 

Iris,  adhesions  of,  712  ;  coloboma  of,  711  ;  cj-sts 
and  tumors  of,  711  ;  inflammation  of,  71  I  ; 
wounds  of.  740 

Iritis,  711;  serous,  716;  from  solution  of 
catanct,    717 

Irreducible  hernia,  618,  622 

Irrigation  of  wounds,  52 

Ischiatic  hernia,  653 


Ischiorectal  abscess,  658 
Issues,  900 
Itch,  877 

Jaws,  closure  of,  593  ;  necrosis  of.  586  ;  ex- 
antheinatous,  587  ;  removal  of,  592  ;  tumors 
of,  588 

J.iw,  lower,  dislocation  of,  200  ;  fracture  of, 
197 

Jaw,  upper,  removal  of,  for  nasoph.iryngeal 
polypus,  601 

Joints,  diseases  of,  459  ;  .tee  also  the  names  of 
the  various  joints  and  of  special  affections, 
as  Synovitis,  Arthritis,  etc.  ;  wounds  of,  289 

Jugular  vein,  wounded  in  fracture  of  clavicle, 

Junks,   142 

Juvenile  incontinence  of  urine,  800 

Keloid,  885  ;  tumors  of  auricle,  756  ;  of  scars, 

419 
Kelotomy,  630 
Keratitis,  701  ;   interstitial,  704;  suppurative, 

705  ) 

Kidney,    diseases    of,    766;    rupture    of,    234;      ' 

stone  in,  766  ■ 

Knee,   amputation  at,   923  ;    diseases  of,  459- 

474  ;  dislocation  of,   325  ;   excision  of.  938  ; 

fracture  into,  305  ;   gunshot  wounds  of,  346  ; 

wounds  of,  289 
Knock-knee,  457,  514 
Kyphosis,  493 

Labia,  abscess  in,  393  ;  adhesion  of,  845  ;  cysts 
of,  846  ;  hypertrophy  of,  846  ;  injuries  of, 
248  ;  tumors  of,  846 

Laceration  of  the  brain,  180 

Lachrym.'il  apparatus,  diseases  of,  750  ;  fistula, 
750 

Licteal  abscess,  859 

Lacunar  abscess,  388 

Laminiir  cat;iract,  718 

L:ipis  divinus,  693 

Laryngismus  stridulus,  674 

Laiynj^itis,  671  ,  chronic,  674  ;  follicular,  675  ; 
phthisical,  674  ;  syphilitic,  675 

Laryngoscopy,  669 

Laryngotomy,  680 

Laryngo-tracheotomy.  680 

Larynx,  burn  of,  214  ;  contusions  of,  206  ;  dis- 
eases of.  669  ;  extirpation  of,  678;  fnctures, 
of.  207;  scald  of,  214;  tumors  of,  676 

Lateral  curvature,  491 

Laughing  gas.  908 

Leather  splints,  898 

Lee's,  Mr.  H. ,  clamp,  605  ;  amputation  of  leg, 
925 

Leg,  amputation  of,  924 ;  fracture  of,  311  ; 
compound,  312 

Lens,  diseases  of,  717;  dislocation  of,  740; 
wounds  of,  740 

Lentigo  hepatica,  876 

Lepra,  882 

Leprosy,  884 

Leucocytes,  emigration  of,  36 

Leucorrhoea  infantum,  393 

Lichen,  880;  .syphilitic,  880 

Ligature,  for  aneurism,  causes  of  failure  of, 
534;  of  arteries,  114;  repair  after,  115; 
gangrene  after,  118  ;  elastic,  in  fistula,  659  ; 
of  nsevus,  360 ;  subcutaneous,  362 ;  round 
penis,  248  ;  of  piles,  656.  For  ligature  of 
special  arteries,  see  their  names. 


954 


INDEX. 


Lightning  stroke,  lofi 

Lime  in  eye,  741 

Linear  eM.iioiion  of  cataract,  724 

Lineiir  knife  for  ciitanict,  724 

Lingual  ;irtery,  ligature  of,  543 

Lip,  chiincre  of,  410  ;   diseases  of,  58 1 

Liponiii,  ;i55  ;    niisi,  594 

Lister's  method  of  dressing  wounds,  49 

Listen's  tenaculum,   121  ;   thigh  splint,  300 

Lithate  of  ainmonii  calculus,  804 

Lithates,  deposit  of  in  uiine,  801 

Lithic  acid  deposit  in  urine,  801;  calculus, 
803 

Lithotomy,  lateral,  810;  median,  8)4;  peri- 
neal, 815;  hypogastric,  816;  causes  of  death 
after,  814  ;  rectal,  815  ;  in  the  fVmale,  816 

Lithotomy  and  lilliotrity  compared,  SdO 

Lithotomy  garters,  809 

Lithotrites,  817 

Lithotrity,  817;  complications  after,  821  ;  re- 
moval of  fragments  in,  822;    perineal,  816 

Littre"s  ojieration,  614 

Liver,  hydatid  tumors  of.  017  ;   rupture  of,  233 

Liverspot,  876 

Lobular  induration  of  brea^t,  860 

Local  anaesthetics,  905 

Locally  malignant  tumors,  348 

Loose  bodies  in  tunica  vaginalis,  831 

Loose  cartilages,  459;   operation  for,  470 

Lordosis,  494 

Lower  exfremitj',  injuries  of,  288 

Lower  jaw,  removal  of,  693 

Lumbar  abscess,  487 

Lumbar  hernia,,  653 

Lung,  gunshot  wound  of,  340  ;  hernia  of.  224  ; 
rupture  of,  228;  wound  of  in  fractured  ribs, 
220 

Lupous  ulcers,  415 

Lupus,  883  ;  erythematous,  884  ;  exedens,  884  ; 
im))etiginous,  884;  non-exedens,  884;  stru- 
mous, 884;   syphilitic,  884 

Lymjihadenoma,  568 

Lymphatic  fistula,  566 

Lymphalies,  inflammation  of,  566 

Lympho-sarcoma,  668 

Lyssi  in  hydrophobia,  103 

Maclntyre's  splint,  314 

M.icroglossia,  609 

Macula,  886 

Maisonneuve's    instrument    for    urethrotomy, 

798 
Miilai'osteon,  453 
Mahir  bone,  fracture  of,  197 
Male  brr.i.vt,  diseases  of,  867 
Malforu)atiiins.    see  the   nauies  of    the   organs 

affected,  as  Pharynx,  Rectum,  etc. 
Malgaigne's  books  lor  fracture  of  patella,  308 
Malignant  pustule,  891  ;   polypus  of  nose,  603; 

tumors,  348 
Mammary  abscess,  860;  artery,  internal, wound 

of,  227;   tumor,  chronic,  861 
Mammilla,  see  Nipple. 
Manipulation  of  aneurism,  638 
M.iny-laileil   bandage,  896 
••Ma.«se,  reduction  en,"  622,  636 
Ma.-toid  cells,  disease  of,  763 
Maxilla,  set;  Jaw. 

Meatu.s,  exieriuil,  inflammation  of,  757 
Median  lithotomy,  814 
Mediastinum,  wounds  of,  225 
Medullary  cancer,  372 
Medullary  tissue  of  bone,  inflammation  of,  426 


Meibomian  glands,  obstruction  of,  684 

Melancholic  form  of  scrofula,  379 

Melanosis,  366,  373 

Membrana  tympani,  artificial,  759;  examina- 
tion of,  767;  incision  of,  762;  perforation 
of,  758 

Meniere's  disease,  765 

Meningeal  artery,  middle,  haemorrhage  from, 
163  ;  ligature  of,  163 

Meningocele,  679 

Mentagra,  876 

Mercurial  erethism,  399;  inunction,  398;  va- 
por bath,  400 

Mercury  in  congenital  ophthalmia,  690  ;  iritis, 
715;  syphilis,  398 

Mesenteric  artery,  superior,  aneurism  of.  550 

Mesentery,  rupture  of,  621 

Metacarpus,  fracture  of.  269 

Metatarsal  bones,  excision  of,  946 

Metatarsus,  dislocation  of,  333  ;  fractures  of, 
316 

Microsporon  Audouini,  875;  furfurans,  876; 
mentagrophytes,  876 

Miliaria,  872 

Miliary  tubercle,  377 

Milk,  irregularities  of  secretion  of,  861 

Milk  cysts,  864 

Minor  surgery,  893 

Mocmain  lever  truss,  626 

Moles.  886 

Mollities  ossium,  453  ^^ 

Molluscum,  883 

Monteggia's  dislocation  of  hip,  325 

Morbus  coxarius,  475 

Moxa,  901 

Mucous  cysts,  350  :  polypus,  599  ;  sarcoma, 
366  ;  tubercle,  366,  402.  662  ;  of  the  tongue, 
608 

Mucus,  accumulation  of  in  tympanum,  762  ; 
ropy,  in  cystitis,  774 

Mulberry  calculus,  804 

Mumps,  oichitis  after,  833 

Muscles,  atrophy  of,  502  ;  progressive,  502  ;  in- 
flammation of,  497;  rupture  of,  218,  496; 
tumors  of,  504 

Myeloid  tumor,  364 

Myopia,  755 

Myxoma,  366 

Noevus,    360;    degeneration    of,    364;    of    lip, 

581  i   of  the  tongue,  609 
Nails,  ingrowing,  892  ;   avulsion   of,  893  ;    pso- 
riasis of,  892 
Nasal  bones,  fracture  of,  197 
Nas.il  douche,  698;   duct,  obstruction  of,  750 
Nasopharyngeal  polypus,  601 
Navel,  fee  Umbilicus. 
Neck,    gunshot   wounds    of,   340  ;    injuries    of, 

203 
Neck   of  femur,  fracture    of,   281  ;   of   hernial 

sac,   618;  of  humerus,  fracture  of,    268;   of 

scapula,  fracture  of,   256 
Necrosis,  433  ;  acute,  436;  operations  for,  436; 

fracture  from,  438 
Needle,  aneurism,   1 14 
Needle,  in  hand,  251 
Nelaton's   operation   for  harelip.   512;   probe, 

336  ;  test  for  dislocation  of  hip,  477 
Nephralgi.i,  calculous,   766 
Nephritis,  766 
Nephrotomy,  767 
Nerves,  wounds  of,   617;  cranial,  injuries  of, 

183 


INDEX, 


955 


Nervous  uphoniii,  678;  deafness,  764  ;  diseases, 
383;   dysphagia,  611 

Net-celled  sarcoma,  366 

Nettlerash,  871 

Neuralgia,  518;   of  joints,  474;  of  scars,  419 

Neuralgic  ulcers.  418 

Neuritis,  optic,  733 

Neurom.i,  620 

Neuroiuiuiesis,  383 

Neurotomy,  519 

Nipple,  epithelioma  of.  867;  eruptions  of,  867; 
malformations  of,  867;   retraction  of,  865 

Nitric  acid,  treatment  of  piles  by,  655 

Nitrous  oxide,  908 

Nodes,  423  ;  strumous,  440 

Nodosity  of  joinis,  471 

Noma,  85 

Nose,  absence  of,  595;  dise;isea  of,  594;  foreign 
bodies  in,  196;  malformations  of  695;  op- 
eration for  restoration  of,  911  ;  plugging  of, 
596 

Nystagmus,  717 


Oblique  inguinal  hernia,  640 

Obstruction  of  intestine,  613  ;  operations  for, 
614 

Obturator  artery,  irregular  distribution  and 
wound  of,  in  femoral  hernia,  648  ;  foramen, 
dislocation  of  hip  into,  322  ;  hernia,  651 

Occlusion  of  arteries,  523 

Odontoid  process,  displacement  of,  in  diseased 
s|iine,  49  I 

Odontomas,  588 

ffidema  of  scrotum,  841 

Q<]dematous  ulcers,  418 

(Esophagotomy,  216 

Qisoph.igus,  foreign  bodies  in,  215  ;  pouch  of. 
610  ;   stricture  of,  610 

Olecranon,  fractures  of,  264 

Omental  sac  in  hernia,  634,  660 

Omentum,  adhesions  of  in  ovarian  disease, 
857;  protrusion  of  from  wound,  237;  treat- 
ment of  in  strangulated  hernia,  635 

Onychia,  892;  syphilitic,  892 

Onyx,  706 

Ophthalmia,  see  Conjunctivitis  ;  strumous,  699; 
sympathetic,  738 

Ophthalmoscope,  the,  727;  use  of  for  detecting 
cataract,  722 

Optic  nerve,  injuries  of,  183 

Optic  neuritis,  733 

Orbit,  pulsating  tumors  of,  544;  wound  of,  171 

Orbital  aneurism,  544 

Orchitis,  832;  chronic,  834;  syphilitic,  834; 
scrofulous,  ^34 

Organization  from  inflammation,  38  ;  of  blood, 
39 

Os  calcis,  diseases  of,  481  ;  excision  of,  945; 
subperiosteal,  945;   fractuie  of,  314 

Os  uteri,  excision  of,  862 

Osteoaneurisin,  452 

Osteoarthritis,  471 

Osteomalacia,  463 

Osteomyelitis,  126  ;  chronic,  428 

Osteoplastic  staphyloraphy,  679 

Osteoporosis,  468 

Osteoid  cancer.  373,  442 

Ostitis,  422 

Otoscope,  the    760 

Outer  table  of  skull,  fracture  of,  168 

Ovariotomy,  856  ;   mortality  of,  868 

Ovary,  tumor  of,  852;  suppuration  in,  853 


Oxalate  of  lime  calculus,  804  ;  deposit  in  urine, 

802 
Ozaena,  598 

Pain,  inflammatory,  34 

Palate,  fissure  of,  574 

Palmar  arch,  wound  of,  251  ;  fascia  contracted, 

514  ;  g.anglion,  602 
Pannus,  698 

Pajiillary  granulations  of  conjunctiva,  1)95 
Papular  eruptions,  880 

Paracentesis    abdominis,  616;   pericardii,  226; 
thoracis.    228;    of   anterior   chamber,    692; 
in  ovarian  dropsy,  865 
Paraffin  splints,  897 

Paralysis  of  bladder,    799  ;    of  ocular  muscles, 
748;   infantum,    603;    pseudo-liypertrophin, 
604  ;  infantile,  of  hip,  479 
Paraphimosis,  388 
Partial  dislocation  of  shoulder,  279 
Passive  congestion,  33 
Pasteboanl  splint,  897 

Patella,  dislocation  of,  326  ;   enlarged  bursa  of, 
498  ;   fracture  of  tninsverse.  3t)6  ;   union  of, 
308;  vertical  or  Y-shaped,  309  ;   compound, 
309 
Pedicle,  treatment  of,  in  ovariotomy,  867 
Pelvis,  (leformily  of    in    riekr-ts,  466  ;   disloca- 
tions of,  243  ;   fractures  of,  241  ;   injuries  of 
the,  240 
Pemphigus,  877;   syphilitic,  877 
Pendulous  growths  on  synovial  membrane,  463 
Penetrating  syphilitic  ulceration  of  bone,  441 
Penis,    amputation    of,   843  ;    cincer    of   842  ; 
gangrene  of,  844;   ligature  of,  248;    persist- 
ent priapism  of  844  ;   wounds  of,  247 
Perforation  of  bowel  in  hernia,  619;  of  mem- 

brana  tympani,  768 
Pericardium,  wounds  of,  225  ;  paracentesis  of, 

226 
Perinseal  hernia,  663  ;  lithotrity,  816  ;  section, 

792 
Perinaeo,  fistula  in,  785,   794  ;  abscess  in,  785, 

993 
Perineum,  injuries  of,  247;   rupture  of  female, 

847 
Periosteal  abscess,  425  ;   cancer,  442 
Periosteum,  transplantation  of,  423 
Periostitis,  423  ;  acute,  426 
Periostitis  of  meatus  of  ear,  767 
Peritomy  of  conjunctiva  in  pannus,  698 
Peritonitis  after  hernia,  729 
Pert  eve's   instrument  for  forcing  a   stricture, 

796 
Petechiae.  872 
Petit's  tourniquet,  909 
Phagedena.  82 
Phagedenic   chancre,  396;   ulceration  of  bone, 

433  ;  ulcers,  83 
Phalanges  of  hand,  dislocation  of,  287  ;  frac- 
ture  of,    269 ;    of  foot,    dislocation   of,    333  ; 
fractures  of.  315 
Pharynge.il  abscess,  490 
Pharyngitis,  610 
Pharynx,   tumors    of   610  ;    malformations  of, 

610 
Phimosis,   congenital,   843;  gonorrhoeal,   388; 

syphilitic,  395 
Phthisis  laryngea,  675 
Phlebitis,  560 
Phlebolithes,  566 
Phlegmatic  form  of  scrofula,  379 
Phlegmonoid  chancre,  395 


956 


INDEX. 


Phlegmonous  erysipelas,  70 

Phlyctenuloe  of  corneii,  IUI9 

Phlycteniiliir  coiijunctiviti-!,  696 

Pblyziioious  imstiiles,  878 

Phosph:itic  c.ilculi.  804;   deposit  in  urine,  802 

Phosphorus  necrosis,  586 

Photophobiii,  699 

Phrenic  herniii,  ()52 

Pigmentnrj'  siircoiua,  366 

Piles.  fi.')4 

Pirogoff  s  iimputntion,  927 

Pituitiiry  nieuibnine.  thickening  of,  597 

Pityriiisis,  882  ;  syphilitic,  871  ;  versicolor,  876 

Plaster  of  Piiris  splints.  898 

Plastic  operations,  910 

Plica  polonica,  886 

Plugging  the  nose,  596 

Pneuinocele,  224 

Pneuuiothoriix,  221 

Poisoned  wounds.  9;^ 

Politzer's  method  of  inflating  the  tympanum, 

760 
Polypus  of  ear,  763  ;  nasopharyngeal,  601  ;  of 

nose.  599  ;  malignant,  603  ;  of  rectum,  661  ; 

uteri,  850 
P(.mph(.lyx,  877 
PiiplitenI  aneurism,   556 
Porrigo,  879 

Port-wine  injection  in  hydrocele,  828 
Potassa  fusa.  902 
Potassa  cum  calce,  900 
Pott's  fracture,  328;   puffy  tumor  of,  161 
Pouch  of  oesophagus,  610 
Presbyopia.  754 

Pressure,  for  arresting  haemorrhage,  125 
Priapism,  persistent,  844 
Primary  union,  41 
Probaiig,  oesophagus.  215 
Projectiles,  modern,  wounds  caused  by,  334 
Polapsus  ani.  6.')7  :   uteri,  849 
Proliferous  cysts,  353 
Propto.-is  oculi,  544 
Prostiite,   affections  of,    776  ;   abscess  of,    776  ; 

enlargement  of,  779  :   inflammation  of,  776  ; 

cancer  of,  781  ;   division  of,  in  lithotomy,  812 
Prostatic  calculi,  824  ;  hasmorrhage,  778 
Prostatitis,  acute,  777  ;  chronic,  777 
Prostration  with  excitement,  129 
Prurigo,  881 

Pruritus  ani,  661  ;  scroti,  .881  ;   vulvae,  881 
Pseudarthrosis,  149 
Pseudoc.ilculi,  805 
Pseudohviertrophic  paralysis,  504 
Psoriasis,  882  ;  of  nails,  892  ;   syphilitic,  882 
Psoas  abscess,  diagnosis  of  fiom  hernia,  649 
Psoas,  enlarged  bursa  of,  478 
Psydracious  pustules,  878 
Pterygium,  697 
Ptosis.  687 
Pubes.  dislocation  of  hip  on,  323;  puncture  of 

bladder  above.  780 
Pudendal  hernia,  653 
Puffy  tumor  of  Pott.  161 
Pulit-ys,  use  of,  in  di>location,  278 
Pulpy  (IfgHner.ilioii  of  synovial  membrane,  462 
Pulsatile  cancer,  452 
Pulsatinir  tunioi  of  bone,  452 
Puncta  lacryiiiali.'i,  obstruction  of,  751 
Puncture   of   bladder  above    the    pubes,   780; 

from  the  rectum,  79 1 
Pupil,  iirlifi(!ij(l^  733;  exclusion  of,  713 
Purpura,  871 
Pus,  42  ;  kinds  of,  64 


Pustular  eruption,  879 

Pustule,  malignant,  892 

Puzz.letoy,  use  of.  in  reduction  of  dislocation 

of  thumb,  286 
Pycemia,  59  ;    chronic,  64 
Pyelitis,  calculous,  766 
Pyogenic  membr.-ine,  54 
Pyramidal  or  punctated  cataract,  718 

Quilled  suture,  847 
Quinsy,  583 

Rabies,  100 

R.idial  artery,  ligature  of,  550 

Radical  cure  of  hernia,  629  ;  of  hydrocele, 
828 

Radius,  dislocation  of  at  elbow,  283  ;  fracture 
of,  267 

Railway  injuries,  192 

Ranula,,  583 

'■  Rapid  ''  compression  in  aneurism,  537 

Rapid  dilatation  of  stricture,  788 

Rashes,  870 

Reiiction  after  collapse,  129 

Rectal  lithotomy.  815 

Rectangular  lithotomy  staff,  812 

Recto-urethral  fistula,  814 

Recto-vaginal  iistula,  849 

Recto-vesical  fistula.  814 

Rectum,  diseases  of,  654  ;  foreign  body  in,  250  ; 
malfonnjition  of,  265  ;  puncture  of  bladder 
from,  791  ;  wound  of,  249;  in  lithotomy, 
813;  sfe.  nlso  the  various  affections,  as  Fis- 
tula, Polypus. 

Recurrent  hsemorrhage,  118;  vascular  ulcer  of 
cornea,  699 

Red  gum,  880 

Reduction  of  dislocation,  see  Shoulder,  Hip, 
etc.:   of  hernia,  621;    "  en  masse, "  622,  636 

Refracture  of  bone,  153 

Relaxed  uvula,  585 

Renal  hsematuria,  767 

Resection,  sve  Excision. 

Residual  abscess,  51 

Resilieiit  strictures.  795 

Resolution  of  inflammation,  38 

Rest,  in  treatment  of  aneurism,  531 

Retained  testis,  825  ;   hernia  with,  641 

Retention  of  urine,  799;  after  lithotrity,  822; 
spasmodic,  798 

Reticulated  syphilitic  ulcer  of  bone,  441 

Retina   affections  of,  733 

Retinitis,  733 

Retraction  of  nipple,  865 

Retractors  in  amputation,  914 

Rheumatic  arthritis,  471 

Rheumatism    gonorrhoeal,  390 

Rhinolithes,  595 

Rhinoplasty,  911 

Rhinoscopy,  671 

Ribs,  fracture  of,  218;   dislocation  of,  223 

Richardson's  S[n;iy  producer,  905 

Rickets,  455  ;  operations  for,  457 

Rigors,  48  :   urethral,  795 

Ringworm,  874 

Rodent  ulcer,  4  16 

Ropy  Miucns,  774 

Roseola,  870  ;   syphilitic.  871 

Round-celled  sarcotna,  364 

llupia.  878;  syphilitic,  878 

Rupture,  sw  Hernia. 

Rupture  of  aneurism,  531  ;  of  artery,  521  ;  of 
bladder,  244  j   from  distension,  786;  of  dia- 


INDEX. 


957 


phragm,  fi52:  of  eyeball,  740  ;  ofhenrt,  228; 
of  intestines,  2;j  I  ;  bytiixis,  (i21  ;  of  kidney, 
284  ;  of  liver,  234  ;  "of  liinj,',  228;  of  mein- 
bi-nna  tynn5ani,  758;  of  perineum.  847;  of 
spleen,  234  ;  of  .stoiniich,  231  ;  of  .«trifitiire, 
790;  of  tendons,  490  ;  of  ureter,  234;  of 
urethra,  246  ;   of  vagina,  248 

Sao.  hernial,  617;  hydrocele  of,  829  ;  lacera- 
tion of,  621  ;  omental,  634,  660;  operation 
for  hernia,  external  to,  632  ;  strangulation 
of  hernia  by,  633 

Sacro-iliao  disease,  48(1 

Sago-griiin  granulations  in  epidemic  ophthal- 
mia, 693 

Salivary  calculus,  582;   fistula,   195 

Salter's  swing  for  the  leg,  313 

Sanguine  form  of  scrofula,  379 

Sanguineous  cysts,  350 

Saphena  vein,  varix  of,  diagnosis  of,  from 
hernia.  649 

Sarcoma,  348,  364  ;  alveolar.  366  ;  giant- 
celled,  365  ;  net-celled,  366  ;  pigmentary, 
366  ;  round-celled,  364  ;  spindle-celled,  364  ; 
in  bone  ;  445  ;   breast,  863  ;  eyeball,  735 

Sarcoptes  hominis,  877 

Scab,  union  under,  45 

Scabies,  877 

Scalding  in  gonorrhoea,  387 

Scalds,   131  ;   of  larynx,  214 

Scalp,  anatomy  of,  157;  congenital  cysts  of, 
362;  c(^tusion  of,  157;  erysipelas  of,  159; 
sebaceous  tumors  of,  251  ;   wounds,  158 

Scalp  bandage,  896 

Scales,  see  Squamous. 

Scapula,  excision  of,  931  ,  fracture  of,  256  ; 
of  neck  of,  256 

Scar,  see.  Cicatrix. 

Scarification  in  gonorrhoeal  ophthalmia,  692 

Scarlet  fever,  disease  of  the  tympanum  in,  763 

Sciatic  notch,  dislocation  of  hip  into,  318 

Scirrhus,  370  ;  operations  for,  370:  of  breast, 
864 

Scissors  for  skin-grafiing,  421 

Scoop,  lithotomy.  813 

Scorbutic  ulcers,  414 

Scorbutus,  871 

Scott's  bandage,  462 

Scrofula,  377  ;  in  bone,  439  ;  see  also  Struma, 
Strumous. 

Scrofulosis,  379 

Scrofulous  orchitis,  834 

Scrotal  truss,  625  ' 

Scrotum,  cancer  of,  842  ;  elephantiasis  of.  841  ; 
inflammation  of,  841  ;  injuries  of,  247;  in- 
dolent tumors  of,  836 

Scurvy,  872 

Sebaceous  tumors,  351 

Secondary  deposits,  61  ;  htomnrrhage  after 
ligature  of  artery.  116,  534;  syphilis,  401; 
treatment  of,  404  ;   union,  42 

Semilunar  cartilages,  dislocation  of,  327 

Semi-malignant  tumors,  348 

Senile  cataract,  721;  gangrene,  84;  scrofula, 
381  ;   ulcer,  413 

Separation  of  epiphyses,  139;  lower  epiphysis 
of  femur,  302  ;  upper  epiphysis  of  femur, 
296  ;  lower  epiphysis  of  humerus,  263  ;  up- 
per epiphysis  of  humerus,  251 

Septicaemia,  69 

Septum  nasi,  diseases  of,  599 

Sequestrum,  434 

Serocystic  tumor  of  breast,  862 


Serous  cysts,  349 

Serous  iritis,  716 

Serous  form  of  scrofula,  379 

Serpent  bites,  96 

Setons,  901  ;  in  hydrocele,  829;  in  strumous 
ophthaliniii,  7li0  ;   in  ununited  fracture,  160 

Setting  fractures,   141 

Seutin's  scissors,  899 

Sexual  hypochondriasis,  839 

Shackles  for  lithotomy,  809 

Shingles,  the,  873 

Shortening  in  hip  dise.ises,  476 

Shoulder,  amputation  at,  915:  diseases  of, 
482;  dislocation  of,  271;  excision  of,  929; 
subperiosteal,  930 

Signorini's  tourni(iuet,  537,  909 

Silver-stain,  886 

Silver  sutures,  899 

Simple  ulcer,  412 

Sinus,  58 

Skin,  eriijitiona  of,  870  ;  diseases  of  append- 
ages of.  886 

Skin-grafting,  421 

Skull,  deformity  of,  in  rickets,  456  ;  fractures 
of,   167;   of  base  of,  170 

Sloughing,  76 

Sloughing  chancre,  395 

Smith's,  Mr.  II.,  clamp  for  piles,  656 

Smith's  gag  for  staphyloraphy,  675 

Snake-bites,  96 

Snuflles,  Ihe,  407 

Solution  of  cataract,  717 

Soot  cancer,  842 

Sore  throat,  .syphilitic,  403 

Sounding  for  stone,  807 

Sounds,  forms  of,  for  stone,  808 

Spasmodic  retention  of  urine,  798 

Spasmodic  stricture,  798 

Spasms  in  gonorrhoei,  389 

Spectacles,  727.  753 

Speculum,  laryngeal,  670 

Spermatic  canal,  tumors  of,  841 

Spermatorrhoei,  838 

Spica  bandage.  894 

Spina  bifida,  495 

Spinal  abscess,  484  ;  instruments,  489,  493 

Spindle-celled  sarcoma,  364 

Spine,  anchylosis  of,  494  ;  cancer  of,  494  ;  con- 
cussion of^  191  ;  curvature  of,  489,491,494; 
from  rickets,  455  ;  disease  of.  484  ;  fracture 
of,  186  ;  gunshot  wounds  of,  339 

Spiral  bandages,  894 

Spiral  spring-truss,  626 

Spleen,  rupture  of,  234 

Splints,  142,  897 

Spontaneous  cure  of  aneurism,  531  ;  fracture, 
459 

Sprains  of  the  back.  185;  of  lower  extremity, 
288  ;  of  upper.  260 

Spray  producer  for  local  anassthesia,  905 

Squamous  eruptions,  882 

Squint,  742  ;  divergent,  748  ;  operation  for, 
745;  secondary.  744 

Staff,  lithotomy,  812 

"  Stammering,"  oesophageal.  61  I 

Staphyloma,  708  ;   removal  of,  709 

Staphyloraphy,  576  ;  osteoplastic,  579 

Starch  bandage,  897 

Sternal  end  of  clavicle,  fracture  of,  254 

Sternoel.ivicular  joint,  dise.ises  of,  482 

Sternomastoid  muscle,  section  of,  516 

Sternum,  fracture  of,  222 

Stilling's  knife  for  lachrymal  obstruction,  752 


958 


INDEX. 


Stoiunch.  operation  for  opening  the,  238;  rup- 
ture ot',  2.S1 

Stone,  .sv«  Calculus. 

Strahisinus,  gff  Squint. 

Strabismus  hook,  747 

Stranorulation   of  hernia.  618  ;  internal,  612 

Strappinji,  .t3 

Stricture  of  oesophagus,  610'  of  the  rectum, 
6.'i2 

Stricture    of  urethra,    782  ;   rupture    of,  796  ; 

spasmodic,  708 
Stricture,  .^eat  of.  in  hernia,  632 
Strophulus.  880 
Struma,  377 
Strumous    diseases   of  joints,    461;   lip,     581  ; 

ophthalmia,  6il9  ;    orchitis,  834  ;   ulcers,   413 
Strychnia  poisoning  and  tetanus,  87 
Stumps,  dressing  of,  915 
Styes.  686 
Styptics,  125 
Subastragaloid   amputation,  927  ;   dislocation, 

33 1 

Subclavian  artery,  aneurism  of,  545;  ligature 
of  first  part  of,  546  ;  of  second  and  third 
part,  547 

Subclavicular  dislocation  of  shoulder,  274 

Subcoracoid  dislocation  of  shoulder,  272 

Subcu'aneous  ligature  of  najvus.  362  ;  method 
of  removing  loose  cartilase,  471 

Subcutaneous  surgery,  sre  Tenotomy. 

Subglenoid  dislocation  of  shoulder,  272 

Submammary  abscess,  860 

Subpectoral  abscess,  218 

Subperiosteal  excision,  426,  930  ;  of  fracture, 
152 

Subspinous  dislocation  of  shoulder,  274 

Suction,  removal  of  cataract  by,  719 

Sudamina,  872 

Sulphuric  .acid  treatment  of  disease  of  bone, 
433  ;   of  joints,  465 

Suppression  of  urine.  768 

Suppuration,  see  Abscess,  Pus  ;  beneath  the 
skull,  160 

Suppuration,  visceral  disease  from,  66 

Suppurative  syphilitic  inflammation,  396 

Supracoracoid  dislocation  of  shoulder,  275 

Suprapubic  lithotomy,  815 

Suprastern.'il  dislocation  of  clavicle,  271 

Surgical  neck  of  humerus,  fracture  of,  259 

Suspensory  b.and.ige,  896 

Suture  of  bowel  in  herniotomy,  634 

Sutures,  53.  899;  continuous,  899;  inter- 
rupted, 899;  quilled,  847;  twisted,  899 

Swings  for  fracture,  143 

Sycosis,  876 

Symblepharon,  741 

Syme's  amputation,  926;  operation  for  stric- 
ture, 795 

Sympathetic   irritation,  738  ;   ophthalmia.   738 

Synovial  membrane,  pulpy  degeneration  of, 
462;   pendulous  growths  from,  46.'i 

Synovitis,  460;  abscess  after,  461  ;  chronic, 
463 

Syphilitic  affections  of  bone,  440;  of  larynx, 
675;  of  meatus  of  ear,  758;  of  retina.  733; 
of  tongue,  604,  608  ;  deafness,  764  ;  erup- 
tions, 401,  406;  see  ah')  the  names  of  the 
various  eruptions,  as  Lichen;  fever,  401; 
iriti.a,  712:  keratitis,  704;  onychia,  892; 
orchiti.a,  834;  sore  throat,  403;  stricture, 
782;   ulcers,  414  ;    of  the  rectum,  664 

Syphilis,  394  ;  congenital,  457  ;  constitutional, 


derived  from  the  foetus,  409  ;  infantile,  407  ; 
secondary,  401  ;   tertiary,  405 
Syphilization,  410 


T  bandage,  896 

Tasriiacotian  operation,  912 

Talipes,  calcaneus,  512  ;  cavus,  513  ;  equinus, 

507  ;   valgus,  512  ;   varus,  509 
Tapping  the  abdomen,  616  ;   for   ovarian  drop- 

.sy,  855  ;   of  hydrocele,  827 
Tarsal  cartil.ige,  incurvation  of,  680;  ophthal- 
mia, 685  ;  tumors,  684 
Tarsus,  diseases  of,   481  ;  dislocation   of,  333; 

friicttires  of,  315 
Taxis  of  hernia,  620  ;  accidents  in,  622  ;  for- 
cible. 621 
Te.ale's  amputation.  924 
Teeth,  syphilitic,  408.  705 

Temperature  in  erysipel.as,  69  ;  hectic,  65  ; 
hysteria,  385  ;  inflammation,  34,  48  ;  inju- 
ries of  head,  178  ;  of  spine,  187  ;  disease  of 
joints,  474  ;  pyaemia,  60  ;  tetanus,  90  ;  trau- 
matic encephalitis,  181  ;  fever,  49 
Tenacula,  120;  Liston's,  121  ;  Assalini's,  121 
Tendo  Achillis,  division  of,  508  ;  in  fracture  of 

the  leg,  314;  rupture  of,  496 
Tendons,  inflammation  of  sheaths  of,  497  ;   rup- 
ture of,  496 
"  Tcnosinite  crepitante,"'  497 
Tenotomy,  505  ;  in  fracture  of  leg,  314 
Tension  of  eyeball,  729 
Tertiary  syphilis,  405 

Testicle,  abnormal  position  of,  726  ;  absence  of, 
825;    affections  of.    825;    cancer    of,    837; 
cystic  disease  of,  835  ;  dermal  tumor  of,  838  ; 
enchondroma   of,     836  ;    foetal     rera.ains   in, 
838;    injuries   of,    248;   inversion   of,    727; 
removal  of,  837  ;  retained,  825  ;  hernia  with, 
641 
Testis,  hernia,  835 
Tests  for  calculi,  805 
Tetanus,  86  ;  idiopathic,  87 
Thickening  of  pituitary  membrane,  597 
Thigh,    amputation   of,    923  ;   fracture    of,    see 

Femur. 
Thompson's  lithotrite,  817;  urethrotome,   798 
Thoracentesis,  228 
Thora.K,  foreign  bodies  in,  225 
Thro.it  deafness.  760 

Thrombosis,  560  ;  connection  with  pyasmin,  64 
Thudichuin's  method  of  washing  out  the  nose, 

598 
Thumb,    amputation   of,    920  ;    dislocation   of, 

285 
Thyroid  arteries,  ligature  of,  543 
Thyroid  body,  diseases  of,  868 
Thyroid  dislocation  of  hip,  322;  hernia,  651 
Thyrotomy,  677 
Tibia,  fracture  of,  311 
Tibial  arteries    ligature  of,  558 
Tibial  tendons,  division  of,  510 
Tinea,     874;     deealvans.    875;     favosa,    875; 

sycosis,  876  ;  tonsurans,  874 
Tinea  tarsi,  685 
Tinnitus  aurium,  764 
Toe,  amputation  of,  928 
Toenail,  ingrowing,  892 

Tongue,  cancer  of,  605  ;  congenital   hypertro- 
phy of,    609 ;    diseases   of,    (iOl  ;    najvus   of, 
609  ;   removal  of  the,  606  ;   ulceration  of,  604 
Tongue-tie,  603 
Tonsil,   acute   inflammation   of,    583 ;    chronic 


INDEX. 


959 


enlargement,  584 ;  denfness  with,  760;  re- 
moval of,  5H5  ;   wounds  of,  585 

Tooth  cysts,  588 

Tooth  tumors,  587 

Torsion  of  arteries,  123 

Torsion  forceps,  123 

Tourni(|uets,  909  ;  aortic,  921  ;  Italian,  909 

Trachea,  rupture  of,  208  ;  foreign  bodies  in, 
208 

Tracheotomy,  680,  681 

Transfusion,  126 

Transplantation  of  bone,  152;  of  skin.  911 

Transverse  ligament  of  spine,  ulceration  of, 
492 

Traumatic  fever,  40  ;  gangrene,  75 

Traumatopiioia,  341 

Trepliine,   184 

Trepiiinincr,  184;  for  abscess,  162;  for  blood 
beneath  the  skull.  163  ;  for  depressed  frac- 
ture. 170.  179  ;  in  injuries  of  the  bead,  338 

Trephining  in  abscess  of  bone,  430 

Trephining  the  spine.  1S9 

Trichophyton  tonsurans,  874 

Trismus.  86  ;  nascentiura,  87 

Trocar  for  ovariotomy-  856 

Trochanter,  disease  tif,  480  ;   fracture  of,  295 

True  aneurism.   526 

Trusses,  624  ;  measuring  for,  626 

Tubercle,  377  ;   in  bone,  439 

Tubercle,  mucous,  402.  662 

Tubercular  eruptions,  882;  syphilitic  ulcera- 
tion of  bone,  441 

Tuberculosis.   379 

Tuberocystic  tumor  of  breast.  862 

Tuberosities  of  humerus,  fracture  of,  261 

Tubular  aneurism,  526 

Tumors,  347  ;  for  special  forms  of  tumor  sre 
their  names,  as  Fatty,  Sarcoma,  etc. 

Tunica  vaginalis,  hydrocele  of,  726  ;  loose 
bodies  in,  831 

Tuning-fork,  diagnosis  of  diseases  of  the  ear 
by,  761 

Twisted  suture,  809 

Tying  arteries,  sei>-  Ligature,  also  the  names  of 
the  vessels,  as  Feuiorai.  Carotid. 

Tying  a  catheter  in  the  bladder,  790 

Tympanum,  affections  of.  761  ;  acute  inflam- 
mation of,  761  ;  catarrh  of,  762;  mucus  in, 
762 ;  scarlatinal  affections  of,  763  :  polypi 
of,  763  ;  see  also  Membrana  Tympani. 

Ulcers,  411;  see  also  their  various  forms,  as 
Eczematous,  Cancerous  ;  of  anus,  660  ;  bone, 
441;  cornea,  707;  recurrent  vascular  of 
cornea,  699 

Ulcerated  cancer,  866 

Ulceration  of  cartilage,  466;  cicatrices,  419  ; 
intestine  in  hernia,  619,  635 

Ulna,  dislocation  of,  at  elbow,  280  ;  fracture 
of,  266 

Ulnar  artery,  ligature  of,  549 

Umbilical  fistula,  616  ;   hernia,  650  ;   truss  629 

Umbilicus,  vascular  protrusion  from,  616  ;  ul- 
ceration of,  616 

Uncipression,  125 

Union,  see  Wounds. 

Union  of  fracture,  144  ;  by  granulation,  146  ; 
irregular,  147;  enlarged,  148;  villous,  152; 
of  neck  of  femur,  294 

Ununited  fracture,  148 

Upper  extremity,  compound  fracture  of,  269  , 
injuries  of.  250 

Upper  jaw,  removal  of,  592 


Urates,  see  Lithates  ;  Uric  acid,  see  Lithic  acid. 

Urea,  decomposition  of,  774 

Ureter,  rupture  of,  234 

Urethra,  affection  of.   781  ;  calculus   in.    824  ; 

foreign  body  in,  249  ;   malformation  of,  781  ; 

rupture  of.  246  ;  stricture  of,   782  ;  vascular 

tumor  of  female,  845 
Urethral  fever,  795  ;   hicmaturia,  767  ;   hajmor- 

rhoids,  845 
Urethrotomy,  external,  795  ;  internal.  797 
Urinary  abs'ce.'^s,  785,  793  ;  deposits,  801 
Urine,  incontinence  of.  799  ;   retention  of.  799  ; 

extravasation  of,  785  ;  suppression  of,  768 
Urticaria,  871 
Uterus,  cancer  of,  862  ;  fibroid  tumor  of,  851  ; 

softened,  854  ;   injuries  of,  249  ;    polypus   of, 

S50  ;   prolapsus,  818  ;   removal  of,  851 
Uvula,  relaxed,  585 

Vaccination,  903  ;  secondary,  904  ;  syphilis 
communicated  by.  410;   ofntevus,  361 

Vagina,  foreign  body  in,  249  ;  imperforate, 
844  ;  injuries  of.  248;   obliteration  of,  849 

Vaginal  cystocele,  653,  849;  fistulso,  849; 
hernia,  653 

Vanzetti,  his  method  of  uncipression,  125,  251 

Vapor-bath,  mercurial,  400 

Varicocele,  839 

Varicose  aneurism,  528;  ulcers,  417;  veins, 
563;  operation  on,  564 

Varix.  aneurismal,  528  ;  arterial,  527 

Vascular  keratitis,  701  ;  tumor,  359  ;  of  ure- 
thra, 845 

Vault  of  the  skull,  fracture  of,  167 

Vegetations,  gonorrhoeal,  393 

Veins,  diseases  of,  560  ;  entrance  of  air  into, 
111;   injuries  of.   110  ;   wound  of,  I  13 

Venereal  disease,  394  ;  warts,  887  ;  see  also 
Syphilis,  Syphilitic. 

Venesection,  902 

Venomous  animals,  bites  of,  96 

Venous  hffiiuorrhage,  112 

Ventral  hernia,  235,  652 

Verruca  necrogenica,  888 

Vertebrae,  see  Spine. 

Vesical  haematuria,  767 

Vesico-intestinal  fistula,   776 

Vesico-prostatic  calculus,  824 

Vesicovaginal  fistula,  849 

Vesicular  eruptions,  167 

Vibices,  871 

Vicious  union  of  fracture,  152 

Vienna  paste,  900 

Villous  tumor,  376  ;  of  bladder,  772  ;  of  rec- 
tum, 662 

Viscera,  abdominal,  wounds  of,  236 

Visceral  affections,  syphilitic,  406 

Vision,  double,   741 

Vitiligo,  886 

Vitreous  body,  diseases  of,  734 

Vitreous  humor,  escape  of,  after  extraction,  726 

Vocal  cords,  paralysis  of,  679  ;   tumors  of,   676 

Volvulus,  612 

Vulva,  cancer  of,  847  ;   injuries  of,  248 

Wardrop's  operation  for  aneurism,  540 
Warm  bath  in  strangulated  hernia.  622 
Warts,  887  ;  di.ssection,  888  ;   venereal,  887 
W.'irty  tumor  of  cicatrix,  420 
Watery  discharge  in  fractures  of  the  skull,  173 
Watson's  splints  for  excisinn  of  the  knee,  941 
Wax,  accumulation  of,  757 
Weak  ulcers,  418 


960 


INDEX. 


Webbed  fingers.  013 

Weber's  enntiliculus  knife.  751 

Weight,  extension  by.  in  fractured  femur,  300  ; 

in  diseiise  of  hip,  479 
Wet-nurses,  infection  of  infants  with  syphilis 

from,  409 
Whitlow,  497 

"  Wind-contusions,"  gunshot,  335 
Windpipe,    foreisn    bodies   in,    209 ;    sfe    also 

Trache.i,  Cut  Throat 
Wire-treatment  of  aneurism,  538 
Women,    gonorrhoe  i    in.    392  ;  stone   in,    816  , 

surgical  diseases  of.  844 
Wounds,  38  ;  union  of,    adhesive   or   primary, 

41  ;  suppurative,  or  secondary,  42  ;  under  a 


scab,  45  ;  dressing  of,  49  ;  poisoned,  93  ;  of 

arteries,    109;    of  veins,    113;   sf.e    also   the 

names  of  the  various  organs. 
Wrist,  amputation  at,   919  ;  diseases  of,   483  ; 

dislocation  of,  284;   excision  of,  935 
Wryneelt,  515  ;  hysterical,  516 

Xanthic  oxide,  802,  804 
Xeroderma,  886 

Yaws,  886 

Yellow  tubercle,  378 

Zoster,  herpes,  or  zona,  873 
Zygoma,  fracture  of,  197 


HENRY  C.  LEA'S  SON  &  CO.'S 

(late  henry  c.  lea) 
OF 

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The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  book- 
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works  not  kept  in  stock.  AVhere  access  to  bookstores  is  not  convenient,  books  will  be 
sent  by  mail  post-paid  on  receijjt  of  the  price,  and  as  the  limit  of  mailable  weight  has 
been  removed,  no  dilhculty  will  be  experienced  in  obtaining  through  the  post-oflice 
any  work  in  this  catalogue.  No  risks,  however,  are  assumed  either  on  tlie  money  or 
on  the  books,  and  no  publications  but  our  own  are  suj)plied,  so  that  gentlemen  will  in 
most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

HENRY  C.  LEA'S  SON  &  CO. 

Nos.  706  and  708  Sansom  St.,  Philadelphia,  July,  1881. 


INCREASED  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL_()F_ THE  MEDICAL  SCIENCES. 

TWO  MEDICAL  JOURNALS,  containing  nearly  2000  LAKGE  PAGES, 

Free  of  Postage,  for  FIVE  DOLLARS  Per  Annum. 


TERMS  FOR  1881. 

The  American  Journal  of  the  Medical  Sciences,  published    ]  Five  Dollars 

quarterly  (1150  pages  per  annum),  with  I  per  annum, 

The  Medical  News  anl>  Abstract,  monthly  (768  pp.  per  annum),  ]  in  advance. 

SEPARATE  SVHSCRIPTIOXS  TO 

The  American  Journal  of  the  Medical  Sciences,   when  not  paid  for  in 

advance,  Five  Dollars. 
The  Medical  News  and  Abstract,  free  of  postage,  in  advance,  Two  Dollars 

and  a  Half. 

*^*  Advance  paying  subscribers  can  obtain  at  the  close  of  the  year  cloth  covers, 
gilt-lettered,  for  each  volume  of  the  Journal  (two  annually),  and  of  the  News  and 
Absti-act  (one  annually),  free  by  mail,  by  remitting  ten  cents  for  each  cover. 


It  will  thus  be  seen  that  for  the  moderate  sum  of  Five  Dollars  in  advance,  the 
subscriber  will  receive,  free  of  postage,  the  equivalent  of  four  large  octavo  volumes, 
stored  with  the  choicest  matter,  original  and  selected,  that  can  be  furnished  by  the 
medical  literature  of  both  hemispheres.  Thus  taken  together,  the  "Journal"  and 
the  "News  and  Abstract"  combine  the  advantages  of  the  elaborate  preparation 
that  can  be  devoted  to  the  Quarterly  with  the  prompt  conveyance  of  intelligence  by 
the  Monthly;  while,  the  whole  being  under  a  single  editorial  supervision,  the  sub- 
scriber is  secured  against  the  duplication  of  matter  inevitable  when  periodicals  from 
ditferent  sources  are  taken  together. 

The  periodicals  thus  otiered  at  this  unprecedented  rate  are  universally  known  for 


2     Henry  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Joum.  Med.  Sci.). 
their  high  prolessionul  standing. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  M.D., 
for  more  than  half  a  century  has  maintained  its  position  in  the  front  rank  of  the 
medical  literature  of  the  world.  Cordially  supported  by  the  profession  of  America,  it 
circulates  wlierever  the  language  is  read,  and  is  universally  regarded  as  the  national 
exponent  of  American  medicine — a  position  to  -which  it  is  entitled  by  the  distinguished 
names  from  every  section  of  the  Union  which  are  to  be  found  among  its  collaborators.* 
It  is  issued  quarterly,  in  January,  April,  July,  and  October,  each  number  containing 
about  three  hundred  octavo  pages,  appropriately  illustrated  wherever  necessary.  A 
large  portion  of  this  space  is  devoted  to  Oi'iginal  Communications,  embracing  papers 
from  the  most  eminent  members  of  the  profession  throughout  the  country. 

FoUoAving  this  is  the  Review  Department,  containing  extended  reviews  by  com- 
petent writers  of  prominent  new  works  and  topics  of  the  day,  together  with  numerous 
elaborate  Analytical  and  Bibliographical  Notices,  giving  a  fairly  complete  survey  of 
medical  literature. 

Then  follows  the  Quarterly  Summary  of  Improvements  and  Discoveries 
IN  THE  Medical  Sciences,  classified  and  arranged  under  difierent  heads,  and  furn- 
ishing a  digest  of  medical  progress,  abroad  and  at  home. 

Thus  during  the  year  1880  the  "Journal"  contained  67  Original  Communications, 
mostly  elaborate  in  character,  170  Reviews  and  Bibliographical  Notices,  and  147  articles 
in  the  Quarterly  Summaries,  illustrated  with  47  wood  engravings. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 

successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  the 

leading  organ  of  medical  progress :  — 

This  is  universally  acknowledged  as  the  leading  i  The  Philadelphia  Medical  and  Physical  Journal 
American  Journal,  and  has  been  conducted  Ijy  Dr.  issued  its  first  number  in  1820,  and,  after  a  brilliant 
Hays  alone  until  18t>9,  when  his  sou  was  associated  career,  was  succeeded  in  1S27  by  the  Ameiican 
with  him.  We  quite  agree  with  the  critic,  that  this  Journal  ol  the  Medical  Sciences,  a  periodical  of 
journal  is  second  to  none  in  the  language,  and  cheer-  world-wide  reputation;  the  ablest  and  one  of  the 
fully  accord  to  it  the  first  place,  for  nowhere  shall   oldest  periodii-alsin  the  world — ajournal  which  has 


we  find  more  able  and  more  impartial  criticism,  and 
nowhere  such  a  repertory  of  able  original  articles. 
Indeed,  now  that  the  "British  and  Foreign  Medico- 
Chirurgical  Review"  has  terminated  its  career,  the 
American  Journal  stands  without  a  rival. — London 
Med.  Times  and  Gazette,  Nov.  24,  1877. 

The  best  medical  journal  on  the  continent. — Bos- 
ton Med.  and  Surg.  Journal,  April,  1879. 

The  present  number  of  the  American  Journal  is 
an  exceedingly  good  one,  and  gives  every  promise 
of  maintaining  the  well-earned  reputation  of  the 
review.  Our  venerable  contemporary  has  our  best 
wishes,  and  we  can  only  express  the  hope  that  it 
may  continue  its  work  with  as  much  vigor  aud  ex- 
cellence lor  the  next  filty  years  as  it  has  exhibited 
in  the  past. — London  Lancet,  Nov.  24,  1877. 


an  unsullied  record. — Gross's  History  of  American 
Med?  Lileraturv.    1876. 

The  best  medical  journal  ever  published  in  Europe 
or  America.— Ko.  Med:  Monthly,  May,  1879. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. — Boston  Med.  and 
Surg.  Journal,  Oct.' 1877. 

This  is  the  medical  journalof  our  country  to  which 
thd  American  physician  abroad  will  point  with  the 
greatest  satisfaction,  as  reflecting  the  state  of  medi- 
cal  culture  in  his  country.  For  a  great  many  yearB 
it  has  been  the  medium  through  which  our  ablest 
writers  have  made  known  their  discoveries  and 
observations.— .^ddrw*  of  L,  P.  Tandelt,  M.D.,  be- 
fore International  Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub- 
lishers in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences" 
has  never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ; 
and  when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical 
News  and  Abstract,"  making  in  all  nearly  2000  large  octavo  pages  per  annum,  free 
of  postage. 

II. 

THE  MEDICAL  NEWS  AND  ABSTRACT. 

Thirty-eight  years  ago  the  "Medical  News"  was  commenced  as  a  monthly  to 
convey  to  the  subscribers  of  the  "American  Journal"  the  clinical  instruction  and 

*  Communications  are  invited  from  gentlemen  In  all  parts  of  the  country.  Articles  Inserted  by  the 
Editor  are  liberally  paid  for  by  the  publishers. 


Henry  C.  Lea's  Son  &  Co.'s  Publications*— (J m.  Joum.  Med.  Sci.).    3 

current  information  which  could  not  be  accommodated  in  the  Quarterly.  It  consisted 
of  sixteen  pages  of  such  matter,  together  with  sixteen  more  known  as  the  Library 
Department  and  devoted  to  the  publishing  of  books.  With  the  increased  progress  of 
science,  however,  this  was  found  insuilicicnt,  and  some  years  since  another  periodical, 
known  as  the  "Monthly  Axjstuact,"  was  started,  and  was  furnished  at  a  moderate 
price  to  subscribers  to  the  "Amekican  Journal."  These  two  monthlies  have  been 
consolidated,  under  the  title  of  "The  Medical  News  and  Abstract,"  and  are 
furnished  free  of  charge  in  connection  with  the  "American  Journal." 

The  "News  and  Abstract"  consists  of  64  pages  monthly,  in  a  neat  cover.  It 
contains  a  Clinical  Department  in  which  will  be  continued  the  series  of  Ohkjinal 
American  Clinical  Lectures,  by  gentlemen  of  the  highest  reputation  through- 
out the  United  States,  together  with  a  choice  selection  of  foreign  Lectures  and 
Hospital  Notd?  and  Gleanings.  Then  follows  the  Monthly  Abstract,  ajstemati- 
cally  arranged  and  classified,  and  presenting  five  or  six  hundred  articles  yearly  ;  and 
each  number  concludes  with  an  Editorial  and  a  News  Department,  civintr  cur- 
rent professional  intelligence,  domestic  and  foreign,  the  whole  fully  indexed  at  the  close 
o^'  each  volume,  rendering  it  of  permanent  value  for  reference. 

As  stated  above,  the  subscription  price  to  the  "News  and  Abstract"  is  Two 
Dollars  and  a  Half  per  annum,  invariably  in  advance,  at  which  rate  it  ranks  as  one 
of  the  cheapest  medical  periodicals  in  the  country.  But  it  is  also  furnished,  free  of 
all  charge,  in  commutation  with  the  "American  Journal  of  the  Medical 
Sciences,"  to  all  who  remit  Five  Dollars  in  advance,  thus  giving  to  the  subscriber 
for  that  very  moderate  sum,  a  complete  record  of  medical  progress  throughout  the 
"world,  in  the  compass  of  about  two  thousand  large  octavo  pages.  • 

In  this  effort  to  furnish  so  large  an  amount  of  practical  information  at  a  price  so  un- 
precedentedly  low,  and  thus  place  it  within  the  reach  of  every  member  of  the  profes- 
sion, the  publishers  confidently  anticipate  the  friendly  aid  of  all  who  feel  an  interest  in 
the  dissemination  of  sound  medical  literature.  They  trust,  especially,  that  the  sub- 
Bcribers  to  the  "American  Medical  Journal,"  will  call  the  attention  of  their 
acquaintances  to  the  advantages  thus  offered,  and  that  they  will  be  sustained  in  the 
endeavor  to  permanently  establish  medical  periodical  literature  on  a  footing  of  cheap- 
ness never  heretofore  attempted. 

PKEMIUM  rOE  OBTAINING  NEW  SUBSGEIBERS  TO  THE  "JOUENAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1881,  one  of 
which  at  least  must  be  for  a  neiv  subscriber,  will  receive  as  a  pkemium,  free  by  mail 
a  copy  of  any  one  of  the  following  recent  works : — 
"  Seiler  on  the  Throat"  (see  p.  19), 
"Barnes's  Manual  of  Midwifery"  (see  p.  24), 
"Tilbury  Fox's  Epitome   of  Diseases  of  the  Skin,"  new  edition  (see 

p.  19), 
"Browne  on  the  Use  of  the  Ophthalmoscope"  (see  p.  29), 
"Flint's  Essays  on  Conservative  Medicine"  (see  p,  15), 
"  Sturges's  Clinical  Medicine"  (see  p.  15), 
"  Swayne's  Obstetric  Aphorisms,"  new  edition  (see  p.  21), 
"Tanner's  Clinical  Manual"  (see  p.  5), 
"West  on  Nervous  Disorders  of  Children"  (see  p.  21). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
■well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1881. 

I^°  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  tiie  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publishers,  by  forwarding  in  registered 
letters.     Address, 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Phila.    Pa. 


Henry  C.  Lea's  Sou  &  Co.'s  Publications — {Dictionaries). 


nUNOLISON  {ROBLEF),  M.D., 

Late  Professor  o/  Institutes  of  Medicine  in  Jefferson  Medical  ColUge,  Philadelphia. 

MEDICAL  LEXICON;   A  Dictionary  of  Medical  Science:  Con- 
taining a  concise  explanation  of  the  various  Subjectp  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes  ;  so  m*  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richaud  J.  Dunglison,  M.D.     In  one  very  large  and  hand- 
someroyal  octavo  volume  of  over  1100  pages.    Cloth,  $6  60  ;  leather,  raised  bands,  $7  60  ; 
half  Russia,  *8.      {Just  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensedview  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
with  this  view;  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
re  visions, io  augment  its  completeness  and  usefulness,  until  at  length  it  hasatta!inedthe  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en-- 
viable  reputation  During  the  ten  years  which  have  elapsed  since  the  Inst  revision,  the  additions 
to  the  no  men  slat  ure  oft  he  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  hiis  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
%uthor  of  the  work  pas.ied  away,  probably  all  of  u.' 
feiired  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, Dr.  Richard  J.  Dunglison,  having  assisted  his 
father  in  the  revi.«ion  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition. — Phila.  Med.  Times,  Jan.  3, 1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  si7ie  qua  non.  In  a 
science  so  extensive,  and  with  such  collaterals  as  medi 
cine,  it  is  as  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physiiaans,  the  dictionary  must  be  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indication.<^  that  it 
became  at  once  tlie  dictionary  of  general  use  wherever 
medicine  wag  studied  in  the  English  language.  In  no 
former  revision  have  thealterations  and  additions  been 
80  great.  Morethan  six  thousand  new  subjects  and  terms 
have  been  added  .The  chief  terms  have  been  set  in  black 
letter,  while  ihe  derivatives  follow  in  small  caps:  an 
arrangement  which  greatly  facilitates  reference.     AVe 


may  safely  confirm  the  hope  ventured  by  the  editor 
'•  that  the  work,  which  possesses  forhim  a  filial  as  well 
as  an  individual  interest,  will  be  found  worthy  a  con- 
tinuunce  of  the  position  so  long  accorded  to  it  as  a 
st-indard  authority." — Oincinnau  Clique.  Jan.  10, 1874  , 
It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accaracyand  extent  of 
references. — London  Medical  ffoaette  . 

As  a  standard  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglispn'a  work  has  been  well  known 
for  about  forty  years,  and  needs  no  words  of  praise 
on  our  part  to  recommend  it  to  the  members  of  the 
medical,  and,  likewise,  of  the  pharmaceatical  pro- 
fession. The  latter  especially  are  in  need  of  such  a 
work,  which  gives  ready  and  reliable  information 
on  thousands  of  sabjects  and  terms  which  they  are 
liable  to  encounter  in  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Am.  Journ.  of  Pharm.,  Feb.  1874. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It  re- 
flects great  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obtained. — British  Med.  Journ., Oct.  31,  1S74. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientific  lore.  The 
extent  of  the  sale  of  this  lexicon  is  sufflcient  to  tes- 
tify to  its  u  .i'ulness,  and  to  the  great  service  con- 
ferred by  Dr.  K.jbley  Dunglison  on  the  profession, 
and  indeed  on  others,  by  its  issue. — London  Lancet , 
May  13   V<lb. 


LJOBLYN  {RICHARD  D.),  M.D 

A.  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac  Hays, 
M.  D.,  Editor  of  the  "  American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
l2mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1   60;  leather,  $2  00 
It  U  the  best  book  of  defiaitions  we  have,  and  ought  always  to  be  upon  the  student's  table.— /SowfAern 
Med.  and  Hurg.  Journal. 

J?ODWELL  {G.  F.),  F.R.A.S.,  Sfc. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 

istry,  Dynamics,  Electricity,  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  with 
many  illustrations  :  cloth,  $6. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Manuals). 


A  CENTURY  OF  AMERICAN  ME  DICINE,  1776-1876.  By  Doctors  E.  H. 
-*^  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  Q.  Thoimis  andJ.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  26.      (Lately  Issued.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sciencesduring  the 
year  187(>.  As  a  detailed  account  of  the  development  of  medical  .■science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
come it  in  a  form  adapted  for  preservatiou  and  reference. 


^EILL  {JOHN),  M.D.,  and     aMITff  {FRANCIS  G.),  M.D., 

Pro/,  o/the  rnstitute«o/  MeAicine  inlheUniv  o/Penna 

AN    ANALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12njO. 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


TIARTSHORNE  {HENRY),  M.D., 

Professor  of  ByyUine  in  the  UnioKrsity  of  Pennsylvania. 

A    CONSPECTUS    OF   THE    MEDICAL    SCIENCES;    containing 

Handbooks  on   Anatomy,  Physiology,  Chemistry,  Materia   Me.licii,,    Practical  Medicine' 
Surgery  and  Obstetrics.     Second  Edition,  thoroughly  revised  and  improved.   In  one  large 
royal  12mo.  volume  of  more  than   1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00.     (Lately  Issued.) 
We  can  say  with  the  tstrictest  truth  that  it  is  the 

best  work  ofthe  kind  with  which  we  areacquainted. 

It  embodie.s  ina  condensed  form  ail  recent  contribu- 


tions to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  thronghout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed. — Charleston  Med.  Journ.,  April,  187.i 

The  work  is  intended  as  an  aid  to  the  medical 
student,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  fnll  compi- 
lation of  facts,  the  perspicuity  and  terseness  of  lan- 
guage, and  the  clear  and  instructive  illustrations 
in  some  parts  of  the  work. — American  Joxirn.  of 
Pharmacy,  Philadelphia,  July,  1674. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, but  to  many  o  t  he  rswho  may  desire  to  refresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — N.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  hie 
hand.^ — Pacific  Med.  and  Surg.  Journ.,  Aug.  1S74. 

Thisis  the  best  book  ofils  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concise 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  change? 
and  the  additions  have  been  so  Judicious  and  tlio- 
rough  as  to  reader  it,  so  far  as  it  goes,  entirely  trust- 


worthy. If  students  must  have  a  conspectus,  they 
will  be  wise  to  procure  that  of  Dr.  Hartshorne.— 
Detroit  Rev.  of  Med   and  Pkarm.,  Aug.  1874. 

The  work  before  us  has  many  redeeming  features 
not  possessed  by  others,  and  is  the  best  we  have 
seen.  Dr.  Hartshorne  exhibits  much  skill  in  con- 
densation. It  is  well  adapted  to  the  physician  in 
active  practice,  who  can  give  but  limited  time  to  the 
familiarizing  of  himself  with  the  important  changes 
which  have  been  made  since  he  attended  lectures. 
The  manual  of  physiology  has  also  been  improved 
and  gives  the  most  comprehensive  view  ofthe  late.st 
advances  in  the  science  possible  in  the  space  devoted 
to  the  subject.  The  mechanical  execution  of  the 
book  leaves  nothing  to  be  wished  for. — Peninsular 
Journal  of  Medicine,  Sept.  1S74. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — tlncinnati  Lancet,  Sept.  1874. 

The  favor  with  which  the  first  edition  of  this 
Compendium  was  received,  was  an  evidence  of  its 
varinus  excellences.  The  present  edition  bears  evi- 
dence of  a  careful  and  thorongh  revision.  Dr.  Harts- 
horne possesses  a  happy  faculty  of  seizing  upon  (he 
salient  points  of  each  subject,  and  of  presenting  them 
in  a  concise  and  yet  perspicuous  manner. — Leaven- 
worth Med.  Herald,  Oct.  1S7-1 


l.D. 


rUDLOW  {J.L.), 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations  In  one  handsome  royal 
12mo.  volume  of  816  large  pages.  Cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


rpANNER  {THOMAS  HA  WKES),  M.D.,  ^c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.    Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  Collei'e  Hospital, 
London,  &c.   In  one  neat  volume,  small  ]2mo.,  of  about  375  pages,  cloth,  $1  50. 
*]ff*  On  page  3,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "American  Jouknal  of  the  Msdioal  Sciences.'' 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 


/IRAT  {HENRY),  F.R.S., 

Lecturer  on  Anatoviy  at  St.  Oeorge's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.   The  Dissections  jointly  by  the  AuTHORand 

Dr.   Cartku.      With  an    Introduction    on    Qenenil    Anatomy   and  Development  by  T. 

lloLMKS,  MA.,  Surgeon  to  St.   George's  Honpiial.     A  new  American,  from  the  Eighth 

enlarged  ^nd  improved  London  edition.     To  which  is  added  "  Lamimarks,  Medical  and 

Surgical,"  by  Lutukb  Holdkn,  F.R.C.S.,  author  of"  Human  Osteology,"  "  A  Manual 

ol  Dissections,"   etc.     In  one  magnificent  imperial   octavo  volume  of  983   pages,  with 

522   large  and  elaborate  engravings  on   wood.     Cloth,  $6;  leather,  raised  bands,  $7  ; 

half  Russia,  $7  50.      {Now  Rmdy.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  isous- 

ternary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 

also  the  application  of  those  detailein  the  practice  of  medicine  andsurgery,  thusrendering  it  both 

a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en-    i 

gravings  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 

original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 

figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 

wtiich  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 

refresh  the  memory  ot  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 

the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 

a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy,  the  work  will  be  found  of 

essential  use  to  all  physicians  who  receive  students  in  their  ofiBces,  relieving  both  preceptor  and 

pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  ofits  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reput.ition  as  acomplete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "  Landmarks,  Medical  and  Surgical" 
— which  gives  in  a  clear,  condensed  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  10(i  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  oiFered  to  the  American  profession. 


The  recent  work  of  Mr.  Holden,  which  was  no- 
ticed by  UR  on  p.  53  of  this  volume,  has  been  added 
as  an  appendix,  so  that,  altogether,  this  is  the  mott 
prnetical  and  complete  aaaiomical  treatise  available 
to  American  students  and  phy.iicianH.  The  former 
finds  in  it  the  necessary  guide  in  making  dissec- 
tions ;  a  very  comprehenhire  chapter  on  minute 
anatomy  ;  and  about  all  that  can  be  taught  him  on 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  addition  of  Air.  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice. — Ntw  Remedies,  Aug  1676. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 
text-book  or  a  general  reference  book  on  anatomy 
to  be.  The  Aruericau  publisher  deserves  the  thanks 
of  th«  profession  for  appending  the  recent  work  of 
Mr.  Holden,  "  Landmarkt,  Medical  and  Hurgical," 
which  has  already  been  commended  as  a  separate 
book.  The  latter  work — treating  of  topographical 
anatomy — lias  become  an  e.ssential  to  the  library  of 
every  Intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distinguished  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anj^thlng  further  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  In  this  country,  and  the  daily  refer- 
ence book  of  every  practitioner  who  has  occasion 


to  consult  his  books  on  anatomy.  The  work  is 
simply  indi.^pensable,  especially  this  present  Amer- 
ican edition.— Fa.  Med.  Monthly,  Sept.  1878. 

The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  tre<ttise  available  to  American  students, 
who  find  in  it  a  comprehensive  chapter  on  minute 
auaiomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  view,  in  the  valu- 
able section  by  Mr.  Hoi  den,  is  all  that  will  be  essen- 
tial to  them  in  practice.— O^io  Medical  Recorder, 
Aug   1878. 

It  is  difficult  to  speak  in  moderate  terms  of  this 
new  edition  of  "  Gruy."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  successively  revised  the 
eight  editions  through  which  it  has  passed,  would 
seem  to  leave  nothing  for  future  editors  to  do.  The 
addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  an4 
surgery  as  it  has  been  heretofjre  to  the  student.  As 
regards  complelemss,  ease  of  reference,  utility 
beauty,  and  cheapness,  it  has  no  rival.  No  stvt- 
dent  should  enter  a  medical  school  without  it;  no 
physician  can  afl'ord  to  have  it  absent  from  hie 
library. — St.  Louis  CUn.  Record,  Sept.  1878. 


H' 


Also  for  sale  separate — 
'OLDEN  (LUTHER),  F.R.C.S., 

Surgeon  to  St.  Bartholoinew'g  and  the  Foundling  no.<ipitnls. 


LANDMARKS,  MKDICAL  AND   SURGICAL.     Second  Amerioan, 

from  the  Third  and  llevijed  English  Edition.     In  one  handsome  12mo.  volume,  of  about 
140  pages.      {Preparing.) 

TIE  A  TH  ( CHRISTOPHER),  F.R.G.S., 

J.  J.  T-arher  of  Oprraiive  Surgery  in  Onivernity  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Krei», 
M.  D.,  Lecturer  on  Patiiological  Anatomy  in  the  .Jeffer.<?on  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo. volume  of  578  pages,  with  247 illustrations.  Cloth,  $3  60  : 
leather,  $4   00.  * 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 


A  LLEN  {HARRISON).  M.D. 

•^^  Profegxor  of  Physiology  in  the.  Univ.  of  Pa. 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCJiUDING  ITS  MEDICAL 

and  Surgical  Relationa.  For  the  Use  of  Practitioners  and  Studentsof  Medicine.   With  :in 
Introductory  Chapter  on  Histology.  B3'  E.  0.  Siiak  espeare,  M  D.,  Ophthalmologist  to  the 
Phila.  Ho^p.    In  one  large  and  h:indsotne  quarto  volume,  with  several  hundred  oricinal 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  text.      {iSkortly.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  has 
Bought  to  give,  not  only  the  details  ofdescriptive  anatomy  in  a  clear  and  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  priiclitioner,  as  well  as  of  the  student,  ennblinghimnotonlyto  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  wiiich  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissections,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "  Qniy, "  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publishers  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

ZpiLIS  [GEORGE   VINER).  ~~ 

-*-•  Eme.ritux  I'ri\ff:fi/ior  0/  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OF  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.   By  Georoe  Viner  Ellis,  Emeritus  Professor 
of   Anatomy   in    University  College,   London.     From  the  Eighth  and  Revised  London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  266  illustrations. 
Cloth,  $4.25  ;  leather,  $5.25.      (Now  Ready.) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  as  is  attested  by  the  numerous  editions  through 
which  it  has  passed.    In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

Ellis's  Demonstrations  is  the  favorite  text-book    its  leadership  over  the  English  manuals  upon  dis- 


of  the  English  student  of  anatomy.  In  passing 
through  eight  editions  it  has  been  so  revised  and 
adapted  to  the  needs  of  the  strident  that  it  would 
seem  that  it  had  almost  reached  perfection  in  this 
special  line.  The  descriptions  are  clear,  and  the 
methods  of  pursuing  anatomical  investigations  are 
given  with  such  detail  that  the  book  is  honestly 
entitled  to  its  name. — St.  Louis  Clinical  Record, 
Jun»Tl879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in  the  present  as  in  the  past  volumes. 
The  book  seems  destined  to  maintain  yet  for  years 


secting. — Phila.  Med.  Times,  May  21,  1879. 

As  a  dissector,  or  a  work  to  have  in  hand  and 
studied  while  one  is  engaged  in  dissecting,  we  re- 
gard it  as  the  very  best  work  extant,  which  is  cer- 
tainly saying  a  very  great  deal.  As  a  text-book  to 
be  studied  in  the  disKecting-room,  it  is  superior  to 
any  of  the  works  npon  anatomy. — Qincinnati  Med. 
News,  May  24,  1879. 

We   most  unreservedly  recommend   It  to   every 

practitioner  of  medicine  who  can  possibly  get  it. 

Va.  Med.  Monthly,  June,  1879. 


w 


ILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  SpeciaL  Edited 

by  W.  H.GoBRECHT,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  pages  ;  oloth,  $4  ;  leather,  $5. 

JgMITH  [HENRY H.),  M.D.,        and  JJORNER  [  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  ofPenna.,Ac.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna. 

AN    ANATOMICAL   ATLAS  ;    Illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 

Cf CHAFER  [ED  WARD  ALBERT),  M.D., 

^  Assistant  Professor  of  Physiology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Bein^  an  Introduction  to 

the  Use  of  the  Microscope.  In  one  handsome  royal  12mo.  volume  of  304  pages  with 
numerous  illustrations:  cloth,  $2  00.     (Just  Issiied.) 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  2  vols.  8vo.,  of  over  1000  pages, 
with  320  wood-outs  :  cloth,  $fi  00 

SHARPEY  AND  QUAIN'S  HDMAN  ANATOMY. 
Revised,  by  Joseph  Lbidy,  M.D.,Prof  of  Anat. 
in  Univ.  of  Penn.  In  two  octavo  vols,  of  about 
1300  pages,  with  611  illustrations      Cloth,  $6  00. 

BELLAMY'S  STUDENT'S  GUIDE  TO  SURGICAL 
ANATOMY:  A  Text-book  for  Students  preparing 


for  their  Pass  Examination.  With  engravings  on 
wood.  In  one  handsome  royal  12mo.  volume 
Cloth,  $2  25. 

CLELAND'S  DIRECTORY  FOR  THE  DISSECTION 
OP  THE  HUMAN  BODY.  In  one  small  volume 
royal  12mo.  of  182  pagen:  sloth  $1  2b.  ' 

HARTSHORNE'S  HANDBOOK  OF  ANATOMY  AND 
PHYSIOLOGY.  Second  edition,  revised.  In  one 
royal  12mo.  vol.,  with  220  wood-cuts;  cloth 
$1  75.  ' 


8 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology). 


nALTON  {J.  C),  M.D., 

-*-^  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  Tork.&c. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.    Sixth  edit.,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.    In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.  Cloth,  $5  50  ;   leather,  $6  50  ;  half  Russia,  $7.   {^Lately  Issued.) 
DuriDg  the  past  few  .venr.-^.-ieveral  new  work.-;  on  pbj-    served  intact,  the  work  in  Che  pn^sent  edition  has  been 
8ioloi;y,aud  new  edition.',  of  old  works,  haveappeared,     brouijht  upfuUy  abreastofthetime,'*.  Thenewchemieal 
competing  for  the  favor  of  the  inedic-al  student,  but    notation  and  nomenclature  have  also  been  introduced 
none  will  rival  this  now  edition  of  D:ilton.    As  now  en-    into  the  present  edition.    Notwithsianding  the  multi- 
larged,  it  will  be  fouudalso  to  be.in  i;eneral,  a  satisfac-  j  plicity  of  text-books  on  physiology,  this  will  lose  none 
torv  work  of  reference  for  the  practitioner. — Chicago  |  of  its  old  time  popularity.    The  mechanical  execution 
M-id.  Journ.  and  Examiner, ^&a.\%~%.  i  of  the  work  i.?  all  that  could  be  desired. — Peninsrilar 

Prof.  Dalton  has  discus.-^ed  contlictinjj  theories  and  I  fnurnnl  of  ^fedicine.■De.a.\^-b. 
conclusion.'  regarding  physiological  questions  with  a  j      This  popular  texi-book  on  physiology  comes  to  us  in 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh-  J  its  sixthedition  with  the  addition  of  about  fifty  per  cent, 
nessand  vigor  to  the  entire  book.    But  his  discussions    of  new  matter,  chietly  in  the  departments  of  patho 


have  been  so  guarded  by  a  refusalof  admission  to  those 
spuculativo  and  theoretjcal  explanations,  which  at  best 
exist  in  the  mindsof  observers  themselvesas  only  pro- 


logical  chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keep  the  work  well 


babilities,  that  none  of  his  readers  need  be  led  into  i  up  to  the  times,  its  continued  popularity  may  beconfi- 
grave  errors  while  making  them  a  Study. — T/ie  .4/edica/ ]  dently  predicted,  notwithstanding  the  competition  it 
Ruord   Feb  19   1S76  may  encounter.     The  publisher's  work  is  admirably 

For  c'learne.«s'  and  perspicuity,  Dalton's  Physiology    done.-St.  Louis  Med.and  ^ur^/.Journ.,  Dec.  1875. 
commended  itself  to  the  student  years  ago.  and  was  a  |      The  revisionofthisgreatworkhas.broughtitforward 
pleasant  relief  from  the  verbose  productions  which  it  i  *ith  the  physiological  advances  of  theday.  and  renders 
supplanted.    Physiology  has,  however,  made  many  ad-  \  it,  as  it  has  ever  been,  the  finest  work  for  students  ex- 
vances  since  then— and  while  the  style  has  been  pre- .  "ant. — NashviVzJoum.of  Med.  and  Surg.,  Ja.n.  1876. 

flARPENTER  (  WILLIAM  B.),  M.D.,  F.R.  S.,  F.G.S.,  F.L.S., 

^-^  Regixtmr  to  University  of  London,  etc 

PRINCIPLES  OF  HUMAN  PHl^SIOLOGY^;  Edited  by  Henry  Power, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  Univer.=ity  of  Oxford.  Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  G-  Smith,  M.D.,  Professor  ol  the  Institutes  cf  Medicinein  the  Univer- 
sity of  Pennsylvania,  etc  In  one  very  large  and  handsome  octavo  volume,  of  IflSH  pages, 
withtwoplates  and  373  engravings  on  wood.  Cloth,  $5  50;  leather,  $6  60  ;  half  Russia, 
$7.     (Just  Issued.) 

new  a  year  or  two  ago,  looks  now  as  if  it  had  been  a 
received  and  established  fact  for  years.  In  this  ency- 
ctopiedic  way  it  is  unrivalled,  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gamtte,  Feb.  17,  1877. 

The  meritsof  "Carpenter's  Phy8iology"are  so  widely 
known  and  appreciated  that  we  need  only  allude  briefly 
to  the  fact  that  in  thelatestedition  will  befound  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
lo<<ical  investigation.  Care  has  been  taken  to  preserve 
the  practical  ch.aracter  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — N.  Y.  JUed.  Journal,  Je,n. 1ST! . 


"We  have  been  agreeably  surprised  to  find  the  vol- 
ume so  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervoun  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  ofthe  most  diffi- 
cult of  all.  In  thewhole  range  of  physiology,  upon 
which  to  produce  a  full  and  .satisfactory  treatise  of 
the  class  to  which  the  one  before  asbfiougs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sense  of  the  word,  is  the  production  of  a  philoso- 
pher aswellas  a  physiologi.-t,  brought  it  up  as  fully 
as  could  beexpected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  iu  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Dinease,  April,  1877. 

Such  enormous  advances  haverecently  been  made  in 
our  physiological  knowledge,  that  what  was  perfectly 


F 


OSTER  [MICHAEL),  M.D.,  F.R.S., 

Prof,  of  Physiology  in  Cambridge  Univ.,  England. 

TEXT-BOOK   OF   PHYSIOLOGY.     Latest 


edition.     In  one   hand- 


some 12mo.  vol.  of  over  800  pages,  with  72  illustrations.     Cloth,  $3  00.     (Just  Ready.) 

to  the  general  practitioner  as  well,  feeling  coolident 
that  an  exainiuatiou  will  result  in  a  jnst  apprecia- 
tion  of  its   merits. — Southern    Practitioner,   Aug. 

1880. 

Dr.  Foster  has  combined  In  this  work  the  conflict- 
ing desiderata  In  all  text-books— comprehensive- 
ness, brevity,  and  clearnecs.  After  a  careful 
perusal  of  the  whole  work  we  can  confidently  re- 
commeiid  it,  both  to  the  student  and  the  practitioner, 
a»  being  one  of  the  best  text-books  on  physiology  ex- 
tant —  The  London  Lancnt. 


This  is  a  valuable  addition  to  medical  literature, 
constituting  one  of  the  most  lucid  expositions  of  the 
Bcience  of  physiology  in  its  most  modern  aspect. 
It  is  one  of  tbe  best  books  for  the  student  that  we 
have  seen.  While  not  so  voluminous  as  some  of  the 
text-books  that  have  heretofore  been  placed  beiore 
students  of  medicine,  it  is  full  and  comprehensive, 
acd  embraces  a  thorough  and  complete  investiga- 
tion of  the  many  intricate  problems  of  the  science  of 
life  fully  brought  up  to  the  most  recent  standpoint. 
We' cordially  commend  it,  not  only  to  students,  but 


LEHMANK'S  MANUAL  OF  CHEMICAL  PHYSIOL- 
OGY. Translated  from  the  German,  with  Notes 
and  Additions,  by  J.  Cheston  Morkis,  M.D.  With 
lllnntratious  oo  wood.  Id  one  octavo  volume  o( 
33e  pages.     Cloth,  ifi  25. 


LEUMANN'S  PHYSIOLOGICAL  CHEMISTRY.  Com- 
plete in  two  large  octavo  volumes  of  120O  paees, 
with  200 Illustrations;  cloth,  $6. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ( GhemiHtry).  9 

A  TTFIELD  {JOHN).  Ph.D., 

•*-*-  Pr<i/e.^fi<ir  of  Practical  Chf.mi stry  t o  thu  Pharmaeetitical  Hnciety  of  Great  Britain.  *c. 

CHEMISTRY,  GENERAL,  MEDICAL  AND   PHARMACEUTICAL; 

Includinf;  the  Chemistry  of  the  U.  S.  PhnrmacO)  oeio  .  A/lanual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eifjhth  edition,  re  vised 
by  the  anthor.  In  one  handsome  royal  12mo.  volame  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.      (Noio  Ready.) 

We  have  repeatedly  expressed  our  favorable  i  of  chemiBtry  In  all  the  medical  colleges  In  the 
opinion  of  thi.s  work,  and  on  the  appearance  of  a  I  United  States.  The  present  edition  contains  such 
new  edition  of  it,  little  remains  for  ns  to  Kay,  ex-  |  alterations  and  additionn  as  seemed  necessary  for 
cept  that  we.  expect  this  eighth  edition  to  be  as  the  demonstration  of  the  latest  developments  of 
indispensnble  to  us  as  the  seventh  and  previons  !  chemical  principles,  and  the  latest  applications  of 
editions  have  been.     While  the  «;eneral  plan  and  '  chemistry  to  pharmacy.     It  is  scarcely  nececsary 


arrangement  have  been  adhered  to,  new  matter 
has  been  added  covering  the  oljservations  made 
since  the  former  edition  The  present  differs  from 
the  preceding  one  chiefly  in  these  alterations  and 
in  about  ten  pages  of  useful  tables  added  in  the 
appendix.— ./4TO.  Jotirn.  of  Pharmacy,  May,  1879. 
A  standard  work  like  Attfield's  Chemistrv  need 


for  us  to  say  that  it  exhibits  chemistry  in  its  pre- 
sent advanced  state. — Cincinnati  Medical  News, 
April,  1S79. 

The  popularity  which  th^s  work  has  enjoyed  is 
owing  to  the  original  and  clear  disposition  of  the 
facts  of  the  science,  the  accuracy  of  the  details,  and 
the  omission  of  ranch  which  freights  many  treatises 


only  be  mentioned  by  its  name,  without  further  i  heavily  without  briugingcorrespondinginstruction 
comments.  The  present  edition  contains  such  al- j  to  the  reader.  Dr.  Attfield  writes  for  students,  and 
teraii"ns  and  additions  as  seemed  necessary  for  |  primarily  for  medical  students;  he  always  has  an 
the  demonstration  of  the  latest  developments  of  l  eye  to  the  pharmacopoeia  aud  its  offlclnal  prepara- 
chfmical  principles,  and  the  latest  applications  of  I  tions ;  and  he  is  continnally  putting  the  matter  in 
chemistry  to  pharmacy.  The  anthor  has  bestowed  !  the  text  so  that  it  responds  to  the  questions  with 
arduous  labor  on  the  revision,  and  the  ex'ent  of  i  which  each  section  is  provided.  Thus  the  student 
the  information  thus  introduced  may  be  estimated  '  learns  easily,  aud  can  always  refresh  and  test  his 
from  the  fact  that  the  index  i-ontains  three  hnn-  knowledge. — Med.  and  Surg.  Reporter,  Aprii'19,^79. 
dred  new  references  relating  to  additional  mater-  \  We  noticed  onlv  about  two  vears  and  a  half  ago 
M  tI'tq^^'*'*  '^"'^^^^^  ""'^  Chemical  Gazette.  \^i^f,  nublication  of  the  preceding  edition,  and  re- 
May,  1S79.  j  marked  upon  the  exceptionally  valuable  character 
This  very  popular  and  raoritorions  work  has  !  of  the  work.  The  work  now  i  icludes  the  whole  of 
now  reached  its  eighth  edition,  which  fact  speaks  I  the  chemistry  of  the  pharmacopoeia  of  the  United 
in  the  highest  terms  in  commendation  of  its  excel-  I  States,  Great  Britain,  and  India. — New  Remedies, 
leuce.     It  has  nCw  become  the  principal  lext-book    May,  1879. 


G 


REENE  [WILLIAM  H.),  M.D., 

Deriinnntratnr  i>f  Ohemisfry  in  Med   Dept  ,  Univ.  of  Penna. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Students. 

Based  upon  Bowman's  Medical  Chemistrv.  In  one  royal  12mo.  volume  of  312  pages. 
With  illustrations.     Cloth,  $1  75.      (Now  Ready.) 

It  is  well  written,  and  gives  the  latest  views  on  i  The  little  work  before  ns  is  one  which  we  think 
vital  chemistry,  a  subject  with  which  most  phy^i-  '  will  be  studied  with  pleasure  and  profit.  The  de- 
cians  are  not  sufficieolly  familiar.  To  those  who  scriptions.  though  brief,  are  clear,  and  in  most  cases 
may  wish  to  improve  their  knowledge  in  that  diiec  sufficisnt  for  the  purpose  This  book  will,  in  nearly 
tion,  we  can  heartily  recommend  this  work  as  being  all  cases,  meet  general  approval. — Am..  Journ.  of 
worthy  of  a  careful  perusal. — Phila.  Med.  and  Surg.  ,  Pharmacy,  April,  ISSO. 
Xeporfer,  April  2i,  1880. 

nLASSEN  [ALEXA^NDER], 

^  Prnfenoor  i  a  the  Rayal  Pr.lijtpchnic  School,  Aixla-ChapeVe. 

ELEMENTARY   QUANTITATIVE    ANALYSIS.     Translated   with 

notes  and  additions  by  Edg^r  F  Swith,  Ph  D..  Assistint  Prof,  of  Chemi.'=try  in  the 
Towne  Scientific  School,  Univ.  of  Penna.  In  one  hand.some  royal  12ino.  volume,  of  ;-{24 
pages,  with  illustrations  ;  cloth,  $2  00.      (Just  Readi/.) 

It  is  proliablythe  best  minual  of  an  elementary  ad vancing  to  the  analysis  of  minerals  and  such  pro- 
nature  extant,  insomuch  as  its  methods  are  the  best,  ducts  as  are  met  with  in  applied  chemistry  It  is 
It  teaches  by  examples,  commencing  with  single  an  indispensable  book  for  students  in  chemistry.—- 
determinations,  followed  by  separations,  and  then  :  Bo.Hoii  Journ.  of  Chemintry,  Oct.  1878. 

ALLOWAT  [ROBERT],  F.C.S., 

Priif  of  Applied  Chemintry  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.   From  the  Fifth  Lon- 

don  Edition.  In  one  neat  royal  12ino.  volume,  with  illustrations  ;  cloth,  §2  75.  (Lately 
Issued.) 

J?EMSEN[IRA),  M.D.,  Ph.D., 

Prnfefisor  of  Cherai-it ry  in  the  Johns  Hopkins  University,  Baltimore. 

PRTNCIF'LESOF  THEORETICAL  CHHJ.MISTllY,  wiih  speoial  reference 

to  the  Constitution  of  Chemical  Compounds.  In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     {Just  Issued.) 


G 


BOWMAN'S     INTRODUCTION     TO     PRACTICAL] 
CHEMISTRY,    INCLUDING    ANALYSIS.       Sixih 
American,  from  the  sixth  and  revised  London  edi- 
tion.    With  numerous  illustrations.     In  one  neat 
Tol.,  royal  12mo.,  cloth,  $2  25. 


WOHLER  AND  FITTIG'S  OUTLINES  OF  ORGANIC 
CHEMISTRY.  Translated  with  additions  from  the 
Eighth  German  Edition.  By  Ika  Remsek.  M  D., 
Ph  D.,  Prof,  of  Chemistry  and  I'hysics  in  Williams 
College,  Mass.  la  one  volume,  royal  12mo.  of  oo8 
pp.,  cloth,  $3. 


10  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Chemistry), 


JfpOWNES  [GEORGE],  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  Revised  and  corrected  by  Henry  Watts,  B.  A.,  F  R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plnte,  and  one  hundred  and  seventy-seven  illus- 
trations. A  new  American,  from  tht  Twelfth  and  enlarged  London  edition.  Edited  by 
Robert  Bridges,  M.D.  In  one  large  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     {Just  Issued.) 

what  formidable  magnitude  with  its  move  than  a 
thua~and  page.-*,  but  with  less  thH,n  this  no  fair  rejire- 
senlation  of  chemistry  as  it  now  is  can  be  given.  The 
typo  is  .small  but  very  clear,  and  the  sections  are  very 
lucidly  arrnnged  to  facilitate  study  and'reference. — 
Med.  and  Surg.  Reporter,  Aug   3,  1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  saflice  it  to  say  that 
the  revi^ion  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  The  book  has  always  been  a  fa- 
vorite in  tliis  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige. — Boston  Jour. 
of  Chemistry,  Aug.  1878. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  geueral  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  eUiborate  and 
thorough  revisions  which  have  been  made  from  time 
to  time  leave  lit  lie  chantje  for  any  wideawake  rival  to 
step  before  it. — Canadian  Pharm.  Joxi^r.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1878. 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  preseuts, 
in  a  remarkably  conveuieut  and  satisfactory  man- 
iifT,  the  principles  and  leadiug  facts  of  the  chemistry 
of  to-day.  Concerning  the  manner  in  which  the 
various  subjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praice  of  the  book.  A  re- 
view of  such  a  work  af  Fownes's  Cheini-Hry  within 
the  limits  of  a  book-notice  for  a  meilical  weekly  is 
simply  out  of  the  question. — Cincinnati  Lancet  and 
Clinic,  DfC.  14,1878. 

When  we  state  that,  in  our  opinion,  the  present 
edition  sustains  in  every  respect  the  high  reputation 
which  its  predecessors  have  acquired  and  enjoyed, 
we  express  therewlih  our  full  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Aug.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English  editors  renders 
it  still,  perhaps,  the  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  [he  acquisitions 
of  his  student  days.    It  has,  indeed,  reached  a  some- 


B 


LOXAMiC.L.),      ^ 

Pro/exsor  of  Chemistry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lon- 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00  ;  leather,  $5  00.     {Lately  Issued.) 


We  have  in  this  work  a  completeand  most  excel- 
lent text-book  for  the  use  of  scliools,  and  can  heart- 
ily recommend  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  28,  1874. 

The  above  isthetitleofawork  which  we  can  most 
conscientiously  recommend  tostudeuts  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesa in e  time  that  it  presentsa  full  account 
of  that  science  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  wants  of 
students;  it  is  quite  aswell  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  what  i.'s 
thecbemistry  of  the  presentday. — American  Prae- 
titioner,  Nov.  1873. 


It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
c)  clopsedia  within  the  limits  of  aconvenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  the 
record  of  new  and  valuable  processes  and  discover- 
ies, while  the  cautious  conservati'^e  does  not  find  its 
pages  monopolized  by  uncertain  theories  and  specu- 
lations. A  peculiar  point  of  excellence  is  the  crys- 
tallized form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragraphs.  One  issurprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little.  If  any  more 
should  have  been  said.  Altogether,  it  is  seldom  yoa 
see  a  text-book  so  nearly  faultless.  —  Cincinnati 
Lancet,  Nov.  1873. 


o 


'LOWES  (FRANK),  D.Sc,  London. 

Senior  Science-Waster  at  the  High  School,  Newcastle-under-Lyme,etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Lalioratorie.s  of  Schools  and  Colleges  and  by  Beginners.  Second  American  from  the 
Third  and  Revised  English  Edition.  In  one  very  handsome  royal  12mo.  volume  of 
372  pages,  with  47  illustrations.      Cloth,  $2  50.      {Just  Ready.) 

fereace  and  instruction  in  his  Horary.  As  a  rnle. 
•such  volumes  are  too  techuicil  and  abstruse  for 
study  without  some  didactic  aid,  but  the  volume 
pieseoted  is  easy  of  comprehension,  and  will  t)e  of 
greit  value  to  college  students  rind  busy  pr  ictition- 
ers.— A^.  r.  Am..  Mi'd.  Bi-We^Uly,  Aprifg,  1881. 

The  tables  partlculnrly  demand  praise,  for  they 
are  admirably  formed,  bi  th  for  convenience  of  re- 
ference and  liilness  of  information.  In  short,  we 
do  not  remember  lo  have  met  with  a  book  which 
could  belter  serve  the  stud'  nt  as  a  guide  to  the  sys- 
ttiroatio  study  of  inorganic  cheiuistry. — LoxiisvMe 
Med.  News,  March  12,  1881. 


This  is  a  valuable  work  for  those  about  to  com- 
mence chemistry,  the  more  so  as  by  its  use  they  are 
simultaneously  acquainted  with  the  manipulation 
of  chemical  analysis,  a  method  which  is  the  most 
valuable  to  Impart  a  Ihor'  ugh  kn'iwlei'go  of  chemis- 
try. It  is  a  very  good  little  book,  and  will  make 
for  itself  man*  warm  friends  and  snpnortirs  It 
treats  the  snbjeci  wel  I  and  the  t«bl's  are  very  clear 
and  valuable. — St.  Louis  Med.  and  Surg.  Journ., 
Mar.  1881. 

This  work  Is  not  only  well  adapted  for  use  as  a 
text  book  I  n  medical  colleges,  but  is  aUo  one  of  the 
best  that  a  praciltlouer  can  have  for  coDvenient  re- 


KX  A  PP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts  and  to  .Manufactures.  Wilh  American 
additions  by  Prof.  Wai.tek  K.Johnson.     In  two 


very  handsome  octavo  volumes,  with  500  wood 
engravings,  cloth,  $6  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (P/mr.,  Mat.  lied.,  etc.).    11 
pARRISH  [EDWARD), 

Late  Profe.iKor  of  MrUeria  Me.dica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON   PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  Thoma.s  S.  Wiegand.  In  one 
h.indsome  octavo  volume  ot  977  pages,  with  280  illustrations  |  cloth.  $6  60;  leather,  $6  60; 
half  Russia,  $7.      {Lately  Issued.) 


Of  Dr  Pari-ish's  great  work  ou  (ilKirniacy  It  only 
remains  to  be  said  thai  tlie  editor  has  accomplished 
his  work  so  well  as  to  nuiiuiaiu,  iu  this  fourth  edi- 
tion, the  high  standard  of  excellence  which  it  had 
attained  in  previous  editions,  under  the  editorship  of 
Its  aecomplished  author.  This  has  not  heen  accom 
plished  with  out  much  labor, an  dm  any  additions  and 
improremeiils,  involving  chauKes  iu  the  arrange- 
ment of  the  several  parts  of  the  work,  and  the  addi- 
tion of  much  new  matter.  With  the  modifications 
thus  effected  it  constitutes, as  now  presented  ,  a  com- 
pendium of  the  science  and  art  indispensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practitioner  of  tnedlcine  desirous  of  familiarizing 
himself  with  the  pharmnreutical  preparation  of  the 
articles  which  he  pre-crihes  forhispatieuts.  —  Chi- 
cago Med.  ./'oitrji.,  July,  1S7-1. 

The  work  is  eminently  pra'ttcal,  and  has  the  rare 
merit  of  being  readable  und  interesting,  while  it  pre 


the  work,  not  only  to  pharmacists,  hut  also  to  the 
multitude  of  medical  practitioners  wh-i  are  obliged 
to  compound  their  own  medicines  It  M  111  ever  hold 
an  honored  place  on  our  own  bookshelves. — Dublin 
Med.  Prennnnd  Circular,  Aug.  12,  1874. 

We  expressed  our  opinion  of  a  former  edition  in 
terms  of  umiualified  praise,  and  we  are  in  no  mood 
to  detract  from  that  opinion  in  reference  to  the  pre- 
sent edition,  the  preparation  of  which  has  fallen  into 
competent  hands.  It  isa  book  with  which  no  pharma- 
cist can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  Information  of  value  to  him  in 
practice.— P«ct.A"c  Med  and  Surg .  Journ. ,  June, '74. 

Perhaps  one,  ifnot  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
gUHge  has  emanated  from  the  tra  nsathi  utic  press. 
"  Parrishs  Pharmacy"  is  a  well-known  work  on  this 
side  of  the  water,  and  the  factshows  us  that  a  really 


serves  a  strictly  •'cieniiliccharacter  The  whole  work  i  useful  work  never  becomes  merely  local  in  its  fame, 
reflects  the  greatest  credit  on  author, editor  and  pub  |  Thanks  to  the, j  udicions  editing  of  Mr.  Wiegand,  the 
Usher  It  will  convey  soineideji  ofthe  liberality  which  |  posthumous  edition  of  "Parrish"  has  been  saved  to 
has  been  bestowed  upon  its  production  when  we  men-  the  public  with  all  the  mature  experience  of  its  au- 
tion  that  there  are  no  less  than  2Sncarefully  executed  thor,  am)  perhaps  none  the  worse  for  a  dash  of  new 
Illustrations.  In  conclusion,  we  heartily  recommend   blood. — Lnnd.  phar'm.  Journal  Oct.  17    1874. 

Q.RIFFITH  [ROBERT  E.),  M.D.  ^ 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciar  s  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  John  M. 
MAiscH.ProfessorofMateriaMedicain  the  Philadelphia  Collegeof  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  son  pp.,  cl.,  $4  50;  leather,  $5  60.  {Lately  Issued.) 
To  the  druggist  a  good  formulary  is  simply  indis- 
pensable, and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 


Many  physicians  have  toofBciate,  also,  as  drug 
gists.  This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  hirn  the  meMni- 
b.r  which  to  administer  or  cotnhine  his  retnedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf  A  formulary  of 
this  kind  is  ofbenefit  also  to  the  city  nhysician  in 
largest  'pr&cVic^.— Cincinnati  Clinic,  Feb.  21.  1874. 


A  more  complete  formulary  than  itis  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  les.<  essential  to  the  |iractitioner 
who  compounds  his  own  mpdirines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  wav  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  '74. 


F 


^ARQUHARSON  [ROBERT),  M.D. , 

Lenture.r  on  Materia  Medina  at  fit.  Mary's  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.  Se- 
cond American  edition,  revised  by  the  Author.  Enlarged  and  adopted  to  the  U.  S. 
Pharmacopoeia.  By  Frank  WoonsuRy,  M.D.  In  one  neat  royal  12mo.  volume  of  498 
pages:  cloth,  $2,25.      (Jtist  Ready.) 

copious  notes  have  bean  introduced,  embodying  the 
latest  revision  of  the  Pharmacopoeia,  together  with 
the  antidotes  to  the  more  prominent  poisons,  and 
such  of  the  newer  remedial  aceots  as  seemed  neces- 
sary f,o  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex end  the  vo\\.\m(i  —Drtigyigts'  Circular  and 
Chemical  Ome.tte,  June,  1879. 

It  isa  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  that  the  sense  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies  i-^  notentlrelj  overwhelmed  in  the  cultiva- 
tion of  pathological  studies,  characteristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  80  quickly  achieved.— JVew  Remedien,  July,  '79. 


The  appearance  of  a  new  edition  of  this  conve- 
nient and  handy  book  in  less  than  two  years  may 
certainly  be  taken  as  an  indic^.tion  of  its  useful- 
ness. Its  convenient  arrangement,  and  its  terse- 
ness, and,  at  the  same  time,  com  ole'eness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Jdiirn.  of  Pharmacy,  June,  1879. 

This  work  contains  in  moderate  compass  snch 
well-digested  facts  concernirg  the  physiological 
and  therapeutical  action  of  renredies  ai  are  reason- 
ably established  up  to  the  present  time.  By  a  con- 
venient arrangement  the  eorrespondi  rg  effects  of 
each  article  in  health  and  disease  are  presented  in 
parallel  c  lumns,  not  only  rendering  reference 
easier  but  also  impressing  the  facts  more  strongly 
tition  the  mind  of  the  reader.  The  book  has  been 
adapted  co  the  wants  of  the  American  student,  and 


CHRTSTISON'S  DISPENSATORY.  With  copiousad- 
ditions.  and  213  large  wood  engravings  By  R. 
EnLF.sFiRiD  Griffith,  M.D.  One  vol.  8vo.,  pp. 
1000,  cloth,  $4  00. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liquorb  in  Health  and  Disease.  New 
edition,  with  a  Preface  by  D.  F  Condib.  M.D.,  and 
explanationsof  scientiflowords.  In  oneueat]2mo. 
volume,  pp.  178,  cloth,  60  cents. 


12  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Jilat.  Med.  and  TJierap.). 
SJTILLE  [ALFRED).  M.  D.,  LL.D.,  and   IfAJSCH  [JOHN  M.).  Ph.D., 

A3         Pro/  of  ThMry  and  Practicfof  Medicine  -^-'J-        Pruf.  ofMnt.  JTed.  and  Hot  in  Phila. 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  ^hnrmncy.  Sceytothe  American 

Pharmaceutico.l  A-i.tociatioii. 

THE   NATIONAL  DISPENSATORY:  Containing  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in 
the  Pharmacopoeia?  of  the  United  St^ites,  Great  Britain  and  Germany,  wiih  numer- 
ous references  to  the  French  Codex.  Second  edition,  thorousrhly  revised,  with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1692  pages, with  239  illustrations. 
Extra  cloth,  $6  75  ;  leather,  raised  bands,  $7  50  ;  half  Russia,  raised  bands  and  open 
back,  $8  25.     {Now  Ready.) 

Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  month?  an  unusually  large  edition  of  the  National 
Dispensatory  is  doubly  gratifying  to  the  authors,  as  showing  that  they  were  correct  in  thinking 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  profes.sions,  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  labors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  favor 
with  which  it  has  been  received.  The  first  edition  of  a  work  of  .'■uch  magnitude  must  necessarily 
be  more  or  less  imperfect ;  and  though  but  little  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la'er.  The 
opportunity  for  a  revision  has  enabled  the  authors  to  scrutinize  the  work  as  a  whole,  and  t» 
introduce  alterations  and  additions  whereve:  there  has  seemed  to  be  occasion  for  improve- 
ment or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drugs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemicals  and  pharma- 
ceutical preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles  :  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investigations  which 
came  to  the  authors'  notice  up  to  the  time  of  publication  have  received  due  consideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  handred  pages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  made  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  disease,  great  care  has  been  taken  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  expressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  making  those  who  employ  the  Dispensatory  familiar  with  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  malang  the  total 
number  in  the  present  edition  about  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  any  time 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  worthlessness  of  certain  medicines  or  with  the 
narrow  limits  of  their  power,  as  to  know  the  well  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  possessed  by  such  an  Index  is,  that  it 
contains  the  elements  of  a  natural  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  treatment  of  disease. 

This    evidence    of    saccess,    seldom    paralleled,  keep  the  work  up  to  the  time. — Kew  Remedies,  Nov. 

ehowB  clearly  how  well  the  authors  have  met  the  1879. 

existing  needs  of  the  pharmaceatical  aod  medical  This  is  a  great  work  by  two  of  the  ablest  writers  on 
professions.  Gratifying  as  it  must  be  to  tbem,  ihey  ^^i^^^  ^^^^^^  i^  America  the  authors  h^ve  pro- 
have  embraced  the  opporuuuy  offered  for  a  thor-  j^^^j  ^  work  which,  for  accuracy  and  comprehensive, 
ongh  reviMoii  of  the  whole  work,  striving  to  em-  I  nes'^.  is  un.=urpassed  by  any  work  on  the  subject.  There 
brace  withm  it  all  that  might  have  been  omitted  in  j^  „„  ^.^^  ;„  the  lin-li.h  language  ^hich  contains  so 
the  f..rtner  edition,  and  all  that  has  newly  appeared  ^^^^^  valuable  inf  .rmation  on  the  various  articles  of 
of  safflcieat  importance  danng  the  time  of  Us  col-  j^e  materia  medica.  The  work  has  cost  the  authors 
laboration,  and  the  short  iQterval  elap.sed  since  the  y^^rs  of  laborious  study,  but  thev  have  succeeded  in 
previous  publication.  After  hnving  gone  carefully  producing  a  dispensatory  which  is  not  only  national, 
through  the  volume  we  must  admit  th^t  the  authors  but  will  be  a  lasting  memorial  of  the  learning  and 
have  labored  faithfully,  and  with  success,  in  main-  ^bilitv  of  the  author.^!  who  produced  it.— Sdinburgh 
taming  the  high  character  of  their  work  as  a  com-  MediialJourna},  Nov.  1879. 
pendinm  meeting  the  requirements  of  the  day,  to  ,  .  .  ,  .  .  .  , 
which  one  can  safely  turn  in  quest  of  the  latest  in-  "  '^  °y  '*"■  ™°''^  international  or  universal  than 


formation  concerning  everything  worthy  of  Dotice  in 
conaection  with  Pharmacy,  Materia  Medica,  and 
Therapeutics. — Am.  Jour,  of  Pkarmacy,  A'ov.  1879. 
It  is  with  great  pleasure  that  we  aanonnce  to  our 
readers  the  appearance  of  a  second  edition  of  the 
National  Dispensatory.    The  total  exhaustion  of  the 


any  other  book  of  the  kind  in  onr  language,  and 
mure  comprehensive  in  every  sense.  -Pacific  Med. 
and  Surg.  .J own.,  Oct.  1879. 

The  National  Dispensatory  is  beyond  dispute  the 
very  best  authority.  It  is  throughout  complete  in 
all  the  necessary  details,  clear  and  lucid  in  its  ex- 


first  edition  in  the  short  -pace  of  six  months,  is  a  P'anatioQs,  and  replete  with  references  to  the  most 
safficieot  testimony  to  the  valne  placed  upon  the  recent  writings^  where  further  particulars  can  be 
work  bv  the  profession.  It  appears  (hat  the  rapid  '  obtained,  if  desired.  Its  value  is  greatly  enhanced 
sale  of  the  first  edition  most  have  induced  both  the  i  ^^  ^^^  extensive  ludices— a  general  index  of  materia 
editors  and  the  publisher  to  make  preparations  for  |  medica,  etc.,  and  also  an  index  of  therapeatics.  It 
a  new  edition  immediately  after  the  first  had  been  :  would  be  a  work  of  supererogation  to  say  more  about 
J-Hoed,for  we  find  a  large  amount  of  new  matter  '  ""is  well-known  work.  Mo  practising  physician  can 
added  and  a  good  deal  of  the  previous  text  alterpd  i  afford  to  he  without  the  National  Dispensatory.— 
ao'i  improved,  which  proves  that  the  authors  do  not  Canada  Med.  and  Surg.  Journ.,  Feb.  1880. 
Intend  to  let  the  grass  grow  ander  their  feet,  hat  to  ' 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Mat.  3Ted.,  Therap.,  etc.).  13 
JUTAISCH  {JOHN  M.),  Phar.  />., 

Pro/,  of  Mnteria  M'tliai  nnrl  Jintnnu  in  thf.  PhUa.  CnV.  rf  Phmrmnn) . 

A  MANUAL  OF  ORGANIC  MATERIA  MEDICA.     Being  a  Guide 

to  Materia  Medica  of  the  Veffetable  and  Animal  Kingdoms.  For  the  use  of  Stadenta, 
Druggists,  Pharmacists  and  Phy.<:ici:ins.  In  one  handsome  12mo.  ▼olume,  with  numer- 
ous illustrations  on  wood.      (Preparing.) 

EXTRACT  FROM  THE  AUTHOr'S  PREFACE. 

When  in  1866  the  author  wa."  called  to  the  chair  of  Materia  Medica  in  the  institution  named 
(the  Philadelphia  College  of  Pharmacy),  he  seriously  felt  the  need  of  a  puitahle  textbook 
which  could  be  used  in  connection  with  his  lectures,  and  made  preparations  for  the  publication 
of  such  a  work  at  an  early  date.  To  elaborate  a  system  of  classification,  which  should  be  with- 
out diflBculty  comprehended  and  readily  applied  by  those  for  whom  it  was  intended,  was  by  no 
means  an  e.isy  task,  and  the  author  found  occasion,  almost  every  year,  to  either  remodel  that 
previou.«ly  selected,  or  to  make  whit  in  his  opinion  seemed  to  be  desirable  improvements.  The 
publication  of  the  "  National  Dispensatory'"  in  a  measure  supplied  the  want  felt,  at  least  a?  far 
as  a  work  of  reference  is  con  en  ed.  but  owing  to  its  local  arrangement,  it  is  not  adapted  to 
systematic  instruction.  However,  its  publication  rendered  a  modification  of  the  original  plan 
for  a  treatise  on  Materia  Medica  desirable,  and  it  is  now  presented  in  a  form  giving  an  outline 
of  the  substance  of  the  lectures  and  embracing  what  are  considered  the  essential  physical,  histo- 
logical, and  chemical  characters  of  the  organic  drug,  so  as  to  render  the  work  also  a  useful  and 
reliable  guide  in  business  transactions.  Regarding  the  classification,  the  author  is  consciuua 
of  its  imperfection.',  but  he  believes  it  to  be  convenient  and  capable  of  practical  application. 

In  reference  to  the  scope  of  the  work,  the  main  aim  has  been  to  embrace  all  the  drugs  recog- 
nized by  the  U.  S.  Ph:irmacoprci;i,  together  with  the  old,  but  nnw  unofficiLal  ones,  and  such 
others,  the  use  of  which  has  been  recently  revived  or  suirgested,  and  which  seem  to  deserve 
attention.  The  medical  properti-^s  and  doses  of  the  various  drugs  are  merely  briefly  stated  as 
subjects  of  general  important  information  :  ti.e  present  work  is  not  intended  for  giving  instruc- 
tion in  the  therapeutic  application  of  drugs. 


C1TILLE  {ALFRED),  M.D., 

ProftuiHor  of  Theory  and  Practicf.  of  Jfedicint  in  the  ITniversitp  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA  ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  twolarge  and  handsome  8vo  .  vols,  of  about  2000 
pages.     Cloth,  $10;  leather,  $12:  half  Russia,  $13.     {L^tdy  Issifd.) 
It  is  unnecessary  to  do  much  more  than  to  an-    of  the  pre^-ent  edition,  a  whole  cyclopsedia  of  thera- 
nonnce  the  appearance  of  the  fourth  edition  of  thi.s    peutics. — Chicago  Medical  Journal,  ¥eh.  187-5. 
well  known  and  excqllen^  work.— Brtt.  and  For.        The  rapid  exhaastion  ofthreeeditiong  and  the  nni- 
Med.-Chir.  Review,  Oct  IfsT.o.  versal  favor  with  which  the  work  has  been  received 

For  all  who  desire  a  complete  work  on  therapen-  by  the  medical  profession,  are  sufficient  proof  of  its 
tics  and  materia  medica  for  reference,  in  cases  in-  excellence  as  a  repertory  of  practical  and  useful  in- 
volving medico-legal  questions,  as  well  as  for  in-  formation  for  the  physician.  The  edition  before  us 
formation  concerning  remedial  agents.  Dr.  St  ilia's  is  fully  sustains  this  verdict,  as  the  work  has  been  care- 
"par  ex^ellence'^  the  work.  Being  out  of  print,  by  fully  revised  and  in  some  portions  rewritten,  bring- 
theexhanstionof formereditions, theanthorhaslaid  ing  it  up  to  the  present  time  by  the  admission  of 
the  profession  under  renewed  obligations,  by  the  chloral  and  croton-chloral.  nitrite  of  amyl,  bichlo- 
earefnl  revision,  importantadditions,  and  timely  re-  ride  of  methylene,  methylic  ether,  lithium  com- 
Issning  a  work  not  exactly  supplemented  by  any  pounds,  gelseminum.  and  other  remedies. — Am. 
other  in  the  English  language,  if  in  any  language.  -Totirn.  of  Pharmacy,  Feb.  1S75. 
The  mechanical  execution  handsomely  sustains  the  We  can  hardly  admit  that  it  has  a  rival  in  the 
well-known  skill  and  good  taste  of  the  pnbliiher.—  i  multitude  of  its  citations  and  the  fulness  of  its  re- 
St.  LouiK  Med.  and  Surg.  Journal,  Dec  1874.  |  gearch  into  clioical  histories,  and  we  must  assign  it 

From 'he  publication  of  the  first  edition  "Still^'s  a  place  in  the  physician's  library  ;  not,  indeed,  as 
Therapeutics"  has  been  one  of  the  classics;  its  ab-  fully  representing  the  present  state  of  knowledge  in 
sence  from  our  libraries  would  create  a  vacuum  pharmacodynamics,  but  as  by  farthe  most  complete 
which  could  be  filled  by  no  other  work  in  the  Ian-  treatise  upon  the  clinical  and  practical  side  of  the 
guage.andits  presence  supplies,  in  the  two  volumes   question. — BostonMed.and  Surg.  Journal,  ^ov.  o, 

.  1S74. 


(lORXIL  (F.).  AXD  T>AXVIER  (L.). 

^         Pr'\f.  inthe  Fncnlty  nf  Med  ,  '■ftrii.  -ti         Prof  in  the  ColUgeof  France. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Translaterl.  Tvith 

Notes  and  Additions,  by  E.  0.  Shakespeare,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 

to  PhilaJa.  Hospital,  Lecturer  on  Refrsction  and  Operative  Ophthalmic  Surgery  in  Uni^i. 

of  Penna.,  and  by  Henrv  C.  SrjrES.  M  D.,  Demonstrate  r  of  Pathological  Histology  in 

the   Univ.  of  Pa.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  over 

350  illustrations.     Cloth,  $5  50;  leather,  $6  50;   half  Russia,  $7.      (Jiist  Ready.) 

We  have  nohesit^tion  in  cordially  recommending  ,   the  subject  idmits  of  definition,  and  this  one  chap- 

the  English  transl  ition  of  Cornil  &  Ranvier's  "  Pa-       ter  is  worth  the  price  of  the  book      The  illustra- 

thological  Histology"  as  the  best  work  of  the  kind       tioos  are  copious  and  well  chosen.     Without  the 

in  any  language,  a^d  as   giving  to  its  readers  a   '   slightest  he-itation,  the  translators  deserve  honest 

trnsiworthy  guide  in  obtaiaiog  a  broad  and  solid      thanks  for  placing  this  indispensable  work  in  the 

basis  for  the  appreciation  of  the-practical  bearings   !   hands  of  American  students. — Phila.  Med.  Tirneg, 

of   pathological   anatomy. — Am.   Journ.   of  Med.   i   April  24,  lS-0 


Sciences,  A.inl.  ISSO.  | 


This  Tolnme  we  cordially  commend  to  theprofes- 


This  important  work,  in  it»  American  dress,  is  a      sion.     It  will  prove  a  valuable,  almost  necessary, 
welcome   offering  to  all  studen's  of   the   subjects  I   addition  to  the  libraries  of  students  who  are  to  be 
which   it   treats.     The   great    mass  of  material  is  !   physicians,  and  to  the  libraries  of  students  who  are 
arranged    naturally   and   comprehensively.      The  '   physicians.— .Imerican  Practitioner,  June,  ISSO. 
cUssificatiou  of  tumors  is  clear  and  full,  so  far  as  ' 


14       Henry  C.  Lea's  Son  &  Co.'s  Publications — {Pathology^  etc.). 


JPEN  WICK  {SA  MUEL),  M.D., 

-*•  A-iKi/itnnl  Fht/sicimi  to  the  Lnnilon  Hospital, 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enl:irp;ed  English  Edition.     With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12iuo.,  cloth,  $2  25.     {Just  Issued.) 


(IREES  {T.  HENRY),  M.D., 

v-^  L-'fturer  on  Palliologp  a7i'i  Morbid  Aruxtomy  nt  Ohnring-CroxK  Hospital  Medical  School,  ete. 

PATHOLOGY  AND  MORBID  ANATOMY.  Fourth  American. from 

the  Fifth  Enlarged  and  Revi.oed  Engli.sh  Edition.     In  one  very  handsome  octavo  volume 
of  about  350  pages,  with  i;J8  tine  engravings;   cloth,  $2  25.      (Just  Ready.) 
Extract  from  thr  Author's  Preface. 
In  preparing  the  fifth  edition  of  my  Text-book  on   Pathology  and  Morbid  Anatomy,  T  have 
ngain  added  much  new  matter,  with  the  object  of  making  the  work  a  more  complete  puide  for 
the  student.     All  the  ch;ipteps  have  been  carefully  revii.ed,  some  alterations  have  been  made  in 
the  arrangement  of  the  work,  and  an  addition  has  been  made  to  the  number  of  wood-cuts.     The 
new  wood  cuts,  a*  in  previous  editions,  have  been  drawn  by  Mr.  Ceilings  from  my  own  micro- 
scopical  preparations. 


We  have  long  cinside'ved  this  the  b'^st  guide  yet 
presented  to  the  "-tudent  for  I  he  identificH  tion  of  va- 
rious morbid  tissue''.  We  hive  fonud  it  more  satis- 
factory thaa  any  other.     The  present  edition    has 


been  thoronurhly  revised,  and  much  new  matter 
has  been  added.  To  the  physician  as  a  guide  in 
diagnosis,  we  recommend  this  volume. — Physician 
and  Surgeon,  Miy,  ISSl. 


B 


RISTOWE  {JOHN  SFBR),  M.D.,  FR.C.P.,        j 

Pliy.iici'in  and  Joint  Lecturer  on  Medicine,  St    Thoman^g  B^oapital. 

A   TREATISE    ON   THE   PRACTICE    OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.  Edited,  with  Additions,  by  James  H.  Hutch- 
inson, MD.,  Physicitin  to  the  Penna.  Hospital.  In  one  handsome  octavo  volume  of 
nearly  1200  pages.      With  illustrations.     Cloth,  $5  00;    leather,  $6  00;  half  Russia, 


$6  50.      (Notv  Rejdy.) 

The  second  edition  of  this  excellent  work,  libe  the 
first,  has  received  the  benefit  of  Or.  Hiitchiu.''on's 
annotntions,  by  which  the  phases  of  disease  which 
are  peculiar  to  this  country  are  indicntod.  and  thus 
a  treatise  which  was  intended  for  British  practi- 
tioners and  .-Indents  is  made  more  practically  nsf  ful 
en  this  side  of  the  water.  We  see  no  rfason  to 
modify  the  high  opinion  previously  expressed  with 
regard  to  Dr.  Bristowe's  work,  except  hy  adding 
our  appreciation  of  the  careful  lab  ts  of  ilie  author 
in  following  the  lateral  growth  of  medical  science. 
—  Boston  Medical  andSurgiculJournal,  February, 
ISRO. 

What  we  said  of  the  first  edition,  we  can,  with 
Increased  emphasis,  repeat  conceroiug  this;  "Every 
page  is  chi(  rMCtei'ized  by  ihe  otterauce>  of  a  thonght- 
fnl  man.  W  lal  has  been  said,  has  been  well  said, 
and  the  book  is  »  fair  reflex  of  all  ihat  is  nertaifly 
kn'wn  on  the  sub  ects  considered." — Ohio  Med 
Recorder,  Jan.  7,  18S0. 


The  views  of  the  author  are  expressed  with  preci- 
sion and  sufficient  promptness  to  impress  the  student 
with  the  weight  of  his  authority  ;  and  should  the 
iiipdical  professor  differ  on  any  subject  from  his  doc- 
trine he  will  need  to  find  strong  arguments  to  carry 
his  class  to  ttiecpposite  conclusion. — N.  0.  Mtd.  and 
Surg.Journ,  Ftb.  ISSO. 

The  reader  will  find  every  conceivable  subioct 
connected  with  the  practice  of  medicine  ably  pre-' 
sented,  iu  a  styl"  at  once  clear,  interesting,  and  con- 
cise. The  additions  m  ide  by  Dr.  Hitchiuson  are 
appropiiate  and  practical,  and  greatly  add  to  its 
usefulness  to  American  re-iders. — Buffalo  Med.  and 
Surg.  Journ  ,  March,  18S0. 

We  regaid  it  as  an  excellent  work  for  students  and 
for  practitioners.  It  is  clearly  written,  the  author's 
^tyle  is  attraclive,  and  it  is  especially  to  be  com- 
mended for  its  excellent  expositiou  of  the  patbol  jgy 
and  clinical  phenomena  of  disease. — St.  Louis  Glin. 
Record,  Feb.  ISSO. 


H 


ABERSHON  {S.  0.)  M.D. 

Senior  Phyxicinn  to,  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at,  Ouy'g 
H'ispitaL,  etc. 

ON  THE   DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  CEsophagus,  Caecum,  Intes- 
tines and  Peritoneum.  Second  American,  from  the  Third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.      {Now  Ready.) 

amended  by  Ihe  author.  Several  new  chapters  have 
been  add^d,  bringing  the  work  fully  up  to  tt.e  timea, 
and  making  it  a  volume  of  interest  to  the  practi- 
tioner in  evry  field  of  medicine  and  suraery.  Per- 
verted nutrition  is  in  some  form  associated  with  nil 
dixea-ies  we  have  to  combat,  and  we  need  all  the 
light  that  ctn  "e  obtained  on  a  subject  so  broad  and 
generil.  Dr  Haberslion's  work  is  one  that  every 
practitloQ'^r  sh  'Uld  read  and  study  for  himself.^ 
N.  Y.  Med.  Journ  ,  April,  1879. 


This  valuable  treatise  on  dlsea'ies  of  th.<  stomach 
and  iibdomen  has  been  o"t  of  print  for  several  years, 
and  is  theref  «re  not  bo  well  known  to  the  profession 
as  it  dpserven  to  be.  It  will  be  found  a  cyclofajdia 
of  Information.  systematlcHlly  arranseil,  on  all  dis- 
»aseii  of  the  alim-'ntary  I ract,  from  the  mo  'th  to  the 
rectum  A  fair  proportion  of  each  chapter  is  devoted 
to  symptoms  palholo^iy,  and  therapeutics.  The 
preHent  edition  Is  fuller  than  former  mesiu  many 
particulars,  and  hag   been  thoruughly  revised   and 


ULDGE'R  ATLAS  op  PATHOLOGICAL  HISTOLOGY. 
Translated,  wilh  Notes  and  Additions,  by  Joseph 
Lbidt,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  .320  copper-plate  figures,  plain  and 
colorpd.  eloth      %4  00 

LA  ROCHE  ON  YELLOW  FEVER. considered  in  Us 
Historical,  Pathological,  Etiological  and  Thera 
peutlcal  Relations.  In  two  large  and  handsome 
•rtavo  rolnmesofnearly  1.100  pp  .cloth      $7  00. 

BTOKES'  LECTtTRES  ON  FEVER  Fdlied  by  JoHS 
WiM.iAM  MooRK,  M.  !>..  A-sistant  Physician  to  the 
Cork  Sireft  Ke^or  Hoapttal.  In  one  neat  8vo 
▼Oiuue.  cloth,  4)2  00. 


PAVY's  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION:  Us  Disorders  and  Iheir  Treatment. 
From  the  Second  London  edition  In  one  band- 
some  volume,  small  octavo,  cloth,  %'2  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIO.XS.     1   vol    8vo..  pp.  lOO,  cloth.    *.S  -lO 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Conbik, 
M    n      1  vol    Rvo.,  pp.  Hon.  cloth.    «2  .50. 

TODD'SCLINICAL  LECTURE.'Jon  CERTAIN  ACUTE 
DiMRASEH.  In  one  neat  octavo  volnme,  of  320  pp. 
cloth.    $2  60. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Practice  of  Medicine).  15 


WLINT  (A  USTIN),  M.D., 

^  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med .  College,  N.  T. 

A   TREATISE    ON   THE    PRINCIPLES  AND   PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fifth 
edition,  entirely  rewritten  and  much  improved.  In  one  large  and  closely  printed  octavo 
volume  of  1163  pp.  Cloth,  $5  50;  leather,  $6  50;  very  handsome  half  Russia,  raised 
bands,  $7.      {Just  Ready.) 


■practically,  this  edition  is  a  new  work;  for  so 
tnany  additions  and  clianges  have  been  made  that 
one  well  ncquainteil  wiih  previous  editions  would 
hardly  recognize  this  as  an  oid  friend  The  size  of 
the  volume  is  somewhat  iucre*hed.  An  enlire  new 
sertiou  and  several  new  chapters  have  been  added. 
It  Ik  universally  conceded  tliat  no  text  Ijook  upon 
this  8ul)ject  •va-(  ever  pttl>listied  in  this  country 
that  can  at  all  compare  with  it  It  has  long  been 
at  the  very  head  of  American  text-book  literature, 
and  til  ere  cin  be  no  doubt  bu.  that  it  will  be  many 
years  before  it  yields  the  place  to  others. — Naa'i- 
ville.  Journ.  of  Med.  and  Surg  ,  Feb.  1881. 

"  Flint's  Practice''  is  recogniziid  to  be  a  standard 
treatise  of  high  rank  upon  the  principles  and  tlie 
practice  of  medicine  wherever  the  English  language 
is  read.  The  opinions  eveiywliere  reveil  the  man 
of  extensive  experience,  diliirent  study,  calm  judg- 
ment, and  unbiassed  criticism.  The  work  ^hould 
be  in  the  hands  of  every  practitioner. — New  Yurk 
Med.  Record,  Feb.  2H,  1881. 

This  edition  differs  so  much  from  all  previous 
editions,  on  account  of  the  revisions  eliminations, 
amplifications,  and  additions,  so  conf-piciously  ma 
nlfest,  that  no  one  can  be  sa'd  to  possess  tne  actual 
views  of  the  author  on  the  practi'^e  of  medicine,  un- 
less he  becomes  the  p  sse<*or  of  this  volume  It  is 
certainly  the  only  American  work  on  this  subject 
which  can  be  unreservedly  recommended,  and  the 
only  one  which  does  luslice  to  American  authors, 
observers,  and  pracUtioaers.  —  G'auiard'*  Medical 
Journal,  Feb.  ISSl. 

>Y  THE  SAME  AUTHOn. 


The  htylo  and  character  of  this  work  are  too  well 
known  to  the  profession  to  require  an  introduction. 
For  a  number  of  years  this  volume  has  ocrupied  a 
leading  p  >sition  as  a  lextb  tok  in  the  majority  of 
medical  schools,  and  tbe  high  position  accorded  to 
it  in  the  past  is  a  guarantee  of  a  hearty  welcome  in 
this  now  edition  I' be  hook  may  be  said  to  represent 
the  present  state  of  the  science  of  medicine  as  now 
understood  and  taught.  It  is  a  safe  guide  to  students 
and  practitioners  of  medicine. — Miiryland  Medical 
Journal.  March  1,  1881. 

A  marked  feature  of  value  In  the  new  edition  of 
Flint  is  the  condensed  fection  r)n  morbid  anatomy 
prefacing  each  subject  disciv^sed,  and  the  very  go"d 
prefix  on  general  pathology,  chapters  all  of  them 
written,  as  the  author  states  in  hi-  preface,  by  Dr. 
Wm  *i.  Welch,  lecturer  on  patli.)logical  bist^dogy 
ill  Bellevue  Hospital  Medical  College.  Dr  Welch 
has  done  his  part  of  the  work  to  ail  acceptatiiin. — 
Cincinnati  Lancet  and  Clinic   March  12   1881. 

The  author  has,  in  this  edition,  revised  and  re- 
written a  great  oart  and  rntde  it  accord  with  the 
more  advanced  idea"  which  have  been  developed 
within  the  past  few  years.  He  is  he  more  liiteJ  to 
do  so,  as  he  is  actively  engaged  in  his  profession, 
and  can  mike  deductions,  not  from  the  work  of 
others,  but  from  his  own  labors.  It  is  a  treatise 
wuich  every  American  physician  should  ha»e  upou 
his  table,  and  which  he  should  consult  on  occasions 
when  his  leisure  permits  him  to  do  so. — St.  Louis 
Med.  and  Surg.  Journal,  March,  1881. 


B' 


CLINICAL  MEDICINE;    a  Systematic   Treatise  on    the  Diagnosis 

and  Treatment  of  Di.seases.  De.signed  for  Students  and  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume  of  795  pages;  cloth,  $4  50;  leather,  $5  50; 
half  Russia,  $6.      (Now  Ready.) 

in  this  country  as  that  of  the  author  of  two  works 
of  g'eat  merit  on  special  subjects,  and  of  numerous 
papers,  exhib'ting  much  originality  and  extensive 
restarch.  —  The  Dublin  Journal,  Dec.  1879. 

There  is  every  reason  to  believe  that  this  book 
will  be  well  received.  The  active  practitioner  is 
frequently  in  need  of  some  work  that  will  enable 
him  to  obtain  information  in  the  diagnosis  and 
treatment  of  cases  with  comparatively  little  labor. 
Dr.  Flint  has  the  faculty  of  expressing  himtelf 
clearly,  and  at  the  same  time  so  concisely  as  to 
enable  the  searcher  to  traverse  the  entire  ground 
of  his  search,  and  at  the  same  time  obtain  all  that 
isesKentiil,  without  plodding  through  an  intermi- 
nab'e  space. — N.  ¥.  Med.  Jour.,  Nov.  1879 

The  great  object  is  to  place  before  the  reader  the 
latest  observations  and  experience  in  dingiiosis  and 
treat  nent.  .Such  a  w  >rk  is  especially  valuahle  to 
students.  Ills  complete  in  its  special  design,  and 
yet  so  condensed,  that  he  can  by  its  aid,  kei'p  up 
with  the  lectures  on  practice  without  neglecting 
oiher  branches.  It  will  not  esc  <pe  the  notii  e  of  the 
practitioner  that  such  a  work  is  most  valuable  ia 
cul'iug  points  in  diagnosis  and  treatmeot  in  the  in- 
tervals iietween  the  daily  rounds  of  visits  since  he 
can  in  a  few  minutes  refresh  his  memory,  or  leara 
tbe  1  itest  ad  vance  in  the  treatment  of  diseases  which 
demand  his  instant  a'tention. — Oiucinnati  Lancet 
and  Jlini^,  Oct.  25,  1879. 


The  eminent  leacher  who  has  written  the  volume 
under  consi  ieration  has  recognized  the  needs  of 
the  American  profession,  and  th*  result  is  all  that 
we  could  wish.  The  style  in  which  it  it  writien  is 
peculiarly  the  author's  ;  it  is  clear  and  forcible,  and 
marked  by  those  characteristies  which  have  ren- 
dered him  one  of  the  best  writers  and  teachers  this 
country  has  ever  produced.  We  have  not  space  for 
so  full  a  consideration  of  this  remarkable  work  as 
we  would  desire. — St.  Louis  Clin.  Record,  Oct.  187.9. 

It  is  here  that  the  skill  and  learnirg  of  tbe  great 
clinician  are  displayed  He  has  given  ns  a  store- 
house of  medical  knowledge,  excellent  for  the  stn 
dent, convenient  for  the  practitioner,  the  result  of  a 
long  life  I'f  the  most  faiihfal  clinical  woik.  collect- 
ed by  an  energy  as  vigilant  und  systematic  as  un- 
tiring, and  weighed  by  a  ju  'gment  no  less  clear 
than  his  observation  is  cioaei.  — Archives  of  Medi- 
cine, Dec.  1S79 

To  give  an  adequate  and  useful  conspectus  of  tbe 
extensive  field  of  modern  clinical  medicine  is  a  task 
of  no  ordinary  difficulty;  bnt  to  accomplish  this 
consistently,  with  brevity  and  clearness,  the  diff->reut 
subjects  and  their  several  parts  receiving  the  atten- 
tion which,  relatively  to  their  importance,  medical 
opinion  claims  for  them,  is  still  more  ditflcult.  This 
t-isk  we  feel  bound  to  say  has  been  executed  wi'h 
more  than  partial  success  by  Dr  Flint,  whose  name 
is  already  familiar  to  students  of  advanced  medicine 


DF  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE   MRDICTNE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  12rao.  volume.     Cloth,  $1  38.     (Just  Issued.) 

DAVIS'S    CLINICAL     LECTURES     ON    VARIonS 

IMPORTAN  r  DISEASES  ;  being  a  collection  of  the 

Clinical   Lctures  delivered  in  the  Medical  Wards 

of  Mercy  H  )spial,  Chicago.     Edited  by  Fra.nk  H 

D.ivis,   M.l).     Second   edition,   enlarge!.     In    one 

handsome  royal  12no   volume.     Cloth,  $1  75. 
THE   CYCLOPEDIA   OF  PRACTICAL  MEOICINE: 

comprising  Treatises  on  the  Nature  and  Treatment 

ot  Diseases,  Materia  Medica  and  Therapeutics,  Dis- 


eases of  Women  and  Children.  Medical  Jurispru- 
dence, etc  etc  By  Dunoi.ison,  FoRBiiS,  Twef.die, 
and  <^0N0i,i,r.  In  four  large  super  royal  octavo 
volumes,  of  :t254  double  columned  p  iges,  strongly 
and  handsomely  bound  in  leather.  *l.'i:  cloth,  til . 
STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  MEttlClNE.  Beinga  Ouide  to  the  lu- 
vesligation  of  Disease.  In  one  handsome  12mi'. 
volume,  cloth,  $1  25.    (Lately  Issued.) 


16    Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine). 


piCHABDSON  (BEXJ.  W.),  M.D.,  F.R.S.,  M.A.,  LL.D.,  F.S.A., 

-L*^         Fellow  ii/th''  Roi/al  O'll/ege  of  Php.iicians,  London. 

TREYENTIVE  MEDICINE.    In  one  octavo  volume  of  about  500  pages. 

(/;/  Press.) 

The  immerse  strides  taken  by  medical  science  during  the  l.'ist  quarter  of  a  century  huive  had 
no  more  conspicuous  field  of  progress  than  the  causation  of  disease.  Not  only  has  this  led  to 
marked  advance  in  therapeutics,  but  it  has  given  rise  to  a  virtually  new  department  of  medi- 
cine— the  prevention  of  disease — more  important,  perhaps,  in  its  ultimate  re^uIts  than  even  the* 
investigation  of  curative  processes  Yet  there  has  been  no  attempt  to  gather  into  a  systematic 
and  intelligible  shape  the  accumulation  of  knowledge  thus  far  acquired  on  this  most  interesting 
subject.  Fortunately,  the  task  h'S  been  at  last  undertaken  by  a  writer  who  of  all  others  is, 
perhaps,  best  qualified  for  its  performance,  and  the  result  of  his  labors  can  hardly  fail  to  mark 
nn  epoch  in  the  history  of  medical  science.  The  plan  adopted  for  the  execution  of  this  novel 
design  can  best  be  explained  in  his  own  words  : — 

"With  the  object  here  expressed  I  write  this  volume.  I  have  nothing  to  say  in  it  that  has 
any  relation  to  the  cure  of  disease,  but  I  base  it  nevertheless  on  the  curative  side  of  medical 
learning  In  other  words,  I  trace  the  diseases  from  their  actual  representation  as  they  exist 
before  us,  in  their  natural  progress  after  their  birth,  as  far  as  I  am  able,  back  to  their  origins, 
and  try  to  seek  the  ^onditions  out  of  which  they  spring.  Thereupon  I  endeavor  further  to 
analyze  those  conditions,  to  see  how  far  they  are  removable  and/bow  far  they  are  avoidable." 

liroODBrRY  {FRANK),  M.D., 

'  '  Phi/fiiHnn  to  the.  German  Hospital,  Philadelphia,  late  Ohie/\  Assist,  to  Med.  Clinic,  Jeff.  College 

Hiixpitnl,  etc.  \ 

A    HAiNDBOOK   OF   THE   PRINCIPLES  AND    PRACTICE    OF 

Medicine  ;   for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.      (In  Press.) 


JPOTHERGILL  [J.  MILNER),  M.U.  Ediv.,  M.R.C.P.  Lond., 

J-  A.tst.  Phyfi.  to  the  Went  Lond   Ho.sp.  :  A.'^s-t.  Phy.s-.  tn  the  City  of  Lo7id.  Ho.<ip.,etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.  Second  edition,  revised  and  enlarged.  In  one  very  neat 
octavo  volume  of  about  650  pages.  Cloth,  $4  00;  very  handsome  half  Russia,  $6  50. 
(Just  Ready.) 

to  the  thonghtful  reader  all  the  charms  and  beau- 
ties of  a  well-writtea  novel.  No  physician  can 
well  afford  to  be  without  this  valuable  work,  for  its 
originality  makes  it  fill  a  niche  in  medical  litera- 


The  junior  members  of  the  profession  will  find  in 
it  a  work  that  should  not  only  be  read,  but  care- 
fully studied.  It  will  assist  them  iu  the  proper 
selection  and  combination  of  therapeutical  ageuis 


best  adapted  to  each  case  and  condition,  and  enable  i  ture   hitherto  vacant. — Nashville  Journ.  of  Med. 
them  to   prescribe  iutellieently  and    successfully.  ]  a^ifi  Sm?-^.,  Oct.  1880. 


To  do  full  justice  to  a  work  of  this  scope  and  char 
acler  will  be  impossible  in  a  review  of  this  kind.  1 
The  book  its.-lf  must  be  read  to  be  fully  appreciated. 
—St.  Louis  Courier  of  Medicine,  Nov.  ISSO.  ! 

The  author  merits  the  thanks  of  every  well-edu- 
cated physician  for  his  efl'orts  toward  rationalizing 
the  treatment  of  diseases  upon  the  scieatitic  basis  i 
of  physiology.  E^ery  chapter,  every  line,  has  the 
iuii'ress  of  a  mast«r  hand,  and  while  the  work  is 
th.jruughly  scientific  iu  «very  particular,  it  presents 


Throughout  the  work,  while  room  is  left  for  dif- 
ference of  opinion  in  matters  of  detail,  the  main 
courses  of  tiealnient  are  so  Ciirefully  founded  on 
well-established  principles,  that  no  essential  dif- 
I'erence  is  felt  to  be  possible.  The  closing  chapter 
contains  much  concentrated  worldly  wisdom  ;  and, 
if  carefully  read,  digested,  and  assimilated,  will,  in 
many  an  emergency,  stand  the  young  medical  man 
in  good  stead. — Lond.  Med!.  Record,  Oct.  12,  1S80. 


F 


UNLAYSON  [JAMES),  M.D., 

Phy.iician  a»d  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

CLINICAL    DIAGNOSIS;    A    Handbook    for    Students   and    Prac- 

titioners  of  Medicine.     In  one  handsome  12mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.     {Just  Issued.) 

live  from  pr'^face  to  the  final  page,  and  ought  to  be 
given  a  place  on  every  office  table,  because  it  contains 
in  a  condensed  form  all  that  is  valuable  in  semeiology 
and  diaguostics  to  be  found  in  bulkier  volumes,  and 
because  in  its  arrangement  and  complete  index,  it  is 
unusually  convenient  for  quick  reference  in  any 
emergency  that  may  comeupon  the  busy  practitioner. 
—N.  C.  Med.  Journ.,  Jan.  1879. 


The  book  is  an  excellent  one,  clear,  concise,  conve- 
nient, practical.  It  is  replete  with  the  very  know- 
ledge the  student  needs  when  he  quits  the  lecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  not  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  men. — Phila.  Med. 
Times,  Jan.  4,  1879. 

This  is  one  of  the  really  useful  books.    It  is  attrac- 


Tf/'ATSON  {THOMAS),  M.D.,  Sfc. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OP 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vi.sed  and  enlarged  Knglish  edition.  Edited,  with  additions,  and  several  hundred  illu.<:tra- 
tion.s,  by  Hbnrv  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania. In  two  large  and  handsome  8vo.  vols.  Cloth,  $9  00  j  leather,  $11  00.  (Lately 
Pvhhshed.)  

ARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  Ihe  Univer-iity  of  Penn.iylvxnia 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 

cine.  A  hnndy  book  for  Studenl.")  and  Practitioners  Fifth  edition,  thoroughly  re- 
vised and  rewritten.  With  over  one  hnndrecl  illustrations.  In  one  handsome  royal 
12mo.  volume,  of  about  600  pages.      {I/i  Press.) 


H 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Practice  of  Medicine}.    17 


'OEYNOLDS  {J.  RnSSELL).  M.D., 

-*■*'         Prof,  of  the  Principle.K  and  Practice  of  Medicinein  Univ.  College.  Londnn. 

A  SYS'I'EM  OP  M»</l)T'MNKi   with  Notks  and  Additions  by  rTi--NRT  T1  arts. 
HORNB,  M.D.,  late  Professor  of  Ilvftiene  in  the  University  of  Penn.i.      In  three  liirge  and 
hiiniisonie  octavo  volumes,  eontaininR  ;^052  closely  printed  doiible-colunineii  piigres    with 
numerous  illustrations.     Sold  ottli)  hy  mhseriplion.     Price  per  vol.,  in  cloth,  $'•00;   in 
sheep,  .f  6.00  :  half  Russia,  raised  bands,  $6.60.     Per  set  in  cloth,  $15  ;  sheep,  $18  ;   half 
Russia,  $19.50 
Volume  I.   {just  ready)  contains  Gknkiial  Diskases  and  Dlskases  of  thk  Nkrvous  System. 
VoLUMR  II.    {just  ready)  contains  Diseases  op  Respiratory  and  Circulatory  Systems. 
Volume    III.    (juH  ready)    contains    Diseases  op   tub  Digestive  and  Blood  Glandular 
Systems,  of  the  Urinary  Organs,  op  the  Female  Reproductive  System,  and  op  the 
Cutaneous  System. 

Reynolds's  System  of  MEniriNE,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well  deserved  reputation  of  being  the  work  in  which  modern  British 
medicine  is  presented  in  its  fullest  an<l  most  prnotical  form.  This  could  scarce  be  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  min<ls  of  the  profession, 
each  subject  being  treated  by  soiue  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance,  Diseases  of  the  BladdeV  by  Sir  Hkpiry  Thompson,  Malpositions  of  the  Uterus  by 
Graily  Hewitt,  tnsanify  by  Henry  Maudsley,  Consumption  by  J.  Hughes  Bennet,  Dis- 
eases of  the  Spine  by  CnATi^.ES  Blamd  Radclikpe,  Pericarditis  by  Francis  Sihson,  Alcoholism 
by  Francis  E.  Anstie.  Renal  Affections  by  William  Roberts,  Asthma  by  Hyde  Salter, 
Cerebral  AflFections  by  H  Charlton  Bastian,  Gout  and  Rheuro;>tism  by  Alfred  Baring  Gab- 
rod,  Constitutionsil  Syphilis  by, Jonathan  Hutchinson,  Diseases  of  the  Stomach  by  Wilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squirk,  Affections  of  the  Laryn.x  by  Morell  Mac- 
KBNKiK,  Diseases  of  the  Reotnra  by  Blizard  Curling,  Diabetes  by  Lauder  ISrunton,  Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Soinnambuli.sm  by  Thomas  King  Cham- 
bers, Apoplexy  by  J.  Hughlings  Jackson,  Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc.  etc.  All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence. St.  Bartholomew's,  Guy's,  St  Thomas's,  University  College,  St.  Mary's,  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.  That  a  work 
conceived  in  such  a  spiri',  .and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it  has  acquired  on  this 
side  of  the  Atlantic,  have  se.-iled  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 

Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  accessible  to  all.  To  meet  this  demand  the  present  edition  has  been  undertaken.  The 
five  vtduraes  and  five  thousar  d  pages  of  the  original  have  by  tne  use  of  a  smaller  type  and  double 
ccdumns,  been  compres<ed  into  three  volumes  of  over  three  thousand  pages,  clearly  and  hand- 
soinelj'  printed,  and  offered  at  a  price  which  renders  it  one  of  the  cheapest  works  ever  presented 
to  the  American  profession. 

But  not  only  is  the  American  edition  more  convenient  and  lower  priced  than  the  English; 
it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  are  required  to  bring  up  the  subjects  to  the  existing  condition 
oi"  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts- 
HORNE,  M.D.,late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  who  has  endeavored 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
td  be  to  his  English  brethren.  The  number  of  illustrations  has  also  been  largely  increased,  and 
no  effort  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 


Really  too  much  praise  can  scarcely  be  given  to 
this  noble  book.  It  is  a  cyclop;ediii  of  medicine 
written  by  some  of  the  best  men  of  Europe.  It  is 
full  of  useful  information  such  as  one  finds  frequent 
Deed  of  in  one's  daily  work  As  a  bonk  of  reference 
it  is  invaluable.  It  is  ap  with  the  times.  It  is  clear 
and  concentrated  in  style,  and  its  form  is  worthy 
of  its  famous  publisher.  —  Louisville  Mtd.  News, 
Jan.  .31,  ISSO. 

"Reynolds'  System  of  Medicine"  is  justly  con- 
sidered the  most  popular  work  on  the  principles  and 
practice  of  medicine  in  the  English  language  Tbe 
contributors  to  this  work  are  gentlemen  of  well- 
known   reputation   on   both   sides   of  the    Atlantic. 


subjects  with  which  he  should  be  familiar. — GaiU 
lard's  Med.  Joxirn.,  Feb.  1880. 

There  is  no  medical  work  which  we  have  in  times 
past  more  frequently  and  fully  consulted  when  per- 
plexed by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symptoms  pre- 
sented to  us  than  "Reynolds'  System  of  Medicine." 
Among  its  contributors  are  gentlemen  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
Atluntic  as  in  Great  Britain,  and  whose  right  to 
speak  with  authority  upon  the  subjects  about 
which  they  have  written,  is  recognized  the  woild 
ove''.  They  have  evidently  striven  to  make  their 
essays  as  practical  as  possible,  and  while  these  are 


Each  gentleman  has  striven  to  make  his  part  of  the  I  sufficiently   full    to   entitle   them    to    the    name    of 
work  as  practical  as  po8-.ible,  and  the  information  !  monographs,  they  are   not  loaded  down  with  such 


contained  is  such  as  is  needed  by  the  busy  practi- 
tioner.—St.  Louis  Med.  and  Sury.  Journ.,Jd.u.  '60. 


an  amount  of  detail  as  to  render  them  wearisome 
to  the  general  reader.  In  a  word,  they  contain  just 
thai  kind  of  iu formation  which  the  busy  practitioner 
Dr.  Hartshorne  has  made  ample  additions  and  j  frequently  finds  himself  in  need  of.  In  order  that 
revisions,  all  of  which  give  increased  value  to  the  i  any  deficiencies  may  be  supplied,  the  publishers 
volume,  and  render  it  more  useful  to  the  Ameri-  I  have  committed  the  preparation  of  the  book  for  the 
can  practitioner.  There  is  no  volume  in  English  '  press  to  Dr.  Henry  Hartshorne,  whose  judicious 
medical  literature  more  valuable,  and  every  pur- |  notesdistributed  throughout  the  volume  afi"ord  abnn- 
chaser  will,  on  becoming  familiar  with  it,  eongrat-  I  dant  evidence  of  the  thoroughness  of  the  revision  to 
nlate  himself  on  the  possession  of  this  v»i>t  store- ,  which  he  hassubjected  it. — Am.  Jour. Mtd.  Sciences, 
huase  of  information,  in  regard  to  so  many  of  the  [  Jan.  ISSO. 


18       Henry  C.  Lea's  Son  &  Co.'s  Publications — (New.  Dis ,  d;c.). 


T>ARTHOLOW  {ROBERTS),  A.M.,  M.D..  LL.D. 

*-*  Prnf.  nf  Materia  MtiUca  and  Oeneral  Therapeutics  in  the  Jeff.  Me.d.  Coll.  of  Phila.,  eta. 

A  PRACTICAL  TREATISE  OX  ELECTRICITY  IN  ITS    APPLI- 

CATION   TO    MEDICINE.      In  one  very  handsome  8vo.  volume  of  about  270  pages, 
with  98  illuEtrations.     (Just  rendy.) 

EXTRACT  FROM  THE  AUTHOH's  PUEFACB. 

I  have  attempted  in  the  preparation  of  this  work  to  avoid  these  errors;  to  prepare  on9  so 
simple  in  stntement  that  a  student  without  previous  ncquaintnnce  with  the  subject,  may  read- 
ily master  the  essentials;  so  complete  as  to  embrace  the  whole  subject  of  medical  electricity, 
and  so  condensed  as  to  be  complete  in  a  moderate  compass.  I  have  endeavored  to  keep  con- 
stantly in  view  the  needs  of  the  two  classes  for  whom  the  work  is  prepared — students  and  prac- 
titioners. I  hiive  as-uraed  an  entire  unaoquaintance  with  the  elements  of  the  subject  as  the 
point  of  departure — for  I  am  !uldre'!<in^  those  who  have  either  failed  to  acquire  this  prelimi- 
nary knowlfdKe,  or  having  acquired  it,  find  that  after  the  Inpse  of  years,  it  has  become  misty 
and  confused.  In  the  accounts  of  electrical  plienoraena  I  have  adhered  to  the  modes  of  expres- 
sion with  which  the  medical  electrical  text-books  have  made  us  familiar. 

This  book,  then,  must  be  regarded  ns  the  exposition  of  electricity  as  a  remedial  agent,  made 
by  a  medio  il  practitioner  for  the  use  of  medical  practitioners.  No  claim  is  made  on  the  ground 
of  pure  science.  It  is  believed,  however,  that  the  work  m^kes  an  adequate  presentation  of  the 
subject,  rejnrding  electricity  as  a  remedial  agent — as  one  ^f  the  means  employed  for  the  treat- 
ment and  cure  of  disease.  I 


So  far  as  we  know,  the  need  of  a  clear,  pimple, 
untechuical,  reliable,  concise,  and  modern  treali.se 
upon  Ihe  subject  of  medical  electricity  ia  only  sup- 
plied by  ihe  volume  under  con^ideration.  It  is  not 
too  mui-h  to  say  tliat,  if  availed  of,  it  will  render 
jiccensible  to  a  vast  number  of  members  of  the  pro- 
fession a  therapeutic  agent  of  tbe  greatest  value,  but 
■which  has  heretofore  been  piactically  of  no  use 
■whatever  to  Ihem. — Maryland  Med.  Journal,  June 
1,  1881. 

We  have  not  yet  come  across  a  book  that  can  com- 
pare wiih  this  in  clearnesn  and  simplicity  of  state 
ment.  We  have  for  a  long  time  needed  a  textbook 
on  meclical  electricity,  condensed  and  yet  comple'e, 
and  this  wan'  has  been  well  supplied  by  the  dittin- 
gnished  autlior.  The  illustrations  are  elegant,  and 
the  book  aS'  a  whole  is  a  valuable  addition  to  tlie 
collection  of  any  student  or  practitioner.  — £K_^a^o 
Med.  and  Hxrg.  J^urnot,  June,  1S81. 

As  a  wh  le,  the  book  must  be  looked  upon  as  an 
exposition  <  f  electricity  for  remedinl  purposes,  writ- 
ten by  a  medical  practitioner  for  the  use  of  medical 


practitioners.  From  this  standpoint  the  work  is 
worthy  of  the  careful  study  of  all  who  desire  to  in- 
vestigate this  subject  for  purely  practical  purposes. 
Thii  work  ineets  a  want  of  very  many  students  and 
medical  practitioners.  We  greatly  err  if  it  be  not 
gladly  welcomed  l)y  them.  The  author,  from  his 
long  experience  as  a  practitioner,  is  admirably  fitted 
to  perform  the  ta&k  of  writing  a  work  of  this  kind 
for  this  special  class  of  men. — Detroit  Lancet,  June, 
1881. 

This  book  is  expressive  of  careful  research  and  a 
nice  discrimination  in  the  selection  of  such  matter 
from  that  at  the  author's  command  as  is  best  adapted 
for  the  guidance  and  insfruction  of  the  physician 
whose  interest  in  eleciricity  is  proportionate  to  its 
practical  bearing  on  diagnosis  and  treatment.  It  is 
thorough,  it  is  accurate,  it  is  readnble,  and  above 
all  is  esseniially  ulilizable,  if  we  may  use  tbe  word, 
and  renders  easy  of  access  to  the  general  practitioner 
the  modii/t  operandi  of  employing  this  very  valu- 
able therapeutic  agent. — N.  T.  Medical  Gaz.,  June 
11,  1881. 


1[P 


TITCHELL  [S.  WEIR),  M.D., 

"^"~         Phys,  to  Orthopadie  Hospital  and  the  Infirmary  for  Dis.  oftheN''rvousSi/sfem,  Phila.,  etc.  etc. 

LECTURES    OX    DISEASES    OF    THE     NERVOUS    SYSTEM, 

ESPECIALLY  IN  WOMEN.     In  one  very  handsome  12mo.  volume  of  about  250  pages, 

with  five  lithographic  plates.  Cloth,  $1  75  (Just  Ready.) 
The  life-long  devotion  of  the  author  to  the  subjects  discussed  in  this  volume  has  rendered  ife 
eminently  r'esirable  that  the  results  of  his  labors  should  be  embodied  for  the  benefit  of  those 
who  may  experience  the  difficulties  connected  with  the  treatment  of  this  class  of  disease. 
Many  of  these  lectures  are  fresh  studies  of  hysterical  affections;  others  treat  of  the  modifica- 
tions his  views  have  undergone  in  regard  to  certain  forms  of  creatinent,  while,  throughout  the 
•whole  work    he  has  been  careful  to  keep  in  view  the  practical  lessons  of  his  cases. 

It  is  a  record  of  a  number  of  very  remarkable  ,  ordinarily  rich  in  acute  observation  and  sound  in- 
cases, with  acute  analyses  and  discussions,  clinical, 
physfoli  gical,  and  therapeutical  It  Is  a  hook  to 
whirh  the  iphysician  met-ling  wi  h  a  new  hysterical 
experience,  or  in  donht  whtither  hxA  new  fxperience 
Is  hvBtHrical,  may  well  turn  with  a  well-grounded 
hope  of  finding  a  parallelism  ;  it  will  be  a  new  ex- 
perinnce,  indetd.  if  no  similar  one  is  here  recorded 
—Phila.  Med.  Times.  June  -1,  1S81. 

The  n:'mB  of  the  author  is  sufHcient  guarantee  that 
these  topii'H  are  ably  and  appreciulivi  ly  di«<u8fed  ; 
Huffictil  to  say  that  I  be  principles  of  treat  men',  both 
hygienic  and  thorapeutc,  are'  clearly  indicated. 
The  articles  bning  in  the  form  of  clinical  Ifclures, 
abound  in  illustrative  cased,  and  are  much  easier 
readinz  than  a  Hystemstic  treaiise  on  the  same 
topics. — flnUitgK  an-t  Clinical  Record,  May  15,  1  81. 

It  is  needless  to  say  that  these  leoinres  are  extra- 


struction.  Tbe  reputation  of  the  author  is  a  guar- 
antee of  that,  and  no  reac  er  will  be  disappointed. 
Korean  too  mnch  he  said  in  praise  of  the  admirable 
s:  yie  of  his  m'-dical  writings,  and  each  of  these  leo- 
lur«s  reads  with  the  fluislied  grace  of  a  polished 
essay.  Indeed,  the  book  throughout  is  -o  fascinating 
a  one  that  it  could  not  fail  to  be  read  entire  by  every 
one  who  begins  its  pages. —i-'Atia.  Med.  and  Surg. 
Reporter,  May  7,  ISSl. 

The  book  throughout  is  not  only  intensely  enter- 
tainini.'.  but  it  contains  a  large  amount  of  rare  and 
valuable  information.  Dr  Mi'chell  bas  recorded 
Lot  only  the  resulis  of  his  most  careful  observation, 
but  has  added  to  the  knowledge  of  the  subjects  treat- 
ed by  his  original  investigation  and  p'actical  study. 
The  book  is  one  we  can  commend  to  all  ot  our  read- 
erg  — Maryland  Med.  Journal,  May  1,  1S81. 


fJAMlLTOS  [ALLAN  Mr  LANE),  M.D., 

•'■■'■  Atlenilivg  Phj/inclnn  at  Ihe  J/o/tpitolfor  KpilepHcs  and  Paralytics.  Blackwell's  Island,  JV.  T., 

and  at  Ihe  Oti.t- I'alienls'  T>epartment  nf  the  New  Y'irk  Honpitnl. 

NERVOUS  DISEASES;  THEIR  DESCRIPTION  AND  TREATMENT. 

Pei^ond   edition,  thoroughly  revis'd   and   rewritten.      In  one  handsome  octavo  volume  of 
about  OUO  pages,  with  numerous  illustrations.     (lit.  Press.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.of  the  Skin,  dtc).    19 
MORRIS  (MALCOLM).  M.D., 

^'-*-  Joint  Lecturfr  on  Dertuntnlnffp,  St.  Mary's  Hnnpttnl  Med.  Srhnol. 

SKIN  DFSEASES,  Incliidinf?  their  Definitions,  Symptoms,  Diasrnosis, 

Pro<?nosi^,  Morbid  Amitomy  nnd  Treatment.      A  Manual  for  Students  :ind  PnintUionerB. 
In  one  12ino.  volume  of  over  300  pages.    With  illustrations.     Cloth,  $1   75.     (Noiv  lii-ady.) 


To  phy^iiians  who  Wduld  like  to  know  sonif iliine 
about  nUin  dlieaoes,  go  tliat  wlien  a  patioiit  present!- 
himcelffor  reli'f  llipy  can  make  a  correct  dla.'noKlH 
and  preKorihea  rational  trea'meut,  we  iialieHitatinifl  y 
recommend  tliiH  liitle  hook  of  Dr.  Moi;nH  The  alfec 
tioDs  of  the  Hkin  are  dencrilieil  in  a  terse,  Incid  man- 
ner, and  their  several  characterisiicH  so  plainly  set 
forth  that  dagnosis  will  he  eai-y.  The  trentTnent 
Id  each  case  is  such  as  the  f  xperience  of  the  niosi 
eminent  dermatolo<i,stg  advise.— •Ci;jff»ina<i  Mi-di- 
cal  New^-,  April,  18S0. 

This  is  emphatically  a  learner's  book  ;  for  we  can 
safely  say,  so  far  as  our  judajment  sjoes.  that  iu  the 
whole  range  of  medical  1  lerainre  of  a  like  scope 
there  is  no  hook  which  for  clearness  of  exDression 
and  methodical  arrangement  is  better  alntited  to 
promote   a   rational    conception    of  dermatology, 


hegianer. — St.    Loiii/i  Courier  of  Mtdicinn,  April, 
1R80. 

The  author  of  this  mannnl  hai  evidently  a  full  and 
intimate  aciiuaintance  with  the  literatnre  of  derraa- 
tologv,  and  with  the  most  recent  developments  and 
appliances  <!f '■utaueotis  medicine.  He  ha»  produced 
a  plain,  practical  book,  by  aid  of  which,  who  so 
chooses  may  tnin  his  eye  to  the  re  ogni  ion  of 
light  hilt  significant  ditfHrences.  Th"  descriptions 
are  neither  loo  va?uo  nor  over-reflne<l  ;  the  direc- 
tions for  treatment  are  clear  and  succinct. — London 
Briiia,  April,  1  S80 

The  author's  task  has  been  well  done  anl  has  pro- 
duced one  of  the  hes'  recent  works  upon  the  difficult 
subject  of  which  it  t- eats  ;  there  is  no  work  pnhtished 
which  gives  a  better  view  of  the  elementary  facts 
and   pri  iciples  of  dermatology.  —  Neio  0  Irana  Medi- 


branch  confessedly  difficult   and  perp  exing   to  the    cal  nnd  Surf/ion  I.  Journal,  April,  IsSO 


F' 


'OX  (  Tlf,BfJRF),  M  D..  F.R.C  P.,  avd  T.  C.  FOX,  D.A.,  M.R.C.S., 

Phy-tictnn  to  thf.  De.pnrtrne.ni  for  Skin  Dimasen,  Univi-rKity  College  Hnnpilnl. 

EPITOME  OP  SKIN"  DISEASES.     WITH  FORMULA.     For  Stu- 

DENTS  AND  Practitionkrs.    Seoond  edition,  thoroughly  reviised  and  greatly  enlarged.  In 
one  very  handsotne  12mo.  volume  of  216  pages.     Cloth,  $1  38.      {Just  Issued.) 


fpLINT  [A  USTIN),  M.D., 

^  Professor  of  fhe  Principle.':  and  Prarfine  of  Medicine  in  Belle.vue  Hospital  Med.  College,  N.  T. 

A   MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic   Aneurism. 
Second  edition.     In  one  handsome  royal  12mo.  volume:  cloth,  $1  6.3.      (Just  Ready.) 

The  little  work  befors  us  has  already  become  a  I  author  has  for  m 'ny  years  given,  in  connedion  with 
standard  one.  and  has  become  exiensively  adopted  |  practical  instruction  in  iiusoultalion  and  percussion, 
as  a  text-hook.  Th^re  is  certainly  none  better.  It  I  to  private  clas.ses.  composed  of  medical  students  and 
contains   tlie   substance   of   the    leysons   which   the  |  practitioners.  —  Cincinnati  Med.  News,  Feb.  1S80. 

or    THE  SAME   AUTHOR. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT AND  PHYSICAL  DIAGNOSIS;  in  a  series  of  Clinical  Studies.  By  Austin 
Flint,  M  D.  ,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hi  sjiital  Med. 
College,  New  York.     In  one  htindsome  octavo  volume  :  $3  50.      (Lately  Issued.) 

T>T  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

■jDY  THE  SAME  AUTHOR.  ' 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  696  pages,  cloth,  $4  60. 

ROWN  [LENNOX),  F.R.C. S.  Ed., 

Senior  Surgeon  to  the  Ci-ntml  Condon  Throat  nnd  Ear  Hospital,  etc.      , 

THE  THROAT   AND  ITS   DISEASES.     Second  American,  from  the 

Second  English  Edition,  thoroughly  revised.  With  one  hundred  Typical  Illustr.itions  in 
colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author.  In  one  very 
handsome  imperial  octavo  volume  of  over  350  pages.      (^Preparing.) 

aEJLER  (CARL),  M.D., 

AJ  Lecturer  on  Laryni.'(tscopy  at  the  Univ.  of  Penna.,   Chief  of  the  Throat  Dispensary  at  the 

Univ.  Hospital,  Philn.,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OP  DISEASES  OF 

THE    THROAT    AND    NAS\L   CAVITIES.      In   one  handsome  royal  12mo.  volume, 
of  166  p.ages,  with  35  illustrations;  cloth,  $1.      (Jii.'st   Ready.) 
We  most  heartily  ooramoud  this  book  a«  showing  ,      A  convenient  little  handbook,  cloar.  concise,  and 


B 


sound  judgment  i  n  practice,  and  peifect  fainiliari'y 
with  the  literature  of  tlje  spec  alty  it  so  ably  epi- 
tomizes.—  Philada.  Med.  Times,  July  5,  1879, 


accurate  in  iis  method,  and  admiral)ly  fulfil  ling  its 
purpose  of  brincing  the  subject  of  which  it  treats 
within  the  comprehension  i)f  the  general  practi- 
tioner.— if  C.  Med.  Jour.,  June.  1879 


OLrNIOAt  OBSERVATIONS  ON  PHNOTIONAL 
NERVOnS  DISORDERS  BvC.  H.^ndpieldJonf.:? 
M.D..  Physician  to  St.  Mary's  Hospital,  .Sic.  Sec 
ond  America  p  Edition,  in  onehdadsomeoctavt 
Tolaineor348  pages.clotb,  iil3  26. 


HILLIER'S  HANDBOOK  OF  SKIN  DISEASES,  for 
Students  and  Craciltioners.  Second  Am  Ed.  In 
one  roval  12mo.TOl.  of  338  pp.  With  illustrations. 
Cluth,  $2  26. 


20    Henry  C.  Lea's  Son  &  Co.'s  Publications — (  Venereal  Disemes^  &c.). 


'DUMSTEAD  {FREEMAN  J.),  M.D.,LL.D., 

~-'         Late  Pro/e/mor  of  Venereal  Dixeaxen  at  the  Ool.  o/  Phy.i.  and  Surg..  New  York.  &c. 

THE  PATHOLOGY  AND   TREATMEXT  OF  VENEREAL  DIS- 

EASES.  Including  the  results  of  recent  investigations  upon  the  subject.  Fourth  Edition, 
revised  and  largt>iy  rewritten  with  the  co-operation  of  R.  W.  Taylor,  M.D.,  of  New 
York,  Prof,  of  Derniatologj'  in  the  Univ.  of  Vt.  In  one  large  and  handsome  octavo 
volume  of  835  pages,  with  I3S  illustrations.  Cloth,  $4  75  j  leather,  $5  75;  half  Russia, 
$6  25.      (Now  Ready.) 


"We  have  to  congnitulate  our  countrymen  upon 
the  truly  valuable  addition  which  they  have  made 
to  American  literature.  The  careful  esiimate  of  the 
value  of  the  volume,  which  we  have  made,  jufitifieH 
OS  in  declaring  that  this  is  the  best  treatise  on 
venereal  diseases  in  the  English  langaagi^.  and  we 
might  add,  if  there  is  a  better  in  any  other  tougiie 
we  cannot  name  It ;  there  are  certainly  no  books  in 
which  the  student  or  the  general  practitioner  can 
find  snch  an  excellent  rinumi  of  the  literature  of 
any  topic,  and  such  practical  suggestions  regarding 
the  treatment  of  the  various  coraplicaiions  of  every 
venereal  disease.  We  take  pleasure  in  repeating 
that  we  believe  this  to  be  the  best  treatise  on  vene- 
real disease  in  the  English  languiigtj,  and  we  con- 
gratulate the  authors  upon  their  brilliant  addition 
to  American  medical  literature. — Chicago  Med.  Jour- 
nal and  Examiner,  February,  ISSO. 

It  is,  without  exception,  the  most  valuable  single 
work  on  all  branches  of  the  subject  of  which  it  treats 
In  any  language.  The  pathology  is  sound,  the  work 
is,  at  the  same  time,  in  the  highest  degree  practical, 
and  the  hints  that  he  will  get  from  it  for  the  man- 
agement of  any  one  case,  at  all  obscure  or  obstinate, 


will  more  than  repay  him  for  the  outlay. — Archives 
of  Mfdicine,  April,  IS'^O. 

This  now  classical  work  on  venereal  disease  comes 
to  us  in  its  fourth  edition  rewritten,  enlarged,  and 
materially  improved  in  every  way.  Dr.  Taylor,  as 
we  had  every  reason  to  expect,  has  performed  this 
part  of  his  work  with  unu.sual  excellence.  We  feel 
that  what  has  been  written  has  dono  but  scanty  jus- 
tice to  the  merits  of  this  truly  great  treatise. — St. 
Louis  Courier  of  Medicine,  Feb.  18S0 

We  find  that  we  have  here  practically  a  new  book 
—  that  the  etateraeut  of  the  title  ppge,  as  to  the  fact 
that  it  has  been  largely  rewritten,  is  a  sufficiently 
modest  announcement  for  the  imporlaut  changes  in 
the  text.  After  a  thorough  examination  of  the  pre- 
sent edition,  we  can  assert  confidently  that  the  enor- 
mous labor  wfl  have  described  has  been  here  most 
faithfully  and  conscientiously  performed. — Amer. 
Journ.  Med.  Sci.,  Jan,  ISSO. 

It  is  one  of  the  best  general  treatises  on  venereal 
diseases  with  which  we  are  acquainted,  and  is  espe- 
cially to  be  recommended  as  a  guide  to  the  treatment 
of  syphilis. — London  Practitioner,  March,  ISSO. 


G 


ROSS  {SAMUEL  W.),  A.3I.,  M.D., 

Lecturer  on  Genito- Urinary  and  Venereal  Di.fera.sfi.*  in  the  Jeffer-ion  Medical  College,  Phila. 

A    PR.lCTfCAL    TREATISE    ON    IMPOTENCE,    STERILITY, 

AND  ALLIED  DISORDERS  OF  THE  MALE  SEXUAL  OKG.XNS.     In  one  ver;?  hand- 
some  octavo  volume  of  174  pages,  with  16  illustrations.    Cloth,  $1  50.     {Just  Ready.) 


flULLERIER  {A.), 

'^        Surgeon  to  the  Hdpital  du  Midi. 


and         Z> UMSTEA D  ( FR EEMA N  J.), 

i.  -*-'        Pro/es-.'ior  of  Venereal  Di.ifia.ie.9  in  Hie  Collegeof  , 

Pky.fic.ian.t  and  Surgeon.^.  N.  Y 

AN  ATLAS  OF  VENEREAL  DISEASES.  Tran.slatetl  and  Edited  by 

Freeman  J.  BuMSTEAD.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 

with  2fi  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  .size  of 

life;  strongly  bound  in  cloth,  $17  00  ;   also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol  - 

LARS  a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 

practice.     GJentleiuen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 

delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


LEE'S  LECTURES  ON  SYPHILIS  AND  SOME 
FORMS  OF  LO(;aL  disease  AFFECTING  I'RIN- 
CIPALLV  THE  ORGANS  OF  GENERATION.  lu 
one  handsome  octavo  volume;  cloth,  $2  2"). 

COM  DIE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised 
and  augmented.  In  one  large  octavo  volume  oi 
nearly  8^0  closely-printed  pages,  cloth,  $6  25  ; 
leather   kd  26. 

WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  With  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
Sf><i  pages;  cloth,  $2  ."lO. 

SLADE  ON  DIPHTHERIA;  Us  Nature  and  Treat- 
ment, with  an  .iccounlofthe  HisloryofitK  Pre- 
valence In  various  Conntries.  Second  and  revised 
edition.  In  one  oeatroyall2mo.  volume,  cloth, 
ifcl  2r,. 

WALSHEON  THE  DISEA8ES0F  THE  HEART  AND 
GREAT  VESSELS.  Third  Amorican  Edition.  In 
1  vol.  ivo.,  420  pp.,  cloth,  ^:i  00. 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  KE 
M'<D(ABLESTAOB«     1  vol.  Rvo.,  pp.  2»4     *2  2f 

WILSON'S  STUDENT'S  BOOK  OV  CUTANEOUS 
HBDICI.VE  and  I>i^kA'<rh  op  thr  Skin.  Id  one 
rtry  haod«ome  royal  12iaQ  volume.    $8  60. 


OHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN   HEALTH  AND  SICKNESS.     In  one  handsome 
octavo  volume.     Cloth,  $2  75, 
b^ULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Uiagiio.sis, 
Symptoms  and  Treatment.    From  the  second  and 
revised  English  edition.    In  one  handsome  octavo 
volume  of  about  500  pages  :  cloth,  %3  50. 
BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagno. is  and  Treatment,  With  Illustra- 
tions.  In  one  l2mo.  vol.  of  804  pages,  cloHi,  ij!'?  00. 
LECTURES  ON  THE  STUDY  OF  FEVER.     By  A. 
HoDBo.v,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital      In  one  vol   8vo.,  cloth,  $2  50. 
A  TREATISE  ON  FfiVER.     By  Robkrt  D.  Lyons, 
K.C  C.  I  n  one  octavo  volume  of  362  pages,  clot  h 
*2  2.1. 
HILL    ON    SYPHILIS  AND    LOCAL   CONTAGIOUS 
DISORDERS      lu  one  handsome  octavo  volume; 
cloth    *8  25. 
SMITH'S   PRACTICAL  TREATISE  ON  THE  WAST- 
ING DISEASES  OF  INFANCY  AND  CHILDHOOD. 
Second  American,  from  the  Sacond   revised  and 
enlai'ged  Eni^lish  edition.     In  one  handsome  acta- 
TO  wolnino.  0. loth  .  i|t^  .^O 

LA  ROCHE  ON  PNEUMONIA.     1  vol.  Svo.,  oloth. 
of  500  pages.    Price,  $3  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — CDi.s.  of  Children^  &c.).   21 


^MITHiJ.  LEWIS),  M.D., 

Clinical  Prnfp.x.inr  f,f  DixeaKfn  of  Clhililri'n  in  thf  flellpvuf  TInxpifnl  Med    College,  N.  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DLSEASES  OF 

CHILDREN.  Fifth  Edition,  thoniiifjlily  revised  and  rewritten.  In  one  handsome  oc- 
tavo volume  of  about  SdO  pages,  with  illustrations.  [In  Press.) 
The  very  marked  favor  with  which  this  vfork  hiis  been  received  wherever  the  English  lan- 
guage is  spoken,  has  stimulated  the  nuthor,  in  the  ])rei)aration  of  the  Fifth  Editinn,  to  sp.ire 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  re.-^peet  of  a  onntinuanee  of  jirofessional 
confidence.  Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  will  not  be  materially 
increased. 


JL 


EATING  {JOHN  M.),  M.D., 

Lecturer  on  the  Defenses  < if  Children  nf  the  Univerxih/  of  Penimyhinitin,  etc. 

THE  MOTHEPv'S  GUIDE  IN  THE  MAXAGEMI<:XT   AND  FEED- 
ING OF  INFANTS.    In  one  handsome  12mo    vol    of  about  100  pages.   {Nearly  Ready.) 


W^-ST  [CHARLES],  M.D., 

Pky.sicianto  the  Hospital  for  Hick  Children,  London,  <fre. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILD- 

HOOD.  Fifth  American  from  the  Sixth  revised  and  enlarged  English  edition.    In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50  ;  leather,  $5  60.  (Lately  Issued.) 

»r  THE  SAME  AUTHOR.    {  Lately  Tn fined.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume   small  12mo.,  cloth,  $1  00. 


JDF  THE  SA^E  AUTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  560  pages,  oloth, 
$3  75;  leather,  $4  76. 


S 


WAYNE  {JOSEPH  GRIFFITHS),  M.D., 

Phy.tioian-Accnucheur  to  the  Brittsh  General  Ho-sjiital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.    Second  American,  from  the  Fifth  and  Revised 
London  Edition    with  Additions  by  E.  R.  Hotchins,  M.D.  With  Illustrations.   In  one 
neat  12mo.  volume.     Cloth,  $1  25.     (Lately  Issued.) 
*^*  See  p.  3  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  American  Journal  of  thb  Medical  Sciences. 


CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1  vol. 
■^vo..  pp.  4.iO,  cloth.     $2  ."iO. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  lastimprovementsand  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    $3  00. 


MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER  1  vol.  Svo.,  pp. 
36fl.  cloth.     .*2  00. 

ASHWELL'S  PRACTICAL  TREATISEONTHE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
Svo.,  pp.  52S,  cloth.    $3  50. 


riHURGHILL  {FLEETWOOD),  M.D.,  M.R.I.A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  Fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.D.,  author  of  a  Practical  Treatise  on  the  Diseases  of  Chil- 
dren, (fee.  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  actaro 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $6  00. 


1J7INCKEL  {F), 

'  '  Professor  and  Director  of  the  Oynacologieal  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  ^Me  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00.     (Lately  Isstted.) 


MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS 
AND  SYMPTOMS  OF  PREGNANCY.  With  two 
exqulsitecolored  plates,  and  numerouR  woodcuts 
In  1  vol.  8to.,  of  nearly  600  pp.,  cloth,  $3  75. 


RXQBY'S  SYSTEM  OF  MIDWIFERY.  With  notas 
and  Additional  illustrations.  Second  American 
■edition.  One  volume  octavo,  cloth,  422  pagea, 
$2  60. 


22      Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Women). 


T'HOMAS  (T.  GAILLARD),M.D., 

-*■  Professor  of  Obntetrirx,  &c. .  in  the  Cullege  nf  Pkyxicians  and  Surgeons,  N.  T.,  <fec 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Fifth 

Edition,  thorou<;hlj'  revised  and  rewritten.     In  one  i;irge  and  handsome  octavo  volume 
of  over  8(10  pages,  with   2fi6  illustrations.     Cloth,  $5;  leather,  $6;  very  handsome  half 
Russia,  raised  bands,  .'ffi  50.      (Just  Ready.) 
The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  a  new  edition  of 
this  work  to  render  it  wurihr  a  continuance  of  the  very  remarkable  favor  with  whioh  it  has 
been   received.     Every  portion  of  the  work   has  been  carefully  revised,  very  much  of  it  has 
been  rewritten,  and  additions  and  .'ilterations  ir  trodur-ed  wherever  the  advance  of  science  and 
the  increased  experience  of  the  author  have  shown  them  desirable.      At  the  same  time  special 
care  has  been  exercised  to  avoid   undue  increase  in  the  size  of  the  volume.     To  accommodate 
the  numerous  additions  a  more  cond-nsed  but  v  ry  clear  letter  has  been  used,  notwithstanding 
which,  the  number  of  pages  has  been  increased  by  more  than  fifty.     The  series  of  illustration* 
has  been  extensively  changed  ;   many  which  seemed  to  be  superfluous  have  been  omitted,  and  • 
large  number  of  new  and  superioi   drawings  have  been  inserted.      In  its  improved  form,  there- 
fore, it  is  hoped   that  the  volume  will  maintain   the  character  it  has  acquired  of  a  standard 
authority  on  every  detail  of  its  important  subject. 

An  pxaraiuation  of  the  work  will  satisfy  that  it  is  its  autlior's  large  experienre,  but  reflect.^  his  care- 
one  of  great  merit.  II  is  nut  a  mere  conipiiation 
from  other  works,  bat  is  the  fruit  of  the  ripe 
thought,  sound  judgment,  and  critical  observMlions 
of  a  le  mod,  scientific  min.  It  is  a  treasury  of 
knowledge  of  the  deaartraent  of  medicine  to  which 
it  is  devoted  In  its  present  revised  stHte  it  cer- 
tainly hold-  a  foremost  position  as  a  gvnajcological 
work,  and  will  continue  to  be  'egarued  as  a  stan- 
dard authority —  Cincinnati  Med.  Nnos,  Deo.  I8S0. 

This  work  needs  no  introduction  to  any  of  the 
civilized  nations  of  the  woi'd.  The  edition  before 
us  adds  to  the  streng  h  of  former  volumes.  With 
the  wisd'^m  of  a  master  teacher  he  here  gives  the 
results  that,  in  his  judgmenf,  are  most  trnsi worthy 
at  the  present  tims.  In  its  own  p'ace  it  has  no 
rival,  becanse  the  author  is  the  best  teacher  on  this 
subject  to  the  niHSses  of  the  profession  As  hitherto 
this  work  will  be  thf  texl-bcjok  on  difeases  of  wo- 
men We  only  wish  that  in  other  branches  of  medi- 
cine a~  capiiblH  teachers  could  be  found  to  write  our 
text-books. — Detroit  Lancet,  Tan   ISSl. 

Since  its  Br-t  appearance  twei  ve  years  .igo,  until 
the  pre-eut  day,  it  ha~  held  a  position  of  high  re- 
gard, and  is  generally  runcc  ed  to  be  one  of  the 
most  p'acti  al  and  trnstworthy  volumes  ye'  pre 
sented  to  the  physician  and  studnnl  in  the  dupnrt- 
meut  of  gynecology.    The  woi  k  embodies  not  only 


ful  study  among  oth.-r  anthorities  in  hi.s  bianch, 
bc)th  at  home  and  abr'fld  Dr.  Thomas  is  an  able 
and  consci.-ntiouH  teacher.  His  wri  ing-;  convey 
his  rae^ni|lgin  ihe  .^aiiie  practical  and  instructive 
manner.  The  last  pdi  tion  of  this  work  is  fresh  from 
hi-i  leo,  wiih  decided  chunge?  and  im'ro  vements 
over  forrapr  edi' ioos.  His  book  presenis  generally 
accepted  facts, Hnd  »*  a  ^nide  lo  (he  student  ismore 
useful  and  reliable  'han  any  work  in  the  language 
on  diseases  of  women.  This  last  edition  will  add 
new  laurels  lo  those  already  won.  —  Md.  Med. 
Journ.,  Nov.  l.o,  18S0. 

It  ha=  been  enlarged  and  carefully  revised.  The 
author  has  brought  it  fully  abreist  with  Ihe  times, 
and  as  Ihe  wave  of  gynecological  pr'gre-'sion  has 
been  widesprend  and  rapid  during  the  twelve  years 
that  have  elapxed  since  theissue  of  the  first  edition, 
one  can  conceive  of  the  great  improvement  this  edi- 
tion must  be  upon  the  enrlier.  It  is  a  condeoseu  en- 
cyclopiedia  of  gynaic.ilogical  medi  ine.  The  style  of 
arrangement,  the  raauerly  m  inner  in  which  each 
suhjeot  is  tr?aled,  and  the  honest  convictions  de- 
rived from  probably  the  Inrgest  cliiicil  experience 
in  that  specialty  if  any  in  this  country,  all  serve  to 
commend  it  in  the  highe-^t  terms  to  the  practitioner. 
— Nashvilie  Journ.  of  Med.  and  Stiry.,  Jan.  1881. 


B 


ARNES  [ROBERT),  M.D.,  F.R.G.F., 

Ob-Rfetric  Phy,sici'in  to  St.  ThomOK'n  Hn.<<pitol,  A'C. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL diseases  of  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  In  onp  handsome  ootavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  1{4  50  ;  leather,  $5  50  ;   half  Russia,  $6.      (Jtist  Issued.) 

Dr  Barnes  stands  at  the  head  of  his  profr'ssion  in 
the  old  country,  and  it  requires  but  scant  Kcruliny 
of  his  book  to  show  that  il  has  been  sketched  by  a 
master      1 1  is  plain,  practical  common  sense  ;  shows 


very  deep  research  without  being  pedantic;  is  emi 
nently  calculated  to  inspire  enthn-iasm  without  in- 
culcating ra-hness;  points  out  the  dangers  to  be 
avoided  as  well  as  the  success  to  be  achieved  in  the 
▼arioas  operMtions  connected  with  this  branch  of 
medicin'':  and  will  do  ranch  to  smooth  the  rugged 
path  of  the  young  gynsecol  )gist  and  relieve  the  per- 
plexity of  the  man  of  mature  years.  —  Canadian 
Journ.  of  Me'i.  Science,  Nov.  1878. 

We   i^tv  the  doctor  who,   having  any   conslder- 


conntry,  is  shown  by  the  second  edition  following 
so   soon   upon   the   first. — A.m.  Practitioner,   Nov. 

1873. 


Dr.  Barnes's  work  is  one  of  a  practical  character, 
largely  illustrated  from  cusesin  his  own  experience, 
bnt  by  no  means  confined  to  such,  as  will  be  learned 
from  the  fact  that  he  quotes  from  no  le^s  than  628 
medical  authors  in  numerous  conntries.  Coming 
'rom  snnh  an  author.  It  is  not  necessarv  to  say  that 
the  work  is  a  vdlnable  one,  nnd  should  be  largely 
con-ulled  hy  the  profession. — Am.  S"pp  Obstetrical 
Journ.  Gt.  Britain  and  Ireland,  Oct.  1S78. 

No  other  gynecological  work  holds  a  higher  posi- 
tion, having   become   an   authority  everywhere  in 


able  practice  in  diseases  of  women,  has  no  copy  of  [  diseases  of  women.  The  work  has  been  bronght 
"  Barnes"  for  dallv  consultaMon  and  instruction.  It  j  fully  abreast  of  present  knowledge.  Every  practi- 
Is  at  once  a  book  of  great  learning,  rpsearch,  and  lioner  of  medicine  should  have  it  upon  the  shelves 
Indivldnal  experience,  and  at  ilia  same  time  emi-  I  of  his  library ,  and  the  student  will  find  It  a  superior 
Dentiv  p  actical.  That  it  has  been  -..pprecialed  by  j  text-book. — Cincinnali  Med.  Kewa,  Oct.  1678, 
the   profession,  both   in   Great   Britain   and  in  this  I 


H 


ODGE  (HUGH  L.),  M.D., 

Emeritun  Prnfeimor  «/  Obnletrics,  &c.,  in  the  Univer/)iti/  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ; including  Displacements 

of  the  UteruB.     With  original  illustrntionn.    Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  631  pages,  oloth,  $4  50. 


23 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.of  Women). 
TPM31ET  {THOMAS  ADDIS).  M.D., 

-■-'  Surgeon  to  the  Wnman'n  Honpital,  New  Y(>rk,etr.. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYN.^=:COLOaY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.  Second  Edition.  Thorouglv  Revised. 
In  one  large  and  very  band.vome  octavo  volume  of  875  pageH,  with  133  illustrations. 
Cloth,  $6;   leather,  $fi  ;  half  Russia,  raised  bands,  $6  50.      (Just  Ready.) 

Preface  to  the  Second  Edition. 
The  unusually  rapid  exhau.stion  of  a  large  edition  of  this  work,  while  flattering  to  the  author 
as  an  evidence  that  his  labors  have  proved  acceptable,  has  in  a  great  measure  heightened  his 
sense  of  responsibility.  lie  has  therefore  endeavored  to  take  full  advantage  of  the  opportunity 
afforded  to  him  for  its  revision.  Every  page  has  received  his  earnest  scrutiny;  the  critici.sms 
of  his  reviewers  have  been  carefully  weighed  ;  and  while  no  marked  increase  has  been  made  in 
the  size  of  the  volume,  several  portions  have  been  rewritten,  and  much  new  matter  has  been 
added.  In  this  minute  and  thorough  revision,  the  labor  involved  has  been  much  greater  than 
is  perhaps  apparent  in  the  results,  but  it  has  been  cheerfully  expended  in  the  hope  of  rendering 
the  work  more  worthy  of  the  favor  which  has  been  accorded  to  it  by  the  profession. 


In  no  country  of  the  world  hnn  gyuwculogy  re- 
ceived more  attention  tb»n  in  America.  Iti.s,  tlien, 
with  a  feeling  of  pleasure  that  we  welcome  a  woit 
on  diKeasei*  of  women  from  ko  e"iluenl  a  gyiueeolo 
gist  as  Dr.  Emmet,  and  the  work  i«  eswentially  clini- 
cal, and  leaves  a  strong  impi-«.-»  of  the  author's  in- 
dividnality.  To  criticiz»>,  with  ilie  care  it  merits, 
the  book  throughout,  would  dem;<  ud  far  more  spacp 
than  is  at  our  command.  In  parting,  we  can  nay 
that  the  work  teems  with  original  ideas,  fresh  and 
valuable  methods  of  practice,  and  is  written  in  a 
dear  and  elegant  style,  worthy  of  the  literary  repu- 
tation of  the  country  of  Loni;  fellow  and  Oliver  Wen- 
dall  Holmes. — Brit.  Med.  Journ.    Feb.  21,  1880. 

No  gynecological  treatise  has  appeared  which 
contains  an  equal  amount  of  original  and  uselul 
matter;  nor  does  the  medical  and  surgical  history 
of  America  include  a  hook  mor»  novel  and  useful. 
The  tabular  and  st.atiKtical  information  which  it 
contains  is  marvellous,  both  in  quaniity  and  accu- 
racy, and  cannot  be  otherwise  than  invaluable  to 
future  investigators.     It  is  a  work  which  dem.nnds 


not  careless  reading'  but  profound  study.  Its  value 
as  a  contribution  lo  gyua;cology  is,  perhaps, greater 
than  that  of  all  previous  literature  on  the  subject 
combined. — Chicago  Me.d    Gaz.,  April  f,  ISSO 

The  wide  reputation  of  the  author  makes  its  pub- 
lication an  event  in  the  gynjccological  world  ;  and 
a  glnnce  through  its  pages  shows  that  it  is  a  work 
to  be  studied  with  care.  .  .  .  It  must  always  be  a 
work  to  be  carefully  Htudied  and  frequently  con- 
sulied  by  those  who  practise  this  branch  of  our  pro- 
fession.—  bond.  Med.  Timeti  and  Gaz  ,  Jan.  10,  18sO. 

The  character  of  the  work  is  too  well  known  to 
require  extended  notice — suflice  it  to  say  that  no 
recent  work  upon  any  subject  has  attained  such 
great  popularity  so  rapidly.  Asa  work  of  general 
reference  upon  the  subjoct  of  Diseases  of  Women  it 
is  invaluable.  As  a  record  of  the  largest  clinical 
experience  and  observation  it  has  no  equal.  No 
phyfician  who  pretends  to  keep  up  with  the  ad- 
vances of  this  department  of  medicine  can  afford  to 
be  without  it. — NashvUle  Journ.  of  Mtdiciue  and 
Surgery,  May,  1880. 


D 


UNCAN  [J.  MATTHEWS),  M.D.,  LL.D.,  F.R.S.E.,  etc. 

CLINICAL    LECTURES    ON    THE    DISEASES    OF   WOMEN, 

Delivered  in  Saint  Bartholomew's  Hospital.     In  one  very  neat  octavo  volume  of  173 
pages.     Cloth,  $1  50.      {Just  Ready.) 


They  are  in  every  way  worthy  of  their  author  ; 
indeed,  we  look  upon  them  as  among  the  most  valu- 
able of  his  contribu'.ions  They  are  all  up  m  mat- 
ters of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  wih  subjects  that  are  not,  as  a 
rule,  adequately  handled  in  the  text-books ;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that,  if  widely  read,  as  they 
certflinly  deserve  to  ba,  they  cannot  fail  to  exert  a 
wholesome  restraint  upon  the  undue  eagerness  with 
which  many  young  physicims  seem"  bent  upon  fol- 
lowing tho  wild  teachings  which  so  infest  the  gyn«8- 
cology  of  the  present  day. — N.  T.  Mud.  Journ., 
March,  1880. 


The  author  is  a  remarkably  clear  lecturer,  and 
his  discussion  of  symptoms  and  treatment  is  full 
and  suggestive.  It  will  be  a  work  which  will  not 
fail  to  be  read  with  benefit  by  practitioners  as  well 
as  by  students.— P/iiia.  Mtd.  and  Surg.  Reporter, 
Feb.  7,  1880. 

We  have  read  this  book  with  a  great  deal  of 
pleasure.  It  is  full  of  good  things.  The  hints  on 
pathology  and  treat  meal  scattered  through  the  book 
are  sound,  trustworthy,  and  of  great  value.  A 
healthy  scepticism,  a  large  expeiience,  and  a  clear 
judgment  are  everywhere  manifest.  Instead  of 
bristling  with  advice  of  doubtful  value  and  un- 
sound character,  the  book  is  in  every  respect  a  safe 
guide. —  The  London  Lancet,  Jan.  21,  1880. 


M 


A  MSB  0  THA  M  ( FRA  NCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE   OF  OBSTETRIC   MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  Ac,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  1  irge 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-outs  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00 

pARRY  {JOHN  S.),  M.D., 

Ob.ttetrieian  to  the  Philadelphin  Hoiftitnl,  Vioe-Prest.  of  the  Ohetet.  Siciety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS  AND    TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  50.     (Late/y  Issued.) 


mANNER  {THOMAS  H.),  M.D. 

ON  THE  SIGNS  AND  DISKASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  volume  of  about  500  pages,  oloth,  $4  26.         y 


24  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Midwifery). 

TEISHMAN  {WILLIAM),  M.D., 

^^  RtgiuK  Prnftsnor  of  itidwifery  in  the.  Univergify  of  GlaKgow,  Ac. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY   AND  THE  PUERPERAL  STATE.     Third  American  edition,  revised  by 
the  Author,  with  addition?  by   John   S.  Parry,  M.D.,  Obstetrician  to  the  Pliiiadelphia 
Hospital,  itc.      In  one  large  and  very  handsome  octavo  volume,  of  TA'6  pages,  with  over 
two  hundred  illuBtrations.     Cloth,  $4  50;   leather,  $5  50  ;  half  Russia,  $6.    {Just  Ready.) 
Few  works  on  this  en^jecl  have  met  withas  great  j  seems  to   require,  aad  we  cannot  bat  adrnire   the 
a  demand  ao  this  one  appears  to   liave.     To  judge     ability  with  wliict    the  task   hag   been   performed, 
by  the  frequency  wUh  which  its  anther's  views  are  i  We  consider  it  an  admirable  text-book  for  sta'Jeuts 
qaoted,  and  Us  staiements  referred  to  in  obstetrical  I  during  tbeir  attendance  npou   lectures,  and   have 
literainre,  one  would  judge  thai  there  are  few  phy-     great  pleasure  in  recommending  it.    As  an  exponent 
Bicians  devoting  rnuch  attention  to  obnetrics  who  ,  uf  the  midwifery  of  the  present  day  It  has  no  sups- 
are  withoutit.     The  author  is  evidently  a   man  of    rior  in  the  English  language. — Canada  Lancet,  Jan. 
ripe  experience  and  coneervative  views,  and  in  no     1680. 

branch  of  medicine  are  these  more  valuable  than  in  |      to  the  American  student  the  work  before  us  must 
this.— Aew  liemediea,  Jan.  18!rO.  |  p^^^g  admirably  adapted,  complete  in  all  its  parts, 

We  gladly  welcome  the  new  edition  of  this  excel-  i  ei'sentially  modern  in  its  teachings  and  with  dem- 
lent  textbook  of  midwifery.  The  former  editions  I  onntratlous  noted  for  clearness  and  precision,  it  will 
have  been  most  favorably  received  by  the  proles-  gain  in  favor  and  be  recognized  as  a  work  of  stand- 
sion  on  both  sides  of  the  Atlantic  In  the  prepara-  '  ard  merit.  The  work  cannot  fail  to  be  popular,  and 
tionof  the  present  edition  the  author  has  made  such  .  is  cordially  recommended. — N.  0.  Med.  and  Surg. 
alterations  as  the  progress  of  obstetricil  science  ' /oMrn..,  March,  1S80. 

PLAYFAIR  (  W.  S.),  M.D.,  F.R.C.P., 
Profe.ysor  of  ObKteirlc  Medicine,  in  King's  College, etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Third  American  edition,  revised  by  the  author.  Edited,  with  additions,  by  Robktit  P. 
Harris,  M.D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  nearly  2C0 
illustrations.     Cloth,  $4;  leather,  $5  j  half  Russia,  $5  50.     iJust  Ready.) 

The  medical  profession  has  now  the  opportunity  i  a  very  intelligent  idea  of  them,  yet  all  details  not 
of  adding  to  their  stock  of  standard  medical  works  .,  nece-sary  for  i  full  understanding  of  the  subject  ace 
one  of  the  best  volumes  on  midwifery  ever  published,  omitted. — Cincinnati  Med.  Newn,  Jan.  1880. 
The  subject  is  taken  up  with  a  master  hand.  The  The  rapidity  with  whicl^oue  edition  of  this  work 
part  devoted  to  labonn  all  Its  various  preientations,  ;  foUows  another  is  proof  alike  of  its  excellence  and 
the  management  and  results,  ..^  admirably  arranged,  ,  ^f  the  estimate  that  the  profession  has  formed  of  it. 
and  the  views  entertamed  will  be  found  e.sseutially  ^  ,[  jg  jn^eed  so  well  known  and  so  highly  valued 
modern,  and  the  opinions  expressed  trustworthy  ■  11,^1  nothing  need  be  said  of  it  as  a  whole.  All 
The  work  aboands  with  plates,  illustra  ing  various  i^^  considered,  we  regard  this  treatise  as  the  very 
ob!.te>rical  positions;  they  are  admirably  wrought,  |  ^e^t  on  Midwifery  in  the  English  language. -i\r.  Y. 
and  afford  great  assistance   to   the  student.— i\r.  0.  [  ^fcdical  -JoHrnal  May   1880 

Med.  and  iSurg.  Journ.,  March,  \SSO.  t^         ,   .    ,      .',.,,  ...  ,   ,, 

,,  .        .      ,  "   ,  J.     ,        J  ,    .         ,  I'  certainly   is  an  admirable  exposition  of   the 

If  inquired  of  by  a  medical  student  what  work  on  Science  and  Practice  of  Midwifery.  Of  course  the 
obstetrics  we  should  recommend  for  him,  as  par  additions  made  by  the  American  editor.  Dr.  R.  P. 
excellence,  we  would  ULdoubtedly  advise  him  to  Harris,  who  never  utters  an  idle  word,  and  whose 
choose  Playfair  «.  It  is  of  convenient  size,  but  what  |  studious  researches  in  fome  special  dei.artinenis  of 
is  of  chief  importance,  its  treatment  of  the  various  |  obstetrics  are  so  well  known  to  the  profession,  are 
subjects  IS  concise  and  plain.    While  the  discussions  |  „(  ^  value.— r/ie  American  Praetiiioner,  April, 

and  descriptions  are  suiQciently  elaborate  to  render  J  <g^^ 


JDARNES  {FANGOURT),  M.D., 

-*-'  PhyHcian  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MIDWIYES  AND  MEDICAL 

STDDENTri.     With  50  illuBtrations.     In  one  neat  royal  12mo.  volume  of  200  pages; 
cloth,  $1  25.     {Now  Ready.) 


P 


AR  VIN  ( THEOPHIL  UH),  M.D., 

Prof,  of  OhxtetricH  and,  of  the  Med.  and  Hurg.  Diseafien  of  Women  in  the  Med.  Coll.  of  Indiana. 

A    TREATISE    ON    MIDWIFERY.      In  one  very  lianclsome  octavo 

volume  of  about  650  jjages,  with  numerous  illustrations.     (Prepart?i.g.) 

TJODOE  {HUGH  L.),  M.D~, 

ErnerUun  ProfenMor  of  Midwifery,  &c.,  in  the  Univernity  of  Pennsylvania,  Ac. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC^.     Illns- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.    In  one  large  and  beautifully  printed 
quarto  volume  of  560  double-columned  pages,  strongly  bound  in  cloth.  $14. 
The  work  of  Dr.  Hodge  Is  something    more  than 

a  simple  presentation  of  bis  particular  views  in  the 

de.>artment   of  Obstetrics;    It  is   something   more 


than  an  >rdinarytreatiseon  midwifery;  it  is, in  fact, 
a  cyclopedia  of  midwifery.     He  has  aimed  to  em- 


body in  a  lingle  volume  the  whole  science  and  art  of 
Obstetrics.  An  elaborate  text  is  combined  with  ac- 
curate and  varied  pictorial  illustrations,  so  that  no 
fact  or  principle  Is  left  unstated  or  unexplained. 
—Arn,.  Med.  Timeit,  Sept.  .S,  1864. 


^  *jff  Specimens  of  the  plates  and  letter-presB  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps.  ^ 


QfTAD  WICK  (JAMES  /?.),  A.M.,  M.D. 

A  MANUAL  OF  THK    I)ISK\SKS  PENULT  .AR  TO  WOMEN.    In  one 

neat  volume,  royal  12mo.,  with  illuistrations.     {Preparing.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (Suryery). 


25 


TJAMILTON {FRANK  H.)  M.D.,  LL.D., 

J-J-  Surgeon  to  the  Btllcvue  Hos/>ital.  AVjo  York. 

A  PrvACTICAL  TREATISE  OX  FRACTURES  AND  DISLOCA- 

TIONS  Sixth  Edition,  thoroughly  revised,  and  nm^'h  improved.  In  one  very  hand.^ome 
oetnvo  volume  of  over  000  im-res,  with  352  illustrntious.  Clolh,  $5  50;  leather,  $0  50; 
half  Russia,  raised  bands,  $7  00. 


So  many  kind  expiessioun  nl  welcome  hare  lieen 
showered  upou  e.ith  ancceasive  edl  iou  of  ihts  val- 
uable tre.-iii^e,  that  ^ca^cely  (nyihiug  leniHius  for 
n.s  to  lio  but  toex.eud  the  cuBloui;iry  cordial  greet- 


Dr  Hamilton  bac  devoted  great  labor  :o  thestiidy 
of  these  m  bjects.  His  large  experience,  extended 
reseHrtb.  i^pd  p.ttieu.  investiitation  have  made  him 
one  01°  the  hiKtie^t  aulhurliii  »  among  living  writers 


ing.     It  18  the  only  complete  wiirk  ou  the  subject  i  In  this  br.< neb  of  smg.ry     This  work  is  systematic 


of  Fractures  iu  the  Eugiisb  luugutige  We  cou 
grainlate  the  accoiiipli;-hed  author  on  the  deser'ed 
success  of  his  work,  and  hope  tlia;  he  may  live  to 
have  many  succeeding  editions  pas- under  his  skill- 
ed supervision. — Phila.  Coll.  and  Clin.  JSecord. 
Nov   15.  ISSO. 

Universal  verdict  has  pronounced  it,  hninanly 
speaking,,!  perfect  treatise  upon  l  his  siibjei't.  As 
it  is  the  only  complet  and  ilUi.olrated  work  in  any 
language  tre.itiug  of  fracture-  and  dislocations,  it 
ii  safe  to  :  tilrm  that  every  wide-awake  surgeon  aad 
geueral  practitioner  will  regard  it  as  iodispeu.-able 
to  the  safe  and  pleasant  conduct  of  their  profes- 
sional work.— i)efroi<  Lancet,  Nov.  IS,  ISSO. 


and  prai  teal  iu  its  arrargement  ana  presents  its 
subject  matter  ele.nrly  and  f.  rcibly  to  the  reader 
or  student. — MarylanU  Mtdical  Journal,  Nov.  15, 
li^SO. 

The  ouly  complete  work  on  its  subject  In  the  Euk" 
lish  tongue,  .ind,  indeed,  may  now  I'S  said  lo  be 
the  ouly  work  of  its  kind  iu  any  lengue.  It  would 
require  an  exceedingly  critical  examiuallou  to  de- 
tecc  in  It  any  panlcnlars  iu  which  it  mii;ht  be  im- 
proved. The  work  is  a  monumenl  to  American 
sHr»;ery,  and  will  long  si  rve  to  keep  green  ibe 
memory  of  its  venerable  author.— Jfic/it^an  Med. 
News,  Nov.  10,  ISjI. 


A  SHHURST  {JOHN,  Jr.),  M.D., 

^-*-  Prof  .of  Clinical  Surfifrxi.  Vniv  of  Pa..  Surgeon  to  the  EpUicopal  Hospital,  Philadelphia. 

THE    PRINCIRLES  AND  PRACTICE  OF  SURGERY.     Second 

Edition,  enlarged  and  revised.  In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illuetrations.  Cloth,  $6;  leather,  $7;  half  Russia,  $7  50.  {Just 
Ready.) 

langna»:e  all  that  is  necessary  to  be  learned  by  the 
student  of  surgery  whilst  iu  attendance  upon  lec- 
tures, or  ibe  geueral  practitioner  in  hi!"  daily  routine 
practice. — Mil.  Mud  Journal,  Jan.  1879. 


Conscientiousness  and  thoroughness  are  two  very 
marked  traits  of  character  iu  the  author  of  this 
book.  Out  of  these  traits  largely  has  grown  the 
success  of  his  mental  fruit  in  the  past,  and  the  pre- 
sent offer  seems  in  nowise  au  exception  to  what  has 
gone  before.  The  geueral  arrangeiueut  of  the  vol- 
ume is  the  same  as  In  the  first  eilUiou,  but  every  part 
has  been  carefully  revised,  and  much  new  matter 
added.— P/ii7a.  Med.  Times,  Feb.  I,  1S79. 

The  favorable  reception  of  the  first  edition  is  a 
guarantee  of  the  popularity  of  this  f  dilion,  which  is 
fresh  from  the  editor's  tjands  with  mauy  euinrge- 
ments  and  improvements.  The  author  of  this  work 
is  deservedly  popular  as  an  editor  and  writer,  aud 
his  contributions  to  the  literature  of  surgery  have 
guiued  for  him  wide  reputation.  The  volume  now 
offered  the  profefsiou  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  cau 
only  add  that  the  work  is  well  arrang<  d,  filled  Tith 
practical  matter,  and  contains  in   brief  and   clear 


The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents aud  physicians, — Cincin.  Mfd.  News,Jau.  '19. 

We  have  previously  spoken  of  Dr.  Ashhur.'^fs 
work  iu  terms  of  i)rrtise  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  has  yet  fallen 
from  the  press.  In  point  of  judicial  fairness,  of 
power  of  condensation,  of  accuracy  aud  conciseness 
of  expression  aud  thoroughly  good  English,  Prof 
Ashhurst  has  no  superior  ;tmoug  the  surgical  writers 
in  America. — Am.  Practitioner,  Jau.  1S79. 


s 


TIMSON  [LE  WIS  A.),  A.M.,  M.D., 

Surgeon  to  the  Presbytt-rian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  veiy  hantlsome 

royall2mo.  volume  of  about  500pages,  with  332  illustrntions  ;  cloth,  $2  50.  {Just  Iss/n'd.) 

The  work  before  us  is  a  well  printed,  profusely  performing  them.  Tht  work  is  handsomely  illus- 
11  lustra  ted  manual  of  over  four  huudred  and  seventy  t  rated,  auil  the  de- criptious  are  cle.i  r  and  well  drawn, 
pages.  The  novice,  by  a  perusal  of  the  work,  will  It  Is  a  clever  aud  useful  volume;  every  student 
gain  a  good  idea  of  the  geueral  domain  of  operative  should  possess  one.  The  preparation  of  this  work 
surgery,  while  the  practical  surgeon  has  presented  ;  does  away  with  the  necessity  of  pondering  over 
to  him  within  a  very  concise  aud  intelligible  form  larger  works  on  surgery  for  descriptions  of  opeia- 
the  latest  aud  most  approved  selections  of  operative  tions,  asit  presents  in  a  nut-shell  just  what  is  wanted 
procedure.  Thepreoision  and  conciseness  with  which  by  the  surgeon  without  au  elaborate  search  to  liud 
the  diflerent  operations  are  described  enable  the  it.  —  Md.  Med  Jmirnnl,  Aug.  1S78. 
author  to  compress  an  immense  amount  of  practical  j  The  authors  conciseness  and  the  repleteness  of 
Information  in  a  vejy  small  compass.— iV.  l.JileiHcal  I  t^e  work  with  valuable  illustrations  entitle  it  to  be 
Becord,  Aug.  3, 187S.  1  cia,sged  with  the  text-books  for  students  of  operative 

This  volume  is  devoted  entirely  to  operative  sur- '  surgery,  and  as  one  of  reference  lo  the  practitioner, 
gery,  and  is  iuteuded  to  tamiliarize  the  student  with    —Oincinnati  Lancet  and  Clinic,  July  27,  ISVS. 
the  details  of  operations  and  the  different  modes  of 


SKKT'S  OPERATIVE  SURGERY.  In  1  vol.  8vo. 
ol.,  of660  pages  ;  withabont  lOOwood-onts  $.S  36 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
PracticeofSuruert.  Inlvol.Svo  crh.7()0p.  I|(2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  8UK- 
HERT.  Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes',about  1000  pp.. leather,  raised  bandf    *6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGEKT. 
By  Wn,Li.\M  PiRRiK,F.R  S  E.,  I'rofes'rof  Surgery 
in'the  University  of  Aberdeen.    Edited  by  John 


NBTI.L,  M.D.,  Professorof  Surgery  In  the  Pe  una. 
Medical  College,  Surg' n  to  the  Pennsylvania  Hos- 
pital.&c.  In  oue  very  handsome  octavo  vol.  of 
780  pages,  with  .Slti  illustrations,  cloth,  $3  75. 

MILLKK'SI'KINCU'LK.-;!.*!'  SUKGKRV  FourthAme- 
rican,  from  the  Third  Kdiiiburtth  Edition.  In  one 
larste  Svo.  vol.  of  700  pages,  with  340  illustrations, 
cloth.  $:i  76. 

MILLKK'S  PRACTICE  OF  SURGERY.  Fourth  A  me- 
rican,  from  the  last  Edinburgh  Kdition  Revised  by 
the  Anierioau  editor  In  ouelarge  8vo.  vol. of  nearly 
700  pages,  with  304  illustrations:  cloth,  $S  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (/Swrgrery). 


/^ROSS  {SAMUEL  D.),  M.D., 

v^  Professor  of  Surgerp  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY :  Pathological,  Diagnostic,  Therapeutic 

and  Operative.  Illustrated  by  upwards  of  Fourteen  Hundred  Engravings,  Fifth  editioB, 
carefully  revised  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2.S00  pp.,  strongly  bound  in  leather,  with  raised  bands,  $16  ;  half  Russia, 
raised  bands,  $16. 


We  have  solilom  rend  a  work  with  the  practical 
value  ol  which  we  have  beeu  uioreimpressed.  Every 
chiipter  is  ^o  concisely  put  tugellier.  that  the  busy 
priiclitioner,  when  in  difficulty,  can  nt  once  find  the 
inforuiation  he  requires.  Ilis  work  ip  cosmopolitan, 
the  surgery  of  the  world  beinj;  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  puiiiiently  practical, that  it  is  almost  a  false  compli- 
ment to  say  thatwe  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surgery  is  the 
practice  of  surgeons.  The  prinlingand  binding  of  the 
work  is  unexceptionable;  indeed,  it  contrasts,  in  the 
latter  respect,  remarkably  with  English  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
80  wretchedly  stitched  as  to  require  re- binding  before 
they  are  any  time  in  \xi&.—Dub.  Journ.  of  Med.  Sci., 
March,  1874, 

Dr,  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
Tlie  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  "ele- 
phant."there  has  been  roomforconsiderabloadditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Lotid.  Lancet, 'Nov.  16,1872, 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 
edition  of  Gross's  "Surgery,"  will  confirm  his  title  ol 


"  PHmus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  socompleteand  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  me'hodical  disposition  and  arrangement 
of  acquired  knowledge  ai^d  personal  experience. — JS.T. 
Med.  Journ..  Feb.  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language, — St. 
Louis  .Medical  and  Surg.  Journ., Oct.  ISli, 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  .years  ago  we  had  the  pleasure  of  presenting-  the 
first  edition  of  Gross's  .Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor, and  study,  all  con- 
densed upon  Ihegreat  work  before  us.  And  to  students 
or  practitioners  desirousof  enriching  theirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immenseresearch. — 
Qincinnati  Lancet  and  Observer,  Sept.  1872. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations, but  asoientific  accountof  surgical  theory 
and  practicein  all  its  departments. — Brit,  and  For. 
Med.  Chir.  ifew.,  Jan.  1873. 


7?r  THE  SAME  AUTBOi.. 

A    PRACTICAL  TREATISE   ON  THE    DISEASES,  INJURIES 

and  Malformations  of  the  Urinary  Bladder,  the  Piostate  Gland  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samqel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  of  574  pages,  with  170  illus- 
trations: oloth,  $4  50.     {Just  Issued.) 


Por  referenceandgeneralinformation,  the  physician 
orsuri;eoncan  find  nowork  that  meets  theirnecessities 
more  Thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustrations  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended,by  the  reasonable  and  practical  manner 
in  which  the  various  subjects  are  syBtematized  and 
arranged  We  heartily  recommend  it  to  the  profession 
as  avaluableadditiontotheimportantliteratureofdis- 


eases  of  the  urinary  organs. — Atlanta  Med.  Journ.,  Got. 
1876. 

It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
chapters  on  "Diseases  of  the  Bladder,"  "Prostate 
Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
descriptive  writing;  while  the  chapter  on  "Stricture" 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — New  York  Med.  iTourn., Nov. 1876. 


TtT  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  76. 


D 


RUITT  [ROBERT),  M.R.G.S.,Src. 

THE  PRINCIPLES  AND  PRACTICE  OP  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  Bighkh enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  aurgical  student  or  practitionercould 
desire. — Dublin  Quarterly  Journal. 

It  is  a  moBladmirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Draltt's  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elacidateevery important  topic. 
We  ttave  examined  thebook  most  thoroughly,  and 
caniay  that  this  success  is  well  merited.  His  hook, 
moreover,  possesses  the  Inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and 
classified  and  of  being  written  In  a  style  at  once 
clear  and  succinct. — Am.  Journal  of  Med.  Sciences. 


ASHTON  ONTHE  DISEASES,  INJURIES,  and  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  ConHtlpation.  Second 
American,  from  the  Fonrthand  enlarged  London 
Edition.  With  lllnHtratlonB.  In  one  8vo.  vol.  of 
287  pages,  cloth, $3  2&. 


SARGENT  ON  BANDAGING  ANDOTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12mo.  vol.  ol383pag3B  withl84  wood-cuts  Cloth, 
$170, 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery).  27 

JJOLMES  [TIMOTHY),  M.A., 

-*—*-  Siirfff.on  find  Lecturer  on  Siirgni-y  at  St.  Oe.nrge.'n  Honpital,  Lonrfon. 

A  SYSTEM  OF  SURJERY;  THEORETICAL  AND  PRACTICAL. 

In  Treatises  by  various  authors.  American  Edition,  Thoroughly  hkvised  and 
KKWHITTEN  bv  JoHN  11  I'ackaui),  M.D.,  SiirgeoD  to  the  Episcopal  and  .St.  Joseph's  Hospi- 
tals, Philadelphia,  as.sisted  by  a  large  corpse  of  the  most  eminent  American  surpeoiis.  In 
three  large  and  very  handsome  imperial  octavo  volumes  of  about  1000  pages  each,  with  over 
1000  illustrations  on  wood  and  thirteen  lithographic  plates,  beautifully  colored.  (Sold 
only  hy  subscription.)  Price  per  volume,  in  cloth,  $000;  in  leather,  $700;  in  half 
Ku'hsia,  $7  50.  Per  set,  in  cloth,  $18  00  ;  in  leather,  $21  00  ;  in  half  Hussia,  $22  50. 
Volume  I.    (nearly  ready)   contains  General  Pathology,   Morbid  Processes,  Injuries  in 

Genhral,  C0MPLICAT10N.S  OF  Injuries  and  Injuuieh  of  Regions. 
Volume  II.   (shortly)  contains  Diseases  of  Organs  of  Special  Sense,  Circulatouy   Sts- 

TEM,  Digestive  Tract  and  Genito-urinaby  Organs. 
Volume  III.   (shortly)  contains  Diseases  op   tub   Respiratory  Organs,  Joints,  Bones,  and 
Muscles,  Operative  and  Minor  Surgery,  Gunshot  Wounds,  Hospitals  and  Miscel- 
laneous Subjects. 
This  gr-at  work,   issued  some  j'ears  since  in  England,  has  won  such  universal   confidence 
wherever  the  language  is  spoken,  that  its    republication    here,  in   a    form    more    tlioroughly 
adapted  to  the  wants  of  the  American  practitioner,  has  seemed  to  be  a  duty  owing  to  the  pro- 
fession. 

To  accomplish  this,  the  aid  has  been  invited  of  over  thirty  of  the  most  distinguished  gentle- 
men, in  every  part  of  the  country,  and  tor  more  than  a  year  they  have  been  assiduously  engaged 
upon  the  tatk.  Though  the  original  work  presents  the  combined  labor  of  the  most  eminent 
members  of  all  the  most  proinirent  schools  of  England,  yet  the  lapse  of  time  since  the  appear- 
ance of  the  last  edition,  the  progress  of  science,  and  the  peculiariliea  of  American  practice, 
have  rendered  necessary  a  most  careful,  thorough,  and  searching  revision.  Each  article  has 
been  placed  in  the  hands  of  a  gentleman  specially  competent  to  treat  its  subject,  and  no  labor 
has  been  spared  to  bring  each  one  up  to  the  foremost  level  of  the  times,  and  to  adapt  it  thor 
oughly  to  the  practice  of  the  country.  In  certain  cases,  this  has  rendered  necessary  the  sub- 
stitution of  an  entirely  new  essay  for  the  original,  as  in  the  case  of  the  articles  on  Skin  Di.'^eases, 
and  on  Diseases  of  the  Absorbent  System,  where  the  views  of  the  authors  have  been  superseded 
by  the  advance  of  medical  science,  and  new  articles  have  therefore  been  prepared  by  Drs.  Arthur 
VAN  Harlingen  and  S.  C.  Busey,  respectively.  So  also  in  the  case  of  Anaesthetics,  in  the  use 
of  which  American  practice  diflers  from  that  of  England,  the  original  has  been  supplemented 
with  a  new  essay  by  J.  C.  Reeve,  M.D.,  treating  not  only  of  the  employment  of  ether  and 
chloroform,  but  of  the  other  anaesthetic  agents  of  more  recent  discovery.  The  same  careful 
and  conscienti  ms  revision  has  been  pursued  throughout,  leading  to  an  increase  of  nearly  one- 
fourth  in  matter,  while  the  series  of  illustrations  has  been  more  than  doubled,  and  the  whole 
is  presented  as  a  complete  exponent  of  British  and  American  Surgery,  adapted  to  the  daily 
needs  of  the  working  practitioner. 

In  order  to  bring  it  within  the  reach  of  every  member  of  the  profession,  the  five  volumes  of 
the  original  have  been  compressed  into  three,  by  employing  a  douole-columned  imperi.il  octavo 
page,  and  in  this  improved  form  it  is  offered  at  less  than  one  half  the  price  of  the  original.  It 
is  beautifully  printed  on  handsome  laid  paper  and  forms  a  worthy  companion  to  Reynolds's 
"  System  of  Medicine,"  which  has  met  with  so  much  favor  in  every  section  of  the  country. 

The  work  will  be  sold  by  subscription  only,  and  in  due  time  every  member  of  the  profession 
will  be  called  upon  and  offered  an  opportunity  to  subscribe. 

The  few  notices  appended  will  serve  to  indicate  the  hearty  approval  accorded  to  the  unrevised 
edition  on  its  appearaice  some  years  since  :  — 


There  is  fo  much  that  is  Instruciive,  even  to  the 
experienced  practitioner,  in  their  practical  and  dis- 
crlminatiug  manner  of  dealing  with  mooted  ques- 
tions, none  tf  which  seem  to  be  neglected;  their 
abundant  illui^tratioiis,  drawn  at  once  from  an  nn 
limited  lield  of  hospital  experience,  and  their  candid 
and  sen.'iible  mode  of  handling  the  whole  snbject, 
that  these  particular  portions  of  the  work  possess  a 
value  which  places  them  far  above  any  publication 
oa  the  same  topics  yet  Issued  in  the  language.  — .il?(i. 
^ourn.  Mtd.  Sciences. 

The  enumeralion  of  the  treatises,  and  the  names 
of  the  surgical  writers  from  whuse  pens  they  pro- 
ceed, sutlice  to  show  that  this  is  no  ordinary  book, 
and  that  in  the  thousand  pages  of  this  goodly  volume 
lies  a  store  of  information  such  a.s  no  other  surgical 
\  work  in  the  language  can  pretend  to  offer.  Those  wlo 
are  acquainted  with  the  special  researches  aud  pub- 
lications of  the  respective  authors  will  not  fail  to 
notice  that  by  a  judicious  exerci.se  of  editorial  dis- 
cretion, each  subject  ha«  been  entrusted,  a.i  far  as 
possible,  to  a  surgeon  of  the  hospitals  who  is  known 
to  have  given  especial  attention  to  it,  and  to  possess 
facilities  for  summiugup  witli  authority  theaccepted 
opittimus  ot  the  day,  and  adding  original  matter  to 
»be  stock. — London  Lanctt. 

The  work  must  be  considered  a  very  complete  ac- 
count of  everything  connected  with  the  science  and 
practice  of  snrgery.  In  conclusion  we  can  cordially 
leeommeud  thlH  work  as  a  valuable  addition  to  the 


library  of  the  surgeon. — Edinhxirgh  M edical  Jour- 
nal. 

It  is  a  cyclopaedia  of  surgery  of  the  most  complete 
and  extensive  charatler ;  and  we  may  justly  state 
that  its  design  and  execution  do  great  honor  to  those 
concerned,  and  that  the  large  number  and  high 
standing  of  the  authors  selectfd  for  the  various 
monographs  render  ihis  "System"  what  it  no  doubt 
was  iuteudtd  to  be,  representative  of  the  actual  state 
of  surgical  science  and  art  in  the  country. — London 
Lancet. 

In  conclusion,  we  will  add  that  we  can  most  con- 
scienciously  recommend  the  book  to  every  medical 
praciitiouer.  In  recommending  the  " Sy/tttm  <>/  Sur- 
ffery"  to  our  friends  who  have  to  deal  in  surgical 
cases,  we  by  no  means  wish  to  confine  our  recom- 
mendation to  them  alone.  Every  practitiouei  of 
medicine  may  cull  something  worthy  of  uoie  from  a 
perusal  of  this  volume.—  T/ie  British  Mtd.  Journal. 

The  four  volumes  remain  a  monument  to  the  sur- 
gical genius  of  our  day.  The  great  majority  of  me- 
tropolitan surgeous  of  eminence  and  proved  ability 
are  represented  in  them  ;  and  lor  many  yeara  to 
come,  whoever  wishes  to  know  the  most  author!, 
tative  words  of  English  Surgical  science  on  most 
subjects  in  the  domaiu  of  surgery  must  turn  to  these 
pages  10  read  what  there  is  het  forth.  But  tHken  as 
a  whole  it  is  the  most  important  surgical  work  which 
has  ever  issued  from  the  English  press.— iowdon 
Lancet. 


28 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


T>RYANT  (THOMAS),  F.R.C.S., 

J-^  Surgeon  to  Guy's  Hospital. 

THE  PRACTICE  OF  SUEGERY.  Tliird  American,  from  the  Sec- 
ond and  Revised  English  Edition.  Tlioroughly  revised  and  luucli  improved,  bj'  Jolin  B. 
Roberts,  M.D.  In  one  large  and  very  handsome  imperial  octavo  volume  of  over  1(100 
pages,  with  672  illustrntions.  Cloth,  $6  60;  leather,  $7  60  ;  very  handsome  half  Russia, 
raised  bands,  $8  00.    (Just  Ready.) 


Mr.  Bryant's  work  has  long  lieen  a  favorite  one 
with  suvgoouR.  As  its  uauie  indicate",  it  is  of  a  tho- 
roughly practical  character.  It  is  distinctly  indi- 
vidual ia  that  it  gives  the  results  of  the  author's 
large  and  varied  experience  as  an  operator  and  cli- 
nical teacher,  and  is  on  tliat  account  prized  deserv- 
edly high  as  an  orij^inal  work.  Tlie  style  is  neces- 
sarily condensed,  the  descriptions  of  surgical  dis- 
eases brief  and  to  the  point.  The  lllustratious  are 
well  chosen,  and  the  typical  ca.-es  of  the  author's 
experience  are  full  of  Interest,  and  are  of  more  than 
ordinary  value  to  the  working  surgeon. — N.  1. 
Medical  Record,  March  5,  18S1. 

It  is  a  work  especially  adapted  to  the  wants  of 
Btudeuts  and  practitioners.  Vhile  not  prolix,  it 
affords  instruction  in  sufficient  detail  for  a  full  un- 
derstanding of  surgical  principles  and  the  treat- 
ment of  surgical  diseases.  It  embraces  in  its  scope 
all  the  diseases  that  are  recognized  as  belonging  to 
surgery,  and  all  traumatic  injuries.  In  discussing 
these  it  has  seemed  to  be  tlie  aim  of  the  author 
rather  to  present  the  student  with  practical  infor- 
mation, acd  that  alone,  than  to  burden  his  memory 
with  the  views  of  different  writers,  however  dis 
tiuguished  they  might  have  been.     In  this  edition 


(he  whole  work  has  been  carefully  revised,  much 
of  it  has  been  rewritten,  important  additions  ha-  e 
lieen  made  to  aim  ist  every  chapter. — Giuoinnati 
Med.  A^cwA-,  Jan.  ISSl. 

The  English  edition,  from  which  this  is  printed, 
lias  V)een  carefully  revised  anil  rewritten;  almost 
every  chapter  h-is  received  additions,  and  nearly 
one  hundred  new  cots  int  odnced.  The  labors  of 
the  American  editor,  Dr.  John  B.  Roberts,  have 
veiy  much  iucreas.d  the  value  of  the  book.  He 
lias  introduced  many  new  illustrations  and  iiuich 
new  niMtfrial  not  found  in  the  English  eilitioa. 
He  has  written  too  with  great  conciseness,  wliich 
is  a  rare  virtue  in  an  American  editor  of  au  English 
work.  If  one  could  procure  or  wished  only  ouo 
surgery,  ihis  volume  would  certainly  be  selected. 
If  he  desired  two,  Erichten's  Surgery  would  be 
lidded,  and  if  he  wished  a  third,  (jross's  Surgery 
would  ju.stly  be  the  work  selected.  As  the  great 
work  of  Gross  is  amply  sufficii-nt  for  the  waits  of 
any  surgeon,  the  priority  given  to  Erichsen,  and 
above  all  others,  to  this  work  of  Bryant,  is  no 
labored  eulogy  of  the  last  volume,  but  a  simple  and 
Just  statement  of  its  demonstrable  and  pre-eminent 
merits.— ^7/i.  Med.  Bi- Weekly,  Feb.  26,  1881. 


fiRICHSEN  [JOHN  E.), 

-LJ  Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 

gical   Injuries,  diseases  and   Operations.       Carefully  revised   by  the  Autlior  from  the 
Seventh  and  enla.ged  English  Edition.    Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.     In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages: 
cloth,  $8  60  ;  leather,  $10  50;  half  Russia,  $11  50.      {Now  Ready.) 
Of  the  many  treatises  on  Surgery  which  it  has  been        The  seventh  edition  is  before  the  world  as  the  last 


our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  sati.'sfied  us  so  well  as  the  classic 
treatise  of  Erichsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  his  unsurpassed  grasj 
of  his  subject,  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish. 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  ir 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  v 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  if 
general,  and  has  led  to  the  appearance  of  another  edi 
tion. — Med.  and  Surg.  Reiiortn-,  Feb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  thai 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up,  and  not  merely  amend 
ed  by  a  few  extra  chapters  A  great  improvement  ba^ 
been  made  in  the  illustrations.  One  hundred  and  tiftj 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn.  The  author  highly  appreciates  tht 
favor  with  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  reniier  his  latest 
edition  more  than  ever  worthy  of  their  ajiproval.  That 
he  has  succeeded  admirably,  must,  we  tliink,  be  the 
general  opinion.  We  heartily  recommend  the  book  tt 
both  student  and  practitioner. — N.Y.Med.  Journal. 
Feb.  1878. 


word  of  surgical  science.  There  may  be  monographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  practitioners  to 
read  it,  for  it  has  been  a  peculiar  province  of  Mr. 
Eiichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
in  invaluable  guide  at  the  bedside. — Am.  Practi- 
tioner, April,  1878. 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  itspiace  as  the  leading  text-book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
CO  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  one  hun- 
dred and  fifty  new  illustraiions  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  pathul  igical  processes.  So  marked  is  this 
change  for  the  i>etter,  that  the  work  almost  appears 
asanentirely  new  one. — Med.  Record,  Feb.  23,1878. 


H 


0 LMES  ( TIM OTHF),  M.D., 

Surgeon  to  St.  George's  Ho-ijntal,  London. 
SURGERY,    ITS    PRINCIPLES    AND    PRACTICE.      In    one    hand- 
some octavo  volume  of  nearly  lOOO  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7  ; 
half  Russia,  $7  60.      (Just  Issued.) 


This  is  a  work  which  has  been  lookedfor  on  both 
Bldeo  ofihe  Atlantic  with  much  intdrest.  Mr.  Holipes 
Is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner.  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  jnsllflesthe  high  expectations 
that  were  formed  oflt.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  ciinciseness  needed 
to  bring  it  within  its  proper  limits  has  not  Impairea 


its  force  and  distinctness. — N.  T.  Med.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  priictiiioner  who  has  not  the 
timelogiveattentionio  more  minute  and  extendt-d 
works,  and  tothe  medical  student.  In  fact,  we  know, 
of  no  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  acconnt  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and  especially  as  a  text- 
book.—C'inci'iwaii  Med.  News,  April,  1S76. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Ophthalmology).       29 


WELLS  {J.SOELBEKG), 

'  '  Prafe.ssor  of  Ophthalmology  in  King's  College  Hospital,  Ac. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Third  London  Edition.  Thoroughly  revised,  with  copious  addili. in?,  by  Ch.-is. 
S.  Bull,  M  1).,  Surgeon  nml  Pathologist  to  the  New  York  Eye  and  Ear  Infirinjiry.  Illus- 
trated with  about  260  engravings  on  wood,  and  six  colored  plates  Together  with  seleo- 
tions  from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  and  very  handsome 
octavo  volume  of  900  pages.  Cloth,  $5  ;  leather,  $C  ;  half  Rusbia,  raised  bands,  $6  60. 
{J/tst  Rr.adij. ) 

The  long-conliuued  illness  of  the  author,  with  its  fatal  termination,  has  kept  this  work  for 
some  time  out  of  print,  and  has  deprived  it  of  the  advantage  of  the  revision  which  he  sought 
to  give  it  during  the  la,st  years  of  hi-  life.  This  edition  has  therefore  been  placed  uuder  the 
editorial  supervision  of  Dr.  Bull,  who  has  labored  earnestly  to  introduce  in  it  all  the  advances 
which  observation  and  experience  have  acquirrd  for  the  theory  and  practice  of  ophthalmology 
since  the  appearance  of  the  last  revision.  To  accomplish  thi?,  considerable  additions  have  been 
required,  and  the  work  is  now  presented  in  the  confidence  that  it  will  fully  deserve  a  continu- 
ance of  the  very  marked  favor  with  which  tt  has  hitherto  been  greeted  us  a  complete,  but  con- 
oif-e,  exposition  of  the  principles  and  facts  of  its  important  department  of  medical  science. 

The  additions  made  in  the  previous  American  editions  by  Dr.  Hays  have  been  retained, 
including  the  very  full  series  of  illustrations  and  the  test-types  of  Jaeger  and  Snellen. 

This  uew  editioo  of  Dr.  Wells's  great  Work  ou  the     guage.     In  the  tecond  edition,   the  author  showed 


eye  will  be  welcomed  by  tiie  profession  at  large  a 
well  as  by  the  oculist.  It  coiitain  s  much  new  m.i  tter 
relating  to  treatmeLtand  pathology,  and  is  brought 
thoroughly  up  with  the  i>re^enl  hiatus  of  ophtbal- 
mjlogy.  Its  chtipter  on  retraction  and  accommo- 
dation— a  subject  much  discussed  of  late  years,  and 
of  great  importance — is  exceedingly  complete. — 
Louibville  Med.  Ntws,  Nov.  l.S,  18S0. 

The  merits  of  Wells's  treatise  on  diseases  of  the 
eye  have  been  so  universally  acknowledged,  and  are 
60  familiar  to  all  who  profess  to  have  given  any  at- 
tention to  ophthalmic  surgery,  that  any  discussion 
of  them  at  this  lale  day  will  be  a  work  of  superero- 
gation. Very  little  that  is  practically  useful  in  re- 
cent ophthalmic  literature  has  escaped  the  editor, 
and  the  third  American  edition  is  well  up  to  the 
times.  As  a  text-book  on  oph  Jialmic  surgery  for  tlie 
English-speaking  practitioner,  it  is  without  a  rival. 
— Ain.Journ.  of  Med.  Set.,  Jan.  1881. 

The  work  has  justly  held  a  high  place  in  English 
ophthalmic  literature,  and  at  the  time  of  ils  first  ap- 
pearance was  the  best  treatise  of  its  kind  in  the  lan- 


indnstrious  research  in  adding  new  material  from 
every  quarter,  and  hi."!  spirit  was  eminently  candid. 
A  work  thus  built  up  by  honest  eifort  should  not  be 
sufl'ered  to  die,  and  we  are  pleased  to  receive  this 
third  edition  from  the  hands  of  L)r.  Bull.  His  labor 
h  IB  been  arduous,  as  the  very  great  number  of  addi- 
tions bracketed  with  his  initial  testify.  Under 
the  editorship  which  the  third  edition  has  enjoyed, 
the  work  is  sure  to  sustain  its  good  reputation,  and 
to  maintain  its  usefulness. — N.  Y.  Med.Journ.,  Jan. 
18S1. 

There  is  really  no  work  which  approaches  it  in 
adaptation  to  the  wants  of  the  general  practitioner, 
while  the  most  advanced  specialist  cannot  rise  fr(un 
a  perusal  of  its  ample  pages  without  having  added 
to  his  knowledge.  The  American  editor,  Ur.  Bull, 
won  his  spurs  in  ophthalmology  some  time  back. 
His  additions  to  the  work  of  the  lamented  Wells  are 
many,  judicious,  and  timely,  and  in  just  so  much 
have  added  to  its  value. — Am.  Practitioner,  Jan. 
1881. 


XFETTLESHIP  (EDWARD),  F.R.C.S., 

•*- •  Oijhtholmic  Snrg.  and  Led.  on  Ophth.  Surg,  at  St.  Thomas''  Hospital,  London. 

MANUAL    OF    OPHTHALMIC    MEDICINE.     In  one  royal  12mo 

volume  of  over  .350  pages,  with  89  illustrations.     Cloth,  $2.     (Just  Ready.) 
The  author  is  to  be  ci^ngratulated  upon  the  very    information  they   contain.     We  do   not  hesitate  to 


successful  manner-  in  which  he  has  accomplished  hia 
task;  he  has  succeeded  in  being  concise  without 
sacriticing  clearness,  and,  including  the  whole 
ground  covered  by  more  voluminous  text-books, 
has  givttu  an  excellent  risumi  of  all  the  practical 


pronounce  Mr.  Nettleship's  book  the  best  manual  on 
ophthalmic  surgery  for  the  use  of  students  and 
"  busy  practitioners"  with  which  we  are  acquain- 
ted.—.kwi.  Jour.  Med.  Sciences,  April,  1880. 


c 


lARTER  (R.  BRUDENELL),  F.R.C.S., 

Ophthalmic  Surgeon  to  St.  George  s  Boxpiial,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE. 


Edit- 


ed,  with  test-types  and  Additions,  by  John  Green,  M.D.   (of  St.  Louis,  Mo.).     In  one 

handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.    Cloth,  $3  75.    (Just 

Issued. ) 

It  Is  with  great  pleasure  that  we  can  endorse  the  work  (chapter  is  devoted  to  adi.^cussion  of  the  uses  and  selec- 

as  a  most  valuable  contribution  to  practical  ophthal- 1  tion  ofspectaoles,  and  is  admirably  compact,  plain,  and 

mology.  Mr. Carter  neverdeviates  from  the  end  he  has  j  useful,  especially  the  paragraphs  on  the  treatment  of 

in  view,  and  presents  the  subjectin  a  clear  and  coucist  I  presbyopia  and  myopia.  In  conclusion,  our  thanks  are 

manner,  easy  of  comprehension,  and  hence  the  morf  j  due  the  author  for  many  useful  hintsin  the  ftreat  sub- 


valuable.  We  would  es)ieciiilly  commend,  however,  as 
worthy  of  high  praise,  the  manner  in  which  the  thera- 
peutics of  disease  of  the  eje  is  elaborated^  for  here  the 
author  is  particularly  clear  and  practicftl.  where  other 
writers  are  unfortunately  too  often  deticient.  The  final 


jeot  of  ophthalmic  snrjrery  and  therapeutics,  a  field 
whereof  late  years  we  glean  but  a  few  grains  of  sound 
wheat  from  a  mass  of  chaff. — Aeto  York  Medical  Record, 
Oct.  23,1875. 


B 


ROWNE  (EDGAR  A.), 

Hurgeon  co  the  Livrpool  Eyeand  Barlnfirma.rj/,  andtotheDispensary  for  Skin  Di.seasea. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

struct  ions  in  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty-five  illustra- 
tions.   In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     (Now  Ready.) 


LAURENCE'S    HAND?  BOOK    OF    OPHTHALMIC 

SURGERY,  for  the  use  of  Practitioners.  Second 
edition,  revised  and  enlarged  With  numerous 
iUnsiraiions.  In  one  very  handsome  octavo  vol- 
ume, cloth,  $2  75. 


LAWSON'S  INJURIES  TO  THE  EYE,  ORBIT 
AND  EYELIDS:  their  Immediate  and  Remote 
Effects.  With  about  one  hundred  iilustrations. 
In  one  very  handsome  octavo  volume,  cloth, 
$3  60. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Med.  Jurisprudence). 


'DURNETT  (CHARLES  H.),  M.A,  M.D., 

J-^  Aura!  Surg  t«  the  Prtsb.  Honp.,  Surgeon-in-tharge  ofthelnfir.forDis.  of  the  Ear,  Phila. 

TIIK    EAR,   ITS    ANATOxMY.   PHYSIOLOGY  AND     DISEASES. 

A  Priictical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some octiivo  volume  of  fi  1 5  pnges,  with  eighty-seven  illustrations  :  oloth,  $4  60  ;  leather, 
$5  60;   half  Russia,  l!i6  OU.      (Now  Ready.) 


Foremott  Hinoug  the  nameroun  receut  coutrilm- 
tions  to  Bural  lUeratur*  will  b."  ranked  tliis  work 
of  Dr.  Buroelt.  It  Is  impossible  to  do  justic»  to 
this  volume  of  over  600  pages  in  a  neces-arily  bri«f 
notice.  It  must  sufflce  to  add  that  the  book  is  pro- 
fusely and  accurately  llluBiraled,  the  relereuces  are 
coDiicieati'  usiy  acknowledged,  while  the  result  has 
been  to  produce  a  treatise  which  wiil  henceforth 
rank  with  the  classic  writings  of  Wilde  and  Von 
Tr61tsch.  — r/i«  Land.  I'mct dinner,  May,  1S79. 

On  account  of  the  great  advances  which  have  been 
made  of  late  years  in  otology,  aud  of  the  increased 
inttrest  manifested  lu  it,  the  medical  profesNion  will 
welcome  this  new  work,  which  presents  clearly  and 
concisely  its  present  aspect  whilst  clearly  indi- 
cating the  direction  in  which  farther  researches  can 
be  most  profi(ably  carried  on.  Dr.  Barn  tt  from  his 
own    matured  experience,  aud  availing  him.->elf  of 


the  observations  and  discoverie.?  of  others,  has  pro- 
duced a  work  which,  as  a  text-book,  stands /rjcite 
firirici'ji.v  \a  our  language.  We  had  marked  several 
pa-sages  as  well  worthy  of  quotation  aud  the  atten- 
tion of  the  general  practitioner,  but  their  number  and 
the  space  at  on r  com m And  forbid.  Perhaps  il  is  bet- 
ter, a.s  the  book  ought  to  be  in  the  hands  of  every 
medical  student,  and  its  study  will  well  repay  the 
busy  practitioner  in  the  pleasure  he  will  derive  from 
the  agreeable  style  in  which  many  otherwise  dry 
and  mosily  unknown  subjects  are  treated.  To  the 
specialist  the  work  is  of  the  highest  value,  and  his 
sense  of  graiitude  to  Dr.  Burnett  will  we  hope,  he 
proportionate  to  ihe  amount  of  benefit  he  can  obtain 
from  the  carelnl  study  of  the  book,  and  a  constant 
reference  to  its  trustworthy  pages.' — Edinburgh 
Med.  Jour.,  Aug.  1878. 


rfAYLOR  [ALFRED    S.),M.D., 

J-  Lecturer  on  Med.  Jurisp.  and  Chemistry  in  Ouy'a  Hospital. 

A  MANUAL  OF   MEDICAL  JURISPRUDENCE.     Eighth  Ameri- 

ciin  edition.    Thoroughly  revised  and  rewritten.     Edited  by  John  J.  Reese,  M.D.,Prof. 

of  Med.  Jurisp.  and  To.xicology  in  the  Univ.  of  Penn.      In  one  large  octavo  volume  of 

■933  pages,  with  70  illtjstralions.     Cloth,  $6;   leather,  $6;    half  Russia,  raised  bands, 

$6  50.  (Just  Ready.) 
The  American  editions  of  this  standard  manual 
have  for  a  Ion.'  time  laid  claim  to  the  attention  of 
the  prol'ession  in  this  country  ;  and  i  hat  the  profes- 
sion has  recognized  this  clai  i  with  favor  is  proven 
by  the  call  for  frequent  new  millions  of  the  work. 
This  one,  the  eighth,  coraes  belore  us  as  embodying 
the  latest  thoughts  and  emendations  of  Dr.  Tayl  ir, 
upon  the  subject  to  which  he  devo  ed  hi.^  life,  with 
an  assiduity  aud  success  which  made  him  facxh. 
prinr^ps  among  English  writers  on  medical  juris- 
prudence. Both  the  author  and  the  book  have 
made  a  mark  too  deep  to  be  affected  by  criticism, 
wliether  it  I  e  censure  or  praise.  In  this  case,  how- 
CTer  we  shoi^ld  only  have  to  seek  for  laudatory 
teims. — Am.  Ji'urn.  of  Med.  Sot.,  Jan.  ISSl. 

It  is  not  very  often  that  a  medical  book  reaches  its 
tenth  edition,  or  that  the  last  eartlily  labor  is  per- 
formed by  the  author  in  retouching  the  work  that 
first  came  from  his  hand  thirty-five  years  before. 
All  this,  however,  has  h.<ppened  in  the  ca-e  of  Dr. 
Taylor  and  liis  classical  treatise.  The  pen  dropped 
from  the  grasp  only  when  the  shadows  of  old  age 
were  rapialy  deepening  into  the  ddrkoess  of  death. 
Under  the  circnmalances,  all  the  journalist  hae  to  do 

>T  THE  SAME  AUTHOR.  ' 

'the  PRINCIPLES  and  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 

volumes,  cloth,  $10  00;  leather,  $12  00. 
This  great  work  is  now  recognized  in  England  as  the  fullest  and  luost  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Amer- 
ican profeision,  the  publishers  trust  that  it  will  assume  the  same  position  in  this  country. 

>r  THE  SAME  AUTHOR. 


is  to  announce,  not  criticize  the  completed  task.  The 
value  of  the  gem  is  too  weil  kuowu  to  requiie  more 
than  the  telling  vhat  the  mtster-hand  has  rebright- 
ened  its  tacets  and  polished  its  angles  before  leaving 
it  as  his  legacv  to  hs  brethren  in  the  profession. — 
Phiia   M'-.d.  Tiifids,  Dec.  4,  1880. 

It  will  Buffiie  to  remark  that  this  new  edition 
shows  the  signs  of  juili.'ious  revision  A  great  num- 
ber of  il.usliaiive  medico- legal  cases  which  have 
occurred  since  the  last  edition  was  pu^'lished  are 
cited  in  heir  proper  connection,  and  add  much  to 
the  interest  aud  value  of  the  work;  they  comprise 
the  bulk  of  the  additions  to  the  text.  As  an  iadicik- 
tionofthe  re^hnesof  the  work,  we  notice  numei"- 
ous  references  to  medic  '-legal  experience  that  has 
transpired  during  the  year  just  ended  ;  among  tbes-e 
is  a  cumment  by  the  American  editof  upon  that 
midsummer  madness,  theTitnner  fasting  exploit  of 
last  Aug'ist.  In  these  features  aud  in  others  there 
is  ample  evidence  that  this  admirable  book  will 
maintain  its  hi^h  place  as  a  standard  authority  eoa- 
cerning  th«  matters  of  which  it  tTea,is.— Boston 
Med.  and  Surg.  Journal,  Jan.  13,  1881. 


Bl 


B 


POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $6  60  ;  leather,  $6  50.     (Just  Issued.) 


The  present  Is  based  upon  the  two  previous  edi- 
tlons;"'butlhe  complete  re  vision  rendered  necessary 
by  tim"  has  converted  it  into  a  new  work."  This 
■  tatement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  In  reference  to  the  new  edition.  The 
works  uf  this  author  are  already  in  Ihe  library  of 
every  pbyi-lcian  who  is  liable  to  be  called  upon  for 
medkco-lega I  testimony  |andwhBt'>Del»noti').sothat 
all  that  IH  required  to  be  known  about  the  present 
book  is  mat  the  aatbor  has  kept  It  abreast  with  the 


being  describod  which  give  rise  to  legal investiga- 
tions.  — r/ie  Olinio,  Nov.  6,  1876. 

Dr.  Taylor  hai-  brought  to  bear  on  the  compilation 
of  this  volume,  stores  of  l«arning,  experience,  and 
practical  acquaintance  with  his  subject,  probably  far 
beyond  what  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fully 
sustained  his  reputation  by  the  consummate  ekill 
and  legal  acumen  be  has  displayed  in  the  arrange- 
ment of  in«  subject-matter,  aud  the  result  is  a  work 


times.  What  makes  It  now,  a»  always,  especially  „„  Poisons  which  will  be  indispensable  to  every  stn- 
Taloable  to  the  practitioner  Is  i  ts  coaci8«ue»s  and  .jem^r  practitioner  in  lawaud  medicine.— r/»«  i>M6 
pr*clical  character,  only  those  poisonoas  subslances  1  n^^  Journ .  uf  Med  Set. ,  Oct.  1875. 


